Jeffrey T. Schiff

Radical nephrectomy with vena caval thrombectomy: a contemporary experience

Study Type – Therapy (case series) 
Level of Evidence 4

Time Course of Recovery of Erectile Function After Radical Retropubic Prostatectomy: Does Anyone Recover After 2 Years?

INTRODUCTION Given the paucity of literature on the time course of recovery of erectile function (EF) after radical prostatectomy (RP), many publications have led patients and clinicians to believe that erections are unlikely to recover beyond 2 years after RP. AIMS We sought to determine the time course of recovery of EF beyond 2 years after bilateral nerve sparing (BNS) RP and to determine factors predictive of continued improved recovery beyond 2 years. METHODS EF was assessed prospectively on a 5-point scale: (i) full erections; (ii) diminished erections routinely sufficient for intercourse; (iii) partial erections occasionally satisfactory for intercourse; (iv) partial erections unsatisfactory for intercourse; and (v) no erections. From 01/1999 to 01/2007, 136 preoperatively potent (levels 1-2) men who underwent BNS RP without prior treatment and who had not recovered consistently functional erections (levels 1-2) at 24 months had further follow-up regarding EF. Median follow-up after the 2-year visit was 36.0 months. MAIN OUTCOME MEASURES Recovery of improved erections at a later date: recovery of EF level 1-2 in those with level 3 EF at 2 years and recovery of EF level 1-3 in those with level 4-5 EF at 2 years. RESULTS The actuarial rates of further improved recovery of EF to level 1-2 in those with level 3 EF at 2 years and to level 1-3 in those with level 4-5 EF at 2 years were 8%, 20%, and 23% at 3, 4, and 5 years postoperatively, and 5%, 17%, and 21% at 3, 4, and 5 years postoperatively, respectively. Younger age was predictive of greater likelihood of recovery beyond 2 years. CONCLUSION There is continued improvement in EF beyond 2 years after BNS RP. Discussion of this prolonged time course of recovery may allow patients to have a more realistic expectation.

PD36-09 INSTITUTIONAL VOLUME IS ASSOCIATED WITH REDUCED 90 DAY MORTALITY RATES FOR BOTH OPEN AND ROBOTIC RADICAL CYSTECTOMY

The association between PBT and oncological outcomes, as well as OCM was assessed using Cox and logistic regression analyses. Imbalances in clinicopathological features of patients receiving PBT vs. patients not receiving PBT were mitigated using conventional adjusting as well as inverse probability of treatment weighting (IPTW). RESULTS: The final population consisted of 525 patients with a median follow-up of 26 months (IQR: 21-30 months) of whom 275 patients (52.4%) received PBT. The two groups (PBT vs. no PBT) differed significantly with respect to most clinicopathological features including perioperative blood loss (median: 1000ml; IQR: 650-1600ml vs. median: 570ml; IQR: 400-800ml). Independent predictors of receipt of PBT in multivariate logistic regression analysis were sex (odds ratio (OR)1⁄44.66; 95% confidence interval (CI)1⁄4[2.34-9.29]; p<0.001), body mass index (OR1⁄40.92; 95% CI1⁄4[0.87-0.97]; p1⁄40.003), type of urinary diversion (OR1⁄40.40; 95% CI1⁄4[0.22-0.75]; p1⁄40.004), estimated blood loss (OR1⁄41.29; 95% CI1⁄4 [1.21-1.39]; p<0.001), and any complication within 30 days (OR1⁄43.00; 95% CI1⁄4[1.75-5.15]; p<0.001). Unweighted and unadjusted survival analyses revealed a significant increase in cumulative incidences of CSM and OCM in the two groups (p1⁄40.017 and p<0.001, respectively). After IPTW-adjustment, those differences no longer held true. PBT was not associated with RFS (HR1⁄40.92; 95% CI1⁄4[0.53-1.59]; p1⁄40.76), OS (HR1⁄41.07; 95% CI1⁄4[0.56-2.04]; p1⁄40.84), CSM (sub-HR1⁄41.09; 95% CI1⁄4[0.62-1.93]; p1⁄40.76) and OCM (sub-HR1⁄41.02; 95% CI1⁄4[0.27-3.84]; p1⁄40.95) in IPTW-adjusted Cox regression and competing-risks regression analyses. The same held true in conventional multivariate Cox and competing-risks regression analyses, where pathological tumor stage and lymphovascular invasion were the only independent predictors of CSM (HR1⁄43.71, 95% CI1⁄4[2.06-6.68], p<0.001 and HR1⁄42.49, 95% CI1⁄4 [1.43-4.33], p<0.001) aswell as disease recurrence (HR1⁄44.48, 95%CI1⁄4 [2.45-8.16], p<0.001 and HR1⁄42.76, 95% CI1⁄4[1.56-4.87], p<0.001). CONCLUSIONS: This study could not determine an adverse impact of PBT on oncological outcome and overall survival after adjusting for differences in patient characteristics.

MP70-04 3-T MULTIPARAMETRIC MRI CHARACTERISTICS OF PROSTATE CANCER PATIENTS SUSPICIOUS FOR BIOCHEMICAL RECURRENCE AFTER PRIMARY FOCAL CRYOSURGERY.

Source of Funding: This research was made possible through the NIH Medical Research Scholars Program, a public-private partnership supported jointly by the NIH and generous contributions to the Foundation for the NIH by the Doris Duke Charitable Foundation (Grant #2014194), the American Association for Dental Research, the Colgate-Palmolive Company, Genentech, and other private donors. For a complete list, visit the foundation website at http://www.fnih. org.

PD56-09 PSA TRENDS FOLLOWING PRIMARY FOCAL CRYOSURGERY FOR EARLY STAGE PROSTATE CANCER

METHODS: Participants were eligible when diagnosed with intermediate risk, unilateral clinically significant localised prostate cancer, fit for either RP or PA. Pre-biopsy mpMRI and targeted biopsy or template guided biopsies were compulsory before randomization to either RP or PA. Target accrual for the feasibility phase was 80 patients over 18 months. Follow-up involved regular PSA measurements and, in the focal therapy arm, mpMRI and targeted biopsies of any suspicious areas. Quality of life data were measured at six weeks and three monthly intervals. RESULTS: The table below summarises recruitment data. Baseline demographics of men randomised to date are Mean age: 66.7yrs (48.4-78.2); BMI: 26.4 (22.0-32.3); PSA: 7.60 (2.5-16.20) and Gleason score: 3+41⁄47 75.6%, 4+31⁄47 24.4%. CONCLUSIONS: A randomised controlled trial of partial ablation of the prostate versus radical treatment with surgery is feasible. The full trial is being developed, and will provide key data to inform men when making the treatment decision for intermediate risk unilateral prostate cancer.

MP70-09 PREDICTORS OF BIOCHEMICAL RECURRENCE AFTER PRIMARY FOCAL CRYOTHERAPY FOR LOCALIZED PROSTATE CANCER: A MULTI-INSTITUTIONAL ANALYTIC COMPARISON OF THE PHOENIX AND STUTTGART CRITERIA

INTRODUCTION AND OBJECTIVES: The Phoenix (PD) and Stuttgart definitions (SD) are used to define biochemical recurrence (BCR) in patients after radiotherapy and High Intensity Focused Ultrasound treatment of organ-confined prostate cancer (PCa) respectively. However, these definitions have also been applied to follow patients who have undergone cryosurgery. We sought to identify predictors of BCR using the PD and SD criteria and evaluate each criterion0s ability to predict biopsy-proven recurrence in primary focal cryosurgery (PFC) patients. METHODS: We performed a retrospective review of patients who underwent PFC at two tertiary care centers. Patients were followed with serial prostate specific antigen (PSA) tests. PSA levels, preand post-PFC biopsy Gleason scores, number of positive cores, and BCR (defined as: PD 1⁄4 [PSA nadir + 2 ng/mL] and SD 1⁄4 [PSA nadir + 1.2 ng/ mL]) were recorded. Patients who experienced BCR were biopsied, monitored carefully or treated at the discretion of the treating urologist. Cox proportional regression and survival analyses were performed to assess time to BCR using the PD and SD criteria. RESULTS: Of 162 patients included [median (range) follow up: 36.6 (2.8-109.4) months] in the study, 64 (39.5%) and 98 (60.5%) experienced BCR based on PD and SD, respectively. On multivariate Cox regression analysis, the number of positive pre-PFC biopsy cores was an independent predictor of both PD (Hazard Ratio [HR]: 1.4, p1⁄40.001) and SD (HR: 1.3, p1⁄40.006) BCRs. Post-PFC PSA nadir was an independent predictor of BCR using the PD (HR: 2.2, p1⁄40.024) but not SD (HR: 1.4, p1⁄40.181) BCR. Survival analysis showed a 3-year BCR free survival of 55% and 36% for PD and SD respectively. Of those biopsied after BCR, 14/26 (53.8%) using the PD and 18/35 (51.4%) using the SD were found to have cancer (57.1% PD and 66.7% SD were clinically significant PCa). CONCLUSIONS: Both the PD and the SD showed about a 50% biopsy-proven rate of recurrence after PFC. The number of positive cores on pretreatment biopsy appears to be a significant predictor of failure after PFC. The ideal definition of BCR after PFC remains to be elucidated.

PD67-05 FACILITY VOLUME AND TYPE IS ASSOCIATED WITH RECEIPT OF CONTINENT DIVERSION FOR BOTH OPEN AND ROBOTIC RADICAL CYSTECTOMY

INTRODUCTION AND OBJECTIVES: Continent urinary diversion (CUD) can offer improved quality of life in select patients follow in radical cystectomy (RC). We aim to evaluate the rate of receipt of CUD in robotic assisted RC (RARC) and open RC (ORC) based on hospital volume and facility type in the National Cancer Data Base. METHODS: We divided all cystectomy cases into volume categories (defined as: 1-2.9, 3-4.9, 5-9.9, 10-19.9 and 20+ cystectomies/ year) and facility type (academic/research (AR), comprehensive community (CC) and other), type of surgery (ORC or RARC) to assess the patterns in the rate of receipt of CUD. To assess the relationship between facility characteristics and receipt of CUD, chi-square was used. Univariate and multivariable logistic regression models for CUD rates were used to adjust for patient, tumor and facility characteristics. RESULTS: 16,923 RC cases were identified (ORC 1⁄4 13,236, RARC1⁄43,687). Overall, 5.7% of ORC (754) and 7.1% of RARC (261) received CUD (p1⁄40.003). RARC had higher rates of receiving CUD compared to ORC in all volume categories except for the highest volume centers (10.2% vs 9.7%). Rates of receipt of CUD increased with increasing RC volume centers (p1⁄40.01); in the ORC group (2.8 vs. 10.2%), and in the RARC group by (5.7% vs. 9.7%; p for interaction1⁄40.10). In adjusted models, center volume remained a highly significant predictor of CUD receipt (p<0.001). Rates of receipt of CUD were higher in RARC vs. ORC in CC and other facility types, but were equal in AR facilities. The difference in the rate of CUD receipt between facility types was significant for ORC (p1⁄40.001) but not for RARC (p1⁄40.09). CUD receipt was observed to decrease linearly over time in both ORC (6.9% in 2010 vs. 4.7 in 2013; p1⁄40.001) and RARC (9.4% in 2010 vs. 6.0% in 2013; p1⁄40.06). CONCLUSIONS: Increasing facility cystectomy volume was associated with increased rates of receipt of CUD in both open and robotic cystectomy while facility type was only significant for open surgeries. The overall rate of receiving CUD was higher in RARC versus ORC surgeries but the overall rate of patients receiving continent diversions remains low and may be decreasing.

PD67-06 PATHOLOGIC METRICS OF SURGICAL QUALITY IN OPEN AND ROBOTIC RADICAL CYSTECTOMY IMPROVED AT HIGHER VOLUME AND ACADEMIC CENTERS

INTRODUCTION AND OBJECTIVES: Continent urinary diversion (CUD) can offer improved quality of life in select patients follow in radical cystectomy (RC). We aim to evaluate the rate of receipt of CUD in robotic assisted RC (RARC) and open RC (ORC) based on hospital volume and facility type in the National Cancer Data Base. METHODS: We divided all cystectomy cases into volume categories (defined as: 1-2.9, 3-4.9, 5-9.9, 10-19.9 and 20+ cystectomies/ year) and facility type (academic/research (AR), comprehensive community (CC) and other), type of surgery (ORC or RARC) to assess the patterns in the rate of receipt of CUD. To assess the relationship between facility characteristics and receipt of CUD, chi-square was used. Univariate and multivariable logistic regression models for CUD rates were used to adjust for patient, tumor and facility characteristics. RESULTS: 16,923 RC cases were identified (ORC 1⁄4 13,236, RARC1⁄43,687). Overall, 5.7% of ORC (754) and 7.1% of RARC (261) received CUD (p1⁄40.003). RARC had higher rates of receiving CUD compared to ORC in all volume categories except for the highest volume centers (10.2% vs 9.7%). Rates of receipt of CUD increased with increasing RC volume centers (p1⁄40.01); in the ORC group (2.8 vs. 10.2%), and in the RARC group by (5.7% vs. 9.7%; p for interaction1⁄40.10). In adjusted models, center volume remained a highly significant predictor of CUD receipt (p<0.001). Rates of receipt of CUD were higher in RARC vs. ORC in CC and other facility types, but were equal in AR facilities. The difference in the rate of CUD receipt between facility types was significant for ORC (p1⁄40.001) but not for RARC (p1⁄40.09). CUD receipt was observed to decrease linearly over time in both ORC (6.9% in 2010 vs. 4.7 in 2013; p1⁄40.001) and RARC (9.4% in 2010 vs. 6.0% in 2013; p1⁄40.06). CONCLUSIONS: Increasing facility cystectomy volume was associated with increased rates of receipt of CUD in both open and robotic cystectomy while facility type was only significant for open surgeries. The overall rate of receiving CUD was higher in RARC versus ORC surgeries but the overall rate of patients receiving continent diversions remains low and may be decreasing.