Benjamin Brucker

Does Race Affect Postoperative Outcomes in Patients With Low-Risk Prostate Cancer Who Undergo Radical Prostatectomy?

OBJECTIVES To assess the magnitude of racial disparities in prostate cancer outcomes following radical prostatectomy for low-risk prostate cancer. METHODS We retrospectively reviewed our database of 2407 patients who under went radical prostatectomy and isolated 2 cohorts of patients with low-risk prostate cancer. Cohort 1 was defined using liberal criteria, and cohort 2 was isolated using more stringent criteria. We then studied pre- and postoperative parameters to discern any racial differences in these 2 groups. Statistical analyses, including log-rank, chi(2), and Fishers exact analyses, were used to ascertain the significance of such differences. RESULTS Preoperatively, no significant differences were found between the white and African-American patients with regard to age at diagnosis, mean prostate-specific antigen, median follow-up, or percentage of involved cores on prostate biopsy. African-American patients in cohort 1 had a greater mean body mass index than did white patients (26.9 vs 27.8, P = .026). The analysis of postoperative data demonstrated no significant difference between white and African-American patients in the risk of biochemical failure, extraprostatic extension, seminal vesicle involvement, positive surgical margins, tumor volume, or risk of disease upgrading. African-American patients in cohort 2 demonstrated greater all-cause mortality compared with their white counterparts (9.4% vs 3.1%, P = .027). CONCLUSIONS In patients with low-risk prostate cancer treated with radical prostatectomy, there exist no significant differences in surrogate measures of disease control, risk of disease upgrading, estimated tumor volume, or recurrence-free survival between whites and African-Americans.

Defining pathological variables to predict biochemical failure in patients with positive surgical margins at radical prostatectomy: implications for adjuvant radiotherapy

Study Type – Prognosis (individual cohort series)
Level of Evidence 2b

Hydronephrosis Is an Independent Predictor of Poor Clinical Outcome in Patients Treated for Muscle-Invasive Transitional Cell Carcinoma With Radical Cystectomy

OBJECTIVES The purpose of this study was to assess the prognostic significance of hydronephrosis on pathologic and clinical outcomes in muscle-invasive bladder cancer. METHODS We performed a retrospective evaluation of a prospectively maintained cystectomy database and identified patients with hydronephrosis on preoperative imaging. Of a total of 306 patients, 57 (19%) had unilateral hydronephrosis and 17 (6%) had bilateral hydronephrosis. We constructed multivariate Cox regression analysis and Kaplan Meier tables to evaluate the association between preoperative hydronephrosis and clinical outcomes. RESULTS In patients without hydronephrosis, 41.4% had extravesical disease compared with 56.1% and 64.7% in patients with unilateral or bilateral hydronephrosis, respectively. Mean overall survival (OS) among patients without hydronephrosis, with unilateral hydronephrosis, and with bilateral hydronephrosis was 55.5, 42.1, and 22.2 months, respectively. Five-year OS and disease-specific survival (DSS) was 46%, 35%, and 22% (P = .001) and 68%, 54%, and 35% (P = .002), respectively. Multivariate analysis demonstrated that both unilateral and bilateral hydronephrosis are significant independent risk factors for DSS and OS. Bilateral hydronephrosis was found to have a hazard ratio of 3.87 (95% confidence interval [CI] = 1.71-8.78, P = .001) and 2.75 (95% CI = 1.45-5.18, P = .002) for DSS and OS, respectively. The hazard ratios for unilateral hydronephrosis were 1.7 (95% CI = 1.05-2.87, P = .03) and 1.5 (95% CI = 1.03-2.23, P = .04) for DSS and OS, respectively. CONCLUSIONS Preoperative hydronephrosis is associated with a significantly poorer prognosis in patients with muscle-invasive bladder cancer. These patients should be appropriately counseled with regard to overall prognosis and the potential benefit of neoadjuvant chemotherapy.

Uterine sparing robotic-assisted laparoscopic sacrohysteropexy for pelvic organ prolapse: safety and feasibility.

BACKGROUND AND PURPOSE The aim of this study was to describe the surgical technique and report the safety and feasibility of robotic-assisted laparoscopic sacrohysteropexy, a uterine sparing procedure to correct pelvic organ prolapse (POP). Hysterectomy at the time of POP surgery has yet to be proven to improve the durability of repair. Nevertheless, the leading indication for hysterectomy in postmenopausal women is POP. PATIENTS AND METHODS We reviewed the medical records of a consecutive case series of uterine sparing prolapse repair procedures from 2005 to 2011. Fifteen women were identified. Procedures utilized a type I polypropylene mesh securing the posterior uterocervical junction to the sacral promontory. This was later modified to utilize a Y-shaped strip that was inserted through the broad ligaments to include the anterior uterocervical junction. RESULTS Objective success was defined as Baden Walker grade 0 uterine prolapse and subjective success was defined as no complaint of vaginal bulge or pressure. The mean age of women was 51.8 years (28-64 years). No intraoperative complications were noted. The mean operating time was 159.4 minutes (130-201 minutes) and mean estimated blood loss was 35 mL (0-100 mL). The mean length of stay was 1.6 days (1-4 days) and mean length of follow-up was 10.8 months. Uterine prolapse improved in all 15 patients. Objective success was 93% (14/15) and subjective success was 80% (12/15). CONCLUSION Robotic-assisted laparoscopic sacrohysteropexy was found to be a safe and feasible surgical treatment option for POP patients who desire uterine preservation.

