Michael Maddox

Contemporary analysis of erectile, voiding, and oncologic outcomes following primary targeted cryoablation of the prostate for clinically localized prostate cancer.

PURPOSE To evaluate erectile function (EF) and voiding function following primary targeted cryoablation of the prostate (TCAP) for clinically localized prostate cancer (CaP) in a contemporary cohort. MATERIALS AND METHODS We retrospectively reviewed all patients treated between 2/2000-5/2006 with primary TCAP. Variables included age, Gleason sum, pre-TCAP prostate specific antigen (PSA), prostate volume, clinical stage, pre-TCAP hormonal ablation, pre-TCAP EF and American Urologic Association Symptom Score (AUASS). EF was recorded as follows: 1 = potent; 2 = sufficient for intercourse; 3 = partial/insufficient; 4 = minimal/insufficient; 5 = none. Voiding function was analyzed by comparing pre/post-TCAP AUASS. Statistical analysis utilized SAS software with p < 0.05 considered significant. RESULTS After exclusions, 78 consecutive patients were analyzed with a mean age of 69.2 years and follow-up 39.8 months. Thirty-five (44.9%) men reported pre-TCAP EF level of 1-2. Post-TCAP, 9 of 35 (25.7%) regained EF of level 1-2 while 1 (2.9%) achieved level 3 EF. Median pre-TCAP AUASS was 8.75 versus 7.50 postoperatively (p = 0.39). Six patients (7.7%) experienced post-TCAP urinary incontinence. Lower pre-TCAP PSA (p = 0.008) and higher Gleason sum (p = 0.002) were associated with higher post-TCAP AUASS while prostate volume demonstrated a trend (p = 0.07). Post-TCAP EF and stable AUASS were not associated with increased disease-recurrence (p = 0.24 and p = 0.67, respectively). CONCLUSIONS Stable voiding function was observed post-TCAP, with an overall incontinence rate of 7.7%. Further, though erectile dysfunction is common following TCAP, 25.7% of previously potent patients demonstrated erections suitable for intercourse. While long-term data is requisite, consideration should be made for prospective evaluation of penile rehabilitation following primary TCAP.

V2-08 RECTOVESICAL FISTULA: ROBOT ASSISTED LAPAROSCOPIC MANAGEMENT

INTRODUCTION AND OBJECTIVES: Management of postoperative rectovesical fistulas following prostatectomy can be a challenge for the practicing surgeon. There have been numerous approaches suggested in the past, but all have high morbidity, extended convalescence, and recurrence can be common. Here we present a 68 year old male who had undergone a laparoscopic prostatectomy. He then developed a rectovesical fistula and large diverticulum, most likely from a posterior disruption of his anastomosis. He underwent several failed attempts at repair including a colonic diversion prior to being displaced by Hurricane Katrina and lost to follow up. He presented 9 years later for definitive treatment. Our objective is to demonstrate a novel and interesting use of robotic and minimally invasive techniques to minimize morbidity and decrease the risk of recurrence. METHODS: After placement of ureteral catheters and a guidewire through the patients fistula; a robot assisted laparoscopic transvescial excision of the patient’s rectovesical fistula and bladder diverticulectomy was performed. This was done similarly to how one would perform a robot assisted laparoscopic simple prostatectomy providing excellent visualization of the diverticulum and fistula. Once excised, the fistula was closed in multiple layers. The mucosal lining of the diverticulum was then excised and the detrusor muscle was closed. The mucosa and detrusor were then closed; re-approximating the bladder neck into a normal anatomical position. RESULTS: This patient has had no recurrence of his fistula, is continent, and scheduled for colostomy reversal. CONCLUSIONS: With a creative mind, minimally invasive techniques can be utilized to treat these devastating complications successfully.

Nomogram to predict prostate cancer diagnosis on primary transrectal ultrasound-guided prostate biopsy in a contemporary series

Objective: Transrectal ultrasound-guided biopsy (TRUSB) remains the mainstay for