Alex Sankin

Factors Predicting Preservation of Erectile Function in Men Undergoing Open Radical Retropubic Prostatectomy

PURPOSE The development of erectile dysfunction represents a major concern for potent men with localized prostate cancer undergoing open radical retropubic prostatectomy. We identified factors predicting the preservation of erectile function in men undergoing open radical retropubic prostatectomy. MATERIALS AND METHODS Between October 2000 and September 2005 a total of 1,110 men underwent open radical retropubic prostatectomy by a single surgeon. The UCLA-PCI was self-administered at baseline, and at 3, 6, 12 and 24 months postoperatively. The 728 (66%) men who responded that they engaged in sexual intercourse with or without taking phosphodiesterase type 5 inhibitors in the month before surgery and who were not dependent on intracavernous injections, intraurethral suppositories, vacuum devices or penile prostheses were considered potent. Followup was available for 659 men. Of the evaluable men 25 received salvage radiation therapy, adjuvant chemotherapy or hormonal therapy and were excluded from the study. Univariate and multivariate analyses using a logistic regression model were used to identify factors predicting the preservation of potency. RESULTS Age, coronary artery disease, diabetes mellitus, quality of preoperative erections, frequency of intercourse, hypertension, neurovascular bundle preservation and the use of phosphodiesterase type 5 inhibitors preoperatively predicted the preservation of potency. On multivariate analysis age, no history of diabetes mellitus and nerve sparing were independent predictors of the preservation of potency. CONCLUSIONS We identified many factors that were predictors of the preservation of potency after open radical retropubic prostatectomy. Only age, no history of diabetes mellitus and neurovascular bundle preservation were independent predictors. These parameters should be considered when counseling surgical candidates so that erectile function expectations are realistic.

Can contemporary transrectal prostate biopsy accurately select candidates for hemi―ablative focal therapy of prostate cancer?

To determine if biopsy characteristics can be used to identify men with unilateral prostate cancer on radical prostatectomy (RP) pathological specimens, thereby selecting candidates for hemi‐ablative focal therapy.

Appropriate Candidates for Hemiablative Focal Therapy Are Infrequently Encountered Among Men Selected for Radical Prostatectomy in Contemporary Cohort

OBJECTIVES To assess the prevalence and pathologic features of men with unilateral prostate cancer at radical prostatectomy (RP), because it has recently been proposed that men with small-volume, well-differentiated, unilateral prostate cancer can be treated with focal therapy. METHODS The records of 1467 consecutive men who underwent open RP by a single surgeon from January 2000 to June 2007 were reviewed after institutional review board approval. The RP pathologic reports were analyzed to determine the frequency of unilateral or bilateral disease, surgical margin status, presence of extracapsular extension, seminal vesicle invasion, Gleason score, percentage of tumor involvement (PTI), prostate-specific antigen (PSA) level, and prostate volume. Logistic regression analysis was performed to analyze the relationship between these factors and the detection of unilateral disease. RESULTS Unilateral cancer was identified in 313 of 1467 patients (21.3%). Of these patients, 206 had a PTI of < or = 5%, 40 had a PTI of 5%-10%, 8 had a PTI of 10%-15%, and 40 had a PTI > 15%. The factors significantly associated with unilateral disease on univariate analysis were PTI, PSA level, pathologic Gleason score, seminal vesicle invasion, and extracapsular extension. The PSA level and seminal vesicle invasion remained significant predictors on multivariate analysis. Overall, 163 men (11.1%) had unilateral, low-risk disease (defined as a PSA level < 10 ng/mL, Gleason score < 7, and PTI < 10%). CONCLUSIONS Although candidates for focal therapy exist among men undergoing RP within a contemporary cohort, they represent a small minority. Before proceeding with focal therapy, the urology community must identify accurate methods of candidate selection.

Laterality alone should not drive selection of candidates for hemi-ablative focal therapy.

