RESUMEN

OBJECTIVES: Cystectomy with urinary diversion is associated with decreased long-term kidney function due to several factors. One factor that has been debated is the type of urinary diversion used: ileal conduit (IC) vs. neobladder (NB). We tested the hypothesis that long-term kidney function will not vary by type of urinary diversion. METHODS AND MATERIALS: We retrospectively identified all patients who underwent cystectomy with urinary diversion at our institution from January 1, 2007, to January 1, 2018. Data were collected on patient demographics, comorbid conditions, perioperative radiotherapy, and complications. Creatinine values were measured at several time points up to 120 months after surgery. Glomerular filtration rate (GFR) (ml/min per 1.73 m2) was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. A linear mixed model with inverse probability of treatment weighting (IPTW) was used to compare GFR between the IC and NB cohorts over time. Multiple sensitivity analyses were performed based on 2 different calculations of GFR (Chronic Kidney Disease Epidemiology Collaboration equation vs. Modification of Diet in Renal Disease), with and without excluding patients with preoperative GFR less than 40 ml/min per 1.73 m2. RESULTS: Among 563 patients who underwent cystectomy with urinary diversion, a NB was used for 72 (12.8%) individuals. Patients who had a NB were significantly younger, had a lower American Society of Anesthesiologists score, greater baseline GFR, better Eastern Cooperative Oncology Group performance status, lower median Charlson comorbidity index, and were less likely to have received preoperative abdominal radiation (all P < 0.05). Both NB and IC patients had decreased kidney function over time, with mean GFR losses at 5 years of 17% and 14% of baseline values, respectively. The IPTW-adjusted linear mixed model revealed that IC patients had slightly more deterioration in kidney function over time, but this was not statistically significant (estimate, 0.12; P = 0.06). The sensitivity analyses yielded a similar trend, in that GFR decrease appeared to be greater in the IC cohort. This trend was statistically significant when using Modification of Diet in Renal Disease (P = 0.04). CONCLUSIONS: Among highly selected patients with an NB, deterioration of kidney function may potentially be lower over time than among IC patients. However, the statistical significance varied between analyses and we cautiously attribute these observed differences to patient selection.

Asunto(s)

Cistectomía/efectos adversos , Complicaciones Posoperatorias/diagnóstico , Insuficiencia Renal Crónica/diagnóstico , Neoplasias de la Vejiga Urinaria/cirugía , Derivación Urinaria/efectos adversos , Factores de Edad , Anciano , Creatinina/sangre , Cistectomía/métodos , Femenino , Estudios de Seguimiento , Tasa de Filtración Glomerular/fisiología , Humanos , Riñón/fisiopatología , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/sangre , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/fisiopatología , Insuficiencia Renal Crónica/sangre , Insuficiencia Renal Crónica/etiología , Insuficiencia Renal Crónica/fisiopatología , Estudios Retrospectivos , Factores de Riesgo , Derivación Urinaria/métodos

RESUMEN

We report a bladder diverticular stone with increased 99mTc-methyl diphosphonate uptake on bone scintigraphy and SPECT/CT. Diverticular stone is a known risk factor for bladder malignancy. The deposition of 99mTc-methyl diphosphonate on the crystal surface of the diverticular stone is a rare phenomenon but of clinical significance. Cystolitholapaxy is indicated to remove the diverticular stone and to reduce the risk of bladder cancer.

Asunto(s)

Huesos/diagnóstico por imagen , Divertículo/diagnóstico por imagen , Medronato de Tecnecio Tc 99m , Vejiga Urinaria/anomalías , Adulto , Humanos , Masculino , Factores de Riesgo , Vejiga Urinaria/diagnóstico por imagen

RESUMEN

INTRODUCTION: The objective was to analyze the diagnostic value of multiparametric magnetic resonance imaging (MRI) prostate lesion volume (PLV) and its correlation with the subsequent MRI-ultrasound (MRI-US) fusion biopsy results. MATERIALS AND METHODS: Between March 2014 and July 2016, 150 men underwent MRI-US fusion biopsies at our institution. All suspicious prostate lesions were graded according to the Prostate Imaging Reporting and Data System (PIRADS) and their volumes were measured. These lesions were subsequently biopsied. All data were prospectively collected and retrospectively analyzed. The PLV of all suspicious lesions was correlated with the presence of cancer on the final MRI-US fusion biopsy. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. RESULTS: There were 206 suspicious lesions identified in 150 men. The overall cancer detection rate was 102/206 (49.5%). The mean PLV for benign lesions was 0.63 ± 0.94 cm3 versus 1.44 ± 1.76 cm3 for cancerous lesions (P < 0.01). There was a statistically significant difference between the PLV of PIRADS 5 lesions when compared to PIRADS 4, 3, and 2 lesions (P < 0.0001, < 0.0001, and 0.006, respectively). The area under the curve for volume in predicting prostate cancer (PCa) was 0.66. The optimal volume for predicting PCa was 0.26 cm3 with a sensitivity, specificity, PPV, and NPV of 80.7%, 42.7%, 41.2%, and 74.6%, respectively. CONCLUSION: PLV may serve as a useful measure to triage patients prior to MRI-US fusion biopsy and help better understand the limits of this technology for individual patients.

RESUMEN

OBJECTIVE: To assess patient-reported functional and quality-of-life (QoL) outcomes associated with various surgical treatments for benign prostate hyperplasia (BPH). MATERIALS AND METHODS: An independent third-party survey was sent to all patients who underwent any surgical treatment for BPH at our institution from January 2007 through January 2013. Overall satisfaction and urinary and sexual outcomes were evaluated using Sexual Health Inventory for Men (SHIM), International Prostate Symptoms Score (IPSS) for urinary function, and International Continence Society-Short Form (ICSmaleSF) questionnaires. RESULTS: Four hundred and seventy-nine respondents (response rate, 55.6%) had undergone holmium laser enucleation of the prostate (HoLEP; n = 214), transurethral resection of the prostate (n = 210), holmium laser ablation of the prostate (n = 21), photoselective vaporization (n = 18), transurethral incision of the prostate (n = 9), and open simple prostatectomy (n = 7). Postoperatively, Sexual Health Inventory for Men scores were not different. However, total IPSS varied significantly among surgical techniques (P < .001). Mean (standard deviation) IPSS was lowest for open simple prostatectomy (4.0 [2.6]), followed by HoLEP (5.8 [5.4]). For individual domains, significant differences were in intermittency (P < .001), weak stream (P = .003), straining (P < .001), and QoL (P = .001). In all these domains, HoLEP had the lowest scores. Regarding International Continence Society-Short Form, we observed a significant difference favoring transurethral resection of the prostate in incontinence (P < .001) and favoring HoLEP in voiding (P = .02) and QoL domains (P = .03). Most patients were satisfied with their surgical intervention, independent of the procedure type. Regret was least in patients who underwent HoLEP (P = .02). CONCLUSION: Patients generally expressed satisfaction with various interventions for BPH. However, those who underwent HoLEP had the best outcomes.

Asunto(s)

Autoevaluación Diagnóstica , Hiperplasia Prostática , Calidad de Vida , Humanos , Masculino , Satisfacción del Paciente , Prostatectomía/métodos , Hiperplasia Prostática/diagnóstico , Hiperplasia Prostática/cirugía , Estudios Retrospectivos , Sexualidad , Micción

RESUMEN

Proton beam therapy for prostate cancer has become a source of controversy in the urologic community, and the rapid dissemination and marketing of this technology has led to many patients inquiring about this therapy. Yet the complexity of the technology, the cost, and the conflicting messages in the literature have left many urologists ill equipped to counsel their patients regarding this option. This article reviews the basic science of the proton beam, examines the reasons for both the hype and the controversy surrounding this therapy, and, most importantly, examines the literature so that every urologist is able to comfortably discuss this option with inquiring patients.

RESUMEN

INTRODUCTION: To evaluate the influence of marriage on the survival outcomes of men diagnosed with prostate cancer. MATERIALS AND METHODS: 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. RESULTS: 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). CONCLUSION: 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.

Asunto(s)

Estado Civil/estadística & datos numéricos , Neoplasias de la Próstata/mortalidad , Neoplasias de la Próstata/patología , Programa de VERF , Factores de Edad , Anciano , Estudios de Cohortes , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Estadificación de Neoplasias , Neoplasias de la Próstata/epidemiología , Análisis de Regresión , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia , Estados Unidos/epidemiología

RESUMEN

PURPOSE: We evaluate long-term disease control and chronic toxicities observed in patients treated with intensity modulated radiation therapy for clinically localized prostate cancer. MATERIALS AND METHODS: A total of 302 patients with localized prostate cancer treated with image guided intensity modulated radiation therapy between July 2000 and May 2005 were retrospectively analyzed. Risk groups (low, intermediate and high) were designated based on National Comprehensive Cancer Network guidelines. Biochemical control was based on the American Society for Therapeutic Radiology and Oncology (Phoenix) consensus definition. Chronic toxicity was measured at peak symptoms and at last visit. Toxicity was scored based on Common Terminology Criteria for Adverse Events v4. RESULTS: The median radiation dose delivered was 75.6 Gy (range 70.2 to 77.4) and 35.4% of patients received androgen deprivation therapy. Patients were followed until death or from 6 to 138 months (median 91) for those alive at last evaluation. Local and distant recurrence rates were 5% and 8.6%, respectively. At 9 years biochemical control rates were 77.4% for low risk, 69.6% for intermediate risk and 53.3% for high risk cases (log rank p = 0.05). On multivariate analysis T stage and prostate specific antigen group were prognostic for biochemical control. At last followup only 0% and 0.7% of patients had persistent grade 3 or greater gastrointestinal and genitourinary toxicity, respectively. 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 intensity modulated radiation therapy for prostate cancer. With a median followup of 91 months, intensity modulated radiation therapy resulted in durable biochemical control rates with low chronic toxicity.

Asunto(s)

Neoplasias de la Próstata/radioterapia , Radioterapia de Intensidad Modulada/métodos , Anciano , Anciano de 80 o más Años , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Neoplasias de la Próstata/patología , Dosificación Radioterapéutica , Radioterapia de Intensidad Modulada/efectos adversos , Estudios Retrospectivos , Factores de Riesgo , Resultado del Tratamiento

RESUMEN

OBJECTIVE: To identify the predictors of cancer-specific mortality of penile squamous cell carcinoma (PSCC) using a population-based database. METHODS: 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. RESULTS: 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). CONCLUSION: 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.

Asunto(s)

Carcinoma de Células Escamosas/mortalidad , Neoplasias de Cabeza y Cuello/mortalidad , Neoplasias del Pene/mortalidad , Anciano , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Pronóstico , Programa de VERF , Carcinoma de Células Escamosas de Cabeza y Cuello

RESUMEN

INTRODUCTION: 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. MATERIALS AND METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Asunto(s)

Adenocarcinoma/cirugía , Estadificación de Neoplasias/métodos , Prostatectomía/métodos , Neoplasias de la Próstata/cirugía , Robótica , Adenocarcinoma/mortalidad , Adenocarcinoma/patología , Adulto , Anciano , Anciano de 80 o más Años , Arizona/epidemiología , Supervivencia sin Enfermedad , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/epidemiología , Periodo Posoperatorio , Pronóstico , Neoplasias de la Próstata/mortalidad , Neoplasias de la Próstata/patología , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Factores de Tiempo

RESUMEN

BACKGROUND AND PURPOSE: Open radical prostatectomy after radiation treatment failure for prostate cancer is associated with significant morbidity. The purpose of the study is to report multi-institutional experiences while performing salvage robot-assisted radical prostatectomy (sRARP). PATIENTS AND METHODS: We retrospectively identified 15 patients with biopsy-proven prostate cancer after definitive radiotherapy who underwent sRARP in three academic institutions over a 20-month period. Continence was defined as the use of 0 pads after surgery. Potency was defined as the ability to achieve erections adequate enough for penetration with or without the use of phosphodiesterase-5 inhibitors. Biochemical recurrence after sRARP was defined as a prostate-specific antigen value of >0.2 ng/mL. RESULTS: Radiation treatment consisted of external-beam radiation therapy (XRT) in five cases, interstitial radioactive 125-iodine brachytherapy (BT) in five cases, proton beam therapy in two cases, and XRT followed by interstitial radioactive 125-iodine BT in three cases. The median operative time, the median estimated blood loss, and the median length of hospital stay were 140.5 min (interquartile range [IQR] 97.5-157 min), 75 mL (IQR 50-100 mL), and 1 day (IQR 1-2 d), respectively. There were no rectal injuries. Two (13.3%) patients had a positive surgical margin. A total of three (20%) patients had postoperative complications. One patient had a deep vein thrombosis (Clavien grade II), one had wound infection (Clavien grade II), and one patient had an anastomotic leak (Clavien gradeId). An anastomotic stricture (Clavien grade IIIa) later developed in this same patient, which was managed by direct visual internal urethrotomy. Of the patients, 71.4% were continent. At a median follow-up of 4.6 months (IQR 3-9.75 mos), four (28.6%) patients presented with biochemical recurrence after sRARP. CONCLUSIONS: The challenge during sRALP is the presence of extensive fibrosis and loss of dissection planes secondary to radiation therapy. It is a technically challenging but feasible procedure. The early complication rates were low, and early continence rates are encouraging.

Asunto(s)

Atención Perioperativa , Prostatectomía/efectos adversos , Neoplasias de la Próstata/fisiopatología , Neoplasias de la Próstata/radioterapia , Robótica/métodos , Terapia Recuperativa , Anciano , Estudios de Factibilidad , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Neoplasias de la Próstata/cirugía , Recto/patología , Factores de Tiempo , Insuficiencia del Tratamiento

RESUMEN

To determine whether men aged 70 years 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 ≥70 years). 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 70 years 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 70 years 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 Clavien I-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 70 years and older compared with men <70 years of age undergoing robot-assisted radical prostatectomy. RARP is a safe treatment option to offer to the selected elderly patient.

RESUMEN

Urologic complications related to vascular surgery involving the ureter have been well recognized. These include ureteral compression from aneurysms, congenital anomalies such as retrocaval ureter, obstruction from retroperitoneal fibrosis, iatrogenic injury, and ureteric fistulas. Complications involving the bladder are more infrequent. Most of these bladder-related complications involve the use of tunneling devices for synthetic bypass grafts. We report an unusual case of a transvesically placed femoral-femoral bypass graft with delayed presentation. We also reviewed the English literature for experience with diagnosis and treatment of bladder injuries during vascular surgical procedures.

Asunto(s)

Arteriopatías Oclusivas/cirugía , Implantación de Prótesis Vascular/efectos adversos , Disuria/etiología , Oclusión de Injerto Vascular/etiología , Arteria Ilíaca/cirugía , Claudicación Intermitente/cirugía , Vejiga Urinaria/lesiones , Infecciones Urinarias/etiología , Anciano , Anciano de 80 o más Años , Antibacterianos/uso terapéutico , Arteriopatías Oclusivas/complicaciones , Constricción Patológica , Remoción de Dispositivos , Disuria/microbiología , Disuria/terapia , Enterococcus faecalis/aislamiento & purificación , Femenino , Arteria Femoral/cirugía , Oclusión de Injerto Vascular/diagnóstico por imagen , Oclusión de Injerto Vascular/microbiología , Oclusión de Injerto Vascular/terapia , Humanos , Enfermedad Iatrogénica , Hallazgos Incidentales , Claudicación Intermitente/etiología , Masculino , Persona de Mediana Edad , Recurrencia , Reoperación , Vena Safena/trasplante , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Vejiga Urinaria/diagnóstico por imagen , Infecciones Urinarias/microbiología , Infecciones Urinarias/terapia

RESUMEN

INTRODUCTION: Measurements of prostate size are obtained to contribute in the diagnosis and follow up of patients with a variety of diseases. Since its introduction, transrectal ultrasonography (TRUS) of the prostate has become the most common method for assessment of prostate volumes. Ultrasonography, in general, has been associated with concerns of operator dependent variability. Herein, we analyze the accuracy of urologists and radiologists performing TRUS. MATERIAL AND METHODS: The accuracy of preoperative TRUS prostate volume estimation was evaluated by comparing it to gross specimen prostate weight following robot-assisted radical prostatectomy (RARP) performed from August 2004 to March 2008 in Mayo Clinic Arizona. A total of 800 RARPs were evaluated retrospectively with 302 patients having a prostate volume measurement with TRUS at our institution followed by RARP being performed within 30 days. The TRUS measurements were divided into two groups: those TRUS measurements performed by urologists (group 1), and those performed by radiologists (group 2). The accuracy of the two groups were compared using a Pearson correlation analysis. RESULTS: The estimated weight by TRUS in the total cohort of patients correlated with the pathological specimen weight at 0.802 with a standard error of 0.90. Group 1 performed a total of 114 ultrasounds with a correlation of 0.835 and a standard error of 1.27. Group 2 performed a total of 188 with a correlation of 0.786 and a standard error of 0.88. CONCLUSIONS: Urologists and radiologists are both consistently within 17%-22% of the estimated prostate specimen weight. Urologists appeared to have a slightly higher accuracy in estimation but a higher range of error for the whole group when compared to radiologists. Transrectal ultrasonography is a reliable technique to estimate prostate weight and accuracy to within 20% of the pathological weight. Urologists and radiologists are essentially equally proficient in estimating prostate weight with TRUS. These findings are particularly important with respect to specialty certification and competency/proficiency evaluation, as health care increasingly moves towards outcomes based reimbursement.

Asunto(s)

Adenocarcinoma/diagnóstico por imagen , Próstata/diagnóstico por imagen , Radiología , Urología , Anciano , Anciano de 80 o más Años , Competencia Clínica , Humanos , Masculino , Persona de Mediana Edad , Tamaño de los Órganos , Próstata/patología , Prostatectomía , Neoplasias de la Próstata/diagnóstico por imagen , Neoplasias de la Próstata/patología , Ultrasonografía

RESUMEN

BACKGROUND: In the current study, the effects of dose escalation for localized prostate cancer treatment with intensity-modulated radiotherapy (IMRT) or permanent transperineal brachytherapy (BRT) in comparison with conventional dose 3-dimensional conformal radiotherapy (3D-CRT) were evaluated. METHODS: This study included 853 patients; 270 received conventional dose 3D-CRT, 314 received high-dose IMRT, 225 received BRT, and 44 received external beam radiotherapy (EBRT) + BRT boost. The median radiation doses were 68.4 grays (Gy) for 3D-CRT and 75.6 Gy for IMRT. BRT patients received a prescribed dose of 144 Gy with iodine-125 (I-125) or 120 Gy with palladium-103 (Pd-103), respectively. Patients treated with EBRT + BRT received 45 Gy of EBRT plus a boost of 110 Gy with I-125 or 90 Gy with Pd-103. Risk group categories were low risk (T1-T2 disease, prostate-specific antigen level or=2 factors). RESULTS: With a median follow-up of 58 months, the 5-year biochemical control (bNED) rates were 74% for 3D-CRT, 87% for IMRT, 94% for BRT, and 94% for EBRT + BRT (P <.0001). For the intermediate-risk group, high-dose IMRT, BRT, or EBRT + BRT achieved significantly better bNED rates than 3D-CRT (P <.0001), whereas no improvement was noted for the low-risk group (P = .22). There was no increase in gastrointestinal (GI) toxicity from high-dose IMRT compared with conventional dose 3D-CRT, although there was more grade 2 genitourinary (GU) toxicity (toxicities were graded at the time of each follow-up visit using a modified Radiation Therapy Oncology Group [RTOG] scale). BRT caused more GU but less GI toxicity, whereas EBRT + BRT caused more late GU and GI toxicity than IMRT or 3D-CRT. CONCLUSIONS: The data from the current study indicate that radiation dose escalation improved the bNED rate for the intermediate-risk group. IMRT caused less acute and late GU toxicity than BRT or EBRT + BRT.

Asunto(s)

Braquiterapia/métodos , Neoplasias de la Próstata/radioterapia , Radioterapia de Intensidad Modulada/métodos , Braquiterapia/efectos adversos , Estudios de Seguimiento , Humanos , Masculino , Dosificación Radioterapéutica , Radioterapia de Intensidad Modulada/efectos adversos , Riesgo

RESUMEN

OBJECTIVE: To determine whether shorter intervals (<4 and 6 weeks) between prostate biopsy and robot-assisted radical prostatectomy (RARP) have a detrimental effect on perioperative outcomes, as recent studies showed that open RP shortly after prostate biopsy does not adversely influence surgical difficulty or efficacy, but RARP relies solely on visual cues rather than tactile sensation to determine posterior surgical planes of dissection. PATIENTS AND METHODS: A series of 559 patients undergoing RARP from March 2004 to July 2007 was retrospectively reviewed. The interval between prostate biopsy and RARP was determined and patients with intervals of 4 weeks. Patient characteristics and perioperative outcomes were analysed to determine statistically significant differences between the groups. This comparison was then repeated with a 6-week interval, and examined with a multivariate logistic regression analysis. RESULTS: In the 4-week group (509 patients), there was a significantly (P < 0.05) higher rate of complications (18.5% vs 6.9%). In the 6-week group (455 patients) there was a smaller but still significantly higher rate of complications (13.6% vs 6.4%). These results were still significant when controlling for patient and disease characteristics and the 'learning curve'. There was also a significantly higher rate of transfusion in the 6-week group (0.7%). CONCLUSIONS: Our data suggest that RARP should be delayed after prostate biopsy; RARP within 6 weeks of biopsy was associated with a greater risk of complications even when controlling for disease and patient characteristics.

Asunto(s)

Próstata/patología , Prostatectomía/métodos , Neoplasias de la Próstata/cirugía , Robótica , Anciano , Biopsia con Aguja , Métodos Epidemiológicos , Humanos , Complicaciones Intraoperatorias/prevención & control , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/prevención & control , Próstata/cirugía , Prostatectomía/efectos adversos , Neoplasias de la Próstata/patología , Factores de Tiempo , Resultado del Tratamiento

RESUMEN

OBJECTIVE: To evaluate retrospectively whether or not previous treatment to the prostate alters the perioperative outcomes from robot-assisted radical prostatectomy (RARP) after the initial 'learning curve', as there are conflicting data on outcomes of RP in patients with previous treatment to the prostate. PATIENTS AND METHODS: We retrospectively reviewed the charts of patients who had RARP between March 2005 and August 2007, and analysed demographic, perioperative variables and pathological data. In all, 510 patient charts were reviewed, identifying 24 patients with a history of previous treatment to the prostate including transurethral resection or incision of the prostate, transurethral microwave therapy, transurethral needle ablation, photoselective vaporization, simple prostatectomy, external beam radiotherapy, brachytherapy, and open bladder neck reconstruction (group 1) and 486 with no previous treatment (group 2). RESULTS: There was no significant difference between the groups in body mass index, clinical stage, grade or prostate volume, but the patients in group 1 were older (70 vs 65 years, P = 0.001). Outcome analysis comparing groups 1 and 2 showed an estimated blood loss of 155 vs 137 mL, length of hospital stay of 2.2 vs 1.5 days, operative duration of 200 vs 186 min and catheter time of 12 vs 8 days, respectively; only the last was statistically significant (P = 0.03). There was an 8.3% and 6.8% complication rate in groups 1 and 2, respectively, and the respective overall positive margin rate was 20.8% and 22.6%. CONCLUSIONS: A history of previous treatment of the prostate does not appear to compromise the perioperative outcomes of RARP.

Asunto(s)

Complicaciones Posoperatorias/etiología , Próstata/cirugía , Prostatectomía/métodos , Enfermedades de la Próstata/cirugía , Robótica , Anciano , Índice de Masa Corporal , Humanos , Tiempo de Internación , Masculino , Próstata/patología , Próstata/efectos de la radiación , Prostatectomía/efectos adversos , Prostatectomía/normas , Enfermedades de la Próstata/radioterapia , Reoperación , Estudios Retrospectivos , Resección Transuretral de la Próstata , Resultado del Tratamiento

RESUMEN

BACKGROUND AND PURPOSE: The role of laparoscopic radical nephrectomy (LRN) for very large renal tumors remains to be defined. We review our experience with LRN for very large (> or =10 cm) renal malignancies. PATIENTS AND METHODS: A retrospective analysis of 360 consecutive patients who underwent LRN for renal tumors between October 1999 and May 2007 in a tertiary academic center identified 11 patients with malignancies > or =10 cm. RESULTS: Median age was 67 years (range 48-80 y), operative time was 170 minutes (range 80-240 min), estimated blood loss was 150 mL (range 50-300 mL), and length of stay was 2 days (range 1-6 d). There were two minor postoperative complications (acute renal insufficiency and ileus). Median tumor size was 12 cm (range 10-21 cm). Pathologic stage for patients with renal cell carcinoma was T(2), T(3a), T(3b), and T(4), in five, three, two, and one patient(s), respectively. One patient died after brain metastasis developed. Two patients in whom pulmonary metastases developed were still alive at last follow-up. CONCLUSIONS: LRN was successfully performed in patients with renal tumors up to 21 cm. Important considerations when performing LRN include the individual clinical picture, surgeon experience, tumor location, and patient well-being. LRN for very large tumors is feasible in properly selected patients and can have significant benefits in the palliative setting.

Asunto(s)

Neoplasias Renales/patología , Neoplasias Renales/cirugía , Laparoscopía , Nefrectomía/métodos , Anciano , Anciano de 80 o más Años , Humanos , Neoplasias Hepáticas/patología , Neoplasias Hepáticas/secundario , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad

RESUMEN

PURPOSE: We present our experience with laparoscopic radical nephrectomy for T(3b) disease focusing on thrombus within the vena cava. PATIENTS AND METHODS: A total of 14 patients with T(3b) disease were identified from a retrospective laparoscopic renal cancer database from 2000 to 2007. Patient demographics, clinical stage, preoperative imaging, intraoperative parameters, final pathology, and postoperative course were analyzed. In patients with a large tumor thrombus, the infraumbilical extraction excision was performed early and a gel port was placed. This was used when laparoscopic milking or determination of the distal extent of the tumor thrombus was difficult. RESULTS: Preoperative imaging identified T(3b) disease in all but four patients. Four patients had caval involvement seen on imaging, with one extending well above 2 to 3 cm above the renal vein. Of the 14 patients, procedures in 13 were completed laparoscopically. There was one conversion early in the experience because of a positive frozen section of the renal vein; however, additional vein and caval margins were negative. There was one complication-a pulmonary embolism 5 days postoperatively, managed with anticoagulation, with no disease recurrence 4 years later. CONCLUSION: In patients with T(3b) disease, laparoscopy is feasible and safe. Using advanced laparoscopic techniques to milk the tumor thrombus into the proximal renal vein with laparoscopic vascular instruments is critical to success in a purely laparoscopic thrombectomy. Placement of a gel port in the extraction incision early in the procedure may aid in hand-milking of the tumor thrombus into the renal vein in cases of extensive inferior vena cava involvement.

Asunto(s)

Laparoscopía/métodos , Nefrectomía/métodos , Venas Renales/cirugía , Trombosis/cirugía , Vena Cava Inferior/cirugía , Anciano , Anciano de 80 o más Años , Carcinoma de Células Renales/cirugía , Humanos , Neoplasias Renales/cirugía , Persona de Mediana Edad , Atención Perioperativa , Cuidados Posoperatorios , Venas Renales/patología , Resultado del Tratamiento , Vena Cava Inferior/patología

RESUMEN

PURPOSE: To evaluate perioperative and pathologic outcomes of patients undergoing robot-assisted extended pelvic lymphadenectomy for bladder cancer. MATERIALS AND METHODS: A retrospective chart review was performed for all 27 patients who underwent robotassisted radical cystectomy (RARC) and extended pelvic lymphadenectomy at Tulane University and Mayo Clinic Arizona between March 2005 and April 2007. Baseline demographic, perioperative, and pathologic data were evaluated. The bifurcation of the aorta was the proximal border of dissection in all patients. RESULTS: There was a total of 27 patients, and all procedures were completed laparoscopically; all urinary diversions were constructed extracorporeally in RARC patients. The mean total operative time was 400 minutes, and mean blood loss was 277 mL. All patients had transitional-cell carcinoma in the bladder cancer group. The mean total lymph node count for the RARC group was 12.3 (range 7-20). There were no intraoperative complications, and 9 (33%) patients experienced postoperative complications. CONCLUSIONS: An extended pelvic lymphadenectomy can be reliably and safely performed robotically during RARC in the management of bladder cancer. The robotic system aids in performing a meticulous dissection and in adhering to sound oncologic principles.

Asunto(s)

Escisión del Ganglio Linfático/métodos , Pelvis/cirugía , Robótica/métodos , Anciano , Anciano de 80 o más Años , Vasos Sanguíneos , Femenino , Humanos , Masculino , Persona de Mediana Edad

RESUMEN

OBJECTIVES: There is no consensus as to the management of positive surgical margins after laparoscopic partial nephrectomy (LPN). A recent study revealed no evidence of malignancy in radical nephrectomy specimens removed for this reason, pointing out that a positive margin does not always translate to residual disease. We present results from our institution for the first 80 LPN performed with minimum 2 years' follow-up, focusing on patients with malignancy noted to have positive margin on final pathology. METHODS: We performed a retrospective chart review for patients who had undergone laparoscopic partial nephrectomy for malignancy and a minimal follow-up of 2 years. Patient demographic, operative, and perioperative data were collected. Those cases with positive margins were selected for specific oncologic analysis. RESULTS: Of the 80 LPN performed, 50 were performed for malignancy. Mean tumor size was 2.2 cm. Five patients were found to have positive margin for renal cell carcinoma. All five of these masses were excised without hilar clamping using thermal dissection with energy ablation of the tumor bed. All patients underwent surveillance with a mean follow-up of 56.4 months with no recurrences. One patient with a negative surgical margin experienced a metachronous lesion in the contralateral kidney 3 years later. CONCLUSIONS: Surveillance in selected patients may be adequate without sacrificing oncologic control. However, long-term follow-up is essential. Hilar clamping may allow optimal visualization for tumor excision and allows excision to be performed without energy, potentially decreasing the rate of true- and false-positive margins.

Asunto(s)

Neoplasias Renales/patología , Neoplasias Renales/cirugía , Laparoscopía , Nefrectomía/métodos , Adulto , Anciano , Anciano de 80 o más Años , Arizona , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Vigilancia de la Población , Estudios Retrospectivos