Comparison of urodynamic findings in women with anatomical versus functional bladder outlet obstruction.

Objectives To characterize the symptoms and urodynamic findings of anatomical bladder outlet obstruction (AO) and functional bladder outlet obstruction (FO) in women and to determine if future endeavors at defining bladder outlet obstruction in women can group these entities together. Methods Retrospective review of all videourodynamic studies was performed on women from March 2003 to July 2009. Women with diagnosis of obstruction were categorized based on the cause of obstruction into 2 groups: AO and FO. Demographic data, symptoms, and urodynamic findings were compared between the 2 groups. Results One hundred fifty-seven women were identified of which 86 (54.8%) were classified as having AO and 71 (45.2%) were classified as having FO. There were no differences in symptoms between the 2 groups. There was no difference (P=0.5789) in the mean detrusor pressure at maximum flow rate Qmax between AO (38.9 cm H20) and FO (41.0 cm H20). There was a difference in the Qmax between AO and FO (10.6 [0–41.7] and 7.4 [0–35.7] mL/s, respectively; P=0.0044), but there was considerable overlap between the values in these 2 groups. Conclusions Anatomical bladder outlet obstruction and FO have similar urodynamic voiding pressure findings, but Qmax was statistically significantly lower in AO. However, there is a large overlap in the Qmax values between the 2 groups. Therefore, future studies that attempt to characterize bladder outlet obstruction in women need not exclude either group.

A case of synchronous bilateral testicular seminoma

Background A previously healthy 51-year-old man with two children sustained a minor testicular trauma and subsequently sought medical care for persistent discomfort.Investigations Physical examination, scrotal ultrasonography, Doppler ultrasound evaluation of testicular blood flow, scrotal MRI, measurement of serum tumor markers and testosterone levels, CT of the chest, abdomen and pelvis, intraoperative frozen section analysis and final pathologic analysis.Diagnosis Bilateral testicular seminoma (clinical stage I).Management The patient initially underwent radical left orchiectomy with intraoperative frozen section analysis, which returned equivocal results. Final pathologic analysis revealed a 2.5 cm left testicular seminoma without vascular invasion. After careful discussion, he ultimately underwent radical right orchiectomy; pathologic analysis revealed a 2.7 cm right seminoma with vascular invasion. Testosterone replacement therapy was initiated. After further discussion, the patient elected to undergo adjuvant abdominal radiotherapy to a total of 25 Gy. The patient showed no evidence of disease over a post-treatment follow-up period of 24 months.

V2-06 FEMALE DORSAL ONLAY BUCCAL MUCOSA GRAFT URETHROPLASTY

tension-free, multilayer closure is feasible, the use of tissue interposition can achieve higher closure rates in larger fistulae or where the surrounding tissue is devitalized. Different materials have been described for fistula closure, including peritoneal tissue and gluteal muscle as well as artificial materials. METHODS: Our videopresentsa robot-assisted techniqueusing a peritoneal flap patch for reconstruction of the VVF. A daVinci SI-system with 4 arms and 6-port access was used. Preoperatively a Fogarthy catheter is placed through the fistula to mark the fistula channel , and the ureters are also stented. After initial adhesiolysis and preparation of the vesicovaginal space, the vagina is incised. Then, the fistula is identified and excised with the surrounding tissue both on the vaginal and bladder side. Following the closure of the vagina, a pedicle peritoneal flap is harvested and interposed between vagina and dorsal bladder wall. Finally, the bladder closure is performed with double-layer sutures. The analysis was performed retrospectively including operative parameters, perioperative complications and functional outcome for all patients. RESULTS: Median operative time (skin to skin) was 219 (181331) minutes without relevant blood loss. Median length of hospital stay was 8 (4-13) days. The indwelling catheter was removed after 10 days and a normal cystogram. Postoperatively all patients (n1⁄410) showed a recurrence-free total continence (0 pad/day). The highest postoperative complication was fever requiring antibiotic treatment (Clavien grade II). CONCLUSIONS: Robotic vesicovaginal repair of high vesicovaginal fistulae and peritoneal flap inlay is a safe minimal invasive approach with a high satisfaction rate and no recurrences in this pilot series to date.

1865 URINARY SYMPTOMS IN YOUNG WOMEN: COMPARING ORAL CONTRACEPTIVE PILL(OCP) USERS AND NON-USERS

Improvement in Stamey score of 1 grade was achieved in 75.4% (107/142) at 1 year, in 75.6% (68/90) at 2 years, in 84.9% (62/73) at 3 years and in 92.9% (39/42) at 4 years. Dry rate (PPWT 2 gms) was 51%, 62% and 74%, and 77% and 50% improved rate was 80%, 86%, 83% and 89% at 1, 2, 3 and 4 years, respectively. IQoL increased from 36.8 (SD 23.1) at baseline compared to 70.0 (SD 25.5), 71.7, 74.1 and 80.6 at 1, 2, 3 and 4 years. Optimal continence was achieved with a mean of 3 adjustments. Mean balloon volumes were 3.9 ml (1.0–11.5 ml). Device or procedure related complications (bladder perforation, port or balloon erosion, balloon migration, port or balloon related discomfort, intermittent urinary retention) were reported in 25% (39/ 156) of subjects at the end of 12 months, 19% (22/116) through year 2, 11.1% (10/90) through year 3 and 13.2% (3/22) through year 4. Of these, the majority were considered to be mild in severity. At 4 years 29 patients had undergone permanent explants of both devices, 43 were lost to follow up and 6 had died of unrelated causes. CONCLUSIONS: Four year data suggest ACT is a simple, safe and minimally invasive effective treatment for recurrent female SUI.

1015 TREATMENT OF POST-PROSTATECTOMY INCONTINENCE WITH MALE SLINGS IN MEN WITH IMPAIRED DETRUSOR CONTRACTILITY AND/OR VALSALVA VOIDING ON URODYNAMICS

INTRODUCTION AND OBJECTIVES: The use of male slings has emerged as a popular and efficacious treatment modality for men with post-prostatectomy incontinence (PPI). Traditionally, slings have been avoided in patients with impaired detrusor contractility because of concern that patients will not be able to overcome the fixed resistance of a sling during micturition. We propose that men with PPI who have impaired contractility and/or void with abdominal straining for urodynamics (UDS) can be safely treated with male slings. METHODS: A retrospective review of 123 consecutive patients with PPI who underwent a sling procedure between 1/04 and 1/10 was conducted at a single institution. Preoperative (preop) age, bladder capacity, post void residual (PVR), involuntary detrusor contractions (IDC), maximum flow rate (Qmax), detrusor pressure (Pdet), abdominal pressure (Pabd) and postoperative (postop) Patient Global Impression of Improvement (PGI-I), PVR and noninvasive uroflow were examined. Poor bladder contractility was defined as having bladder contractility index (BCI) 100. Valsalva voiding was defined as a change in Pabd at Qmax from baseline ( Pabd) 20. Exclusion criteria were lack of preop UDS and/or postop PVR or PGI-I. A total of 63 patients were analyzed. The variables were compared using Student’s t-test and chi-square test. RESULTS: No statistically significant difference was shown in postop PVR (mean 4 mos. postop) or urinary retention when comparing by BCI. Comparing by Pabd, a smaller PVR was seen with abdominal voiders, albeit likely clinically insignificant. Table 1 illustrates the preand postop outcomes compared by both BCI and Pabd. 31 patients (BCI 100, n 17 vs BCI 100, n 14) had postop uroflow available and there was no difference in postop Qmax (10.2 vs 13.1, p 0.22) or flow pattern. No patients excluded for incomplete data were treated for obstructive voiding or poor emptying. CONCLUSIONS: The results of this study indicate that men that may not have been traditionally offered a sling based on preop UDS findings can be safely treated with perineal sling. This may be a reflection of how contractility is measured in this population. Prospective studies comparing outcomes of men with impaired contractility that undergo various treatments may also be helpful. TABLE 1: Preand Postoperative Urodynamics Characterics of Male Sling Patients

THE IMPACT OF OBESITY ON BIOCHEMICAL FAILURE AFTER RADICAL PROSTATECTOMY IN AFRICAN-AMERICAN AND EUROPEAN AMERICAN PATIENTS

428 THE IMPACT OF OBESITY ON BIOCHEMICAL FAILURE AFTER RADICAL PROSTATECTOMY IN AFRICAN-AMERICAN AND EUROPEAN AMERICAN PATIENTS Benjamin M Brucker*, Meredith Bergey, Matthew J Resnick, Seema Sonnad, Daniel Canter, Thomas J Guzzo, Timothy R Rebbeck, Alan J Wein, S Bruce Malkowicz. Philadelphia, PA, and Baltimore, MD. INTRODUCTION AND OBJECTIVE: The relationship between body mass index (BMI) and prostate cancer deserves investigation as the obesity epidemic is nearing a health care crisis. Racial differences have been implicated in explaining poorer prostate cancer outcomes among African-Americans. We evaluated the role of race and obesity on PSA-free survival in a cohort of men larger than we had previously reported. This was drawn from a radical prostatectomy database from 1991 to 2005. METHODS: There were a total of 2,163 patients from a prospectively maintained database of radical prostatectomy patients were evaluated for the impact of obesity on pathologic and clinical