PURPOSE Because many investigators have suggested that ideal candidates for focal therapy are those with unilateral prostate cancer, we evaluated whether these men are at decreased risk for adverse pathological and oncological outcomes. MATERIALS AND METHODS We reviewed the charts of 1,458 consecutive patients who underwent open radical prostatectomy, as performed by a single surgeon. Patients were divided into 311 with unilateral (group 1) and 1,147 with bilateral (group 2) disease on final surgical pathology. They were also substratified by clinical risk into low risk (prostate specific antigen less than 10 ng/ml, clinical stage less than T2b or Gleason score less than 7) and high risk groups. The groups were compared with respect to extracapsular extension, seminal vesical invasion, percent of tumor involvement, pathological Gleason score and biochemical recurrence. RESULTS Compared to patients with bilateral disease those with unilateral disease had a lower rate of extracapsular extension (p = 0.004), seminal vesical invasion (p = 0.003), greater than 10% tumor involvement (p <0.001) and Gleason score 7 or greater (p <0.001). At a median followup of 36 months 8.3% and 16.7% of the men in groups 1 and 2, respectively, experienced biochemical recurrence (p = 0.001). Low risk disease was more prevalent in those with unilateral disease than in those with bilateral disease. Of men with low risk disease the risk of adverse pathological features/biochemical recurrence did not differ between groups 1 and 2. CONCLUSIONS Although men with unilateral prostate cancer have more favorable oncological outcomes than those with bilateral prostate cancer, this appears to be due to the higher prevalence of low risk disease. While focality/laterality may direct the method of subtotal gland treatment, clinical risk features may be adequate to select candidates for focal therapy.

Stent-assisted Gugliemi detachable coil repair of wide-necked renal artery aneurysm using 3-D angiography

Purpose To report a wide-necked renal artery aneurysm treated successfully with stent-assisted Gugliemi detachable coil occlusion, assisted by three-dimensional (3-D) angiography. Case Report A 56-year-old woman with history of hypertension presented with a 2.5-cm wide-necked saccular aneurysm involving her distal right renal artery. A balloon-expandable stent was positioned across the neck of the aneurysm and multiple Gugliemi detachable coils were deployed through a microcatheter inserted through the interstices of the stent into the aneurysm sac, guided by 3-D angiography. Follow-up 3-D angiography at 6 months revealed a patent renal artery with continued exclusion of the aneurysm and preservation of renal blood flow. Conclusion Stent-assisted coil occlusion assisted by 3-D angiography is a potential renal-sparing endovascular approach to treating wide-necked renal artery aneurysms with complex vascular anatomy.

Side-specific factors associated with extracapsular extension and seminal vesicular invasion in men undergoing open radical retropubic prostatectomy

This study provides further insights into those preoperative parameters that predict side-specific risk of pathological stage in men undergoing radical prostatectomy (RP). The transrectal ultrasound-guided tissue biopsy cores obtained from the right and left sides of the prostate were collected in separate jars and examined independently according to the side of origin in 1250 men with clinically localized prostate cancer who underwent RP. The side-specific biopsy specimens were examined for Gleason score, number of positive cores, percentage of positive cores, percent tumor volume in the biopsy specimens and the presence of perineural invasion. All of the surgical specimens were processed and analyzed by pathologists at NYUMC using a standardized protocol. The surgical specimens were examined for side-specific extracapsular extension (ECE) and seminal vesicle invasion (SVI). Using a univariate analysis, age, serum prostate-specific antigen (PSA), prostate volume, clinical stage, Gleason score, number of positive biopsies, percent positive biopsy cores, percent volume of prostate cancer in cores and perineural invasion were all significant predictors of both ECE and SVI. A multivariate analysis was performed to determine the independent predictors of ECE and SVI. Serum PSA, biopsy Gleason score, percent volume of biopsy cores with cancer and perineural invasion were independent predictors of side-specific ECE. Age, serum PSA, Gleason score and prostate volume were independent predictors of side-specific SVI. Our study identified previously unrecognized independent predictors of side-specific ECE and SVI. Our study also provides evidence that the independent predictors of ECE and SVI are different.

MEN WITH UNILATERAL PROSTATE CANCER HAVE MORE FAVORABLE PATHOLOGIC AND ONCOLOGIC OUTCOMES THAN THOSE WITH BILATERAL DISEASE: IMPLICATIONS FOR FOCAL THERAPY

1151 MEN WITH UNILATERAL PROSTATE CANCER HAVE MORE FAVORABLE PATHOLOGIC AND ONCOLOGIC OUTCOMES THAN THOSE WITH BILATERAL DISEASE: IMPLICATIONS FOR FOCAL THERAPY Basir Tareen*, Alex Sankin, Guilherme Godoy, Steve Temkin, Herbert Lepor, Samir S Taneja. New York, NY. INTRODUCTION AND OBJECTIVE: Recent attention on focal therapy for prostate cancer has lead to greater interest in identifying patients at low risk of adverse surgical pathology and disease progression. Since focal therapy may be ideal for men with unilateral disease, we undertook this study to determine if men with unilateral disease on radical prostatectomy pathology have more favorable pathologic outcomes and lower risk of relapse than men with bilateral disease. METHODS: The charts of 1458 consecutive patients undergoing open radical prostatectomy by a single surgeon from January 2000 to June of 2007 were reviewed following IRB approval. Patients were segregated on the presence of either unilateral disease (n=311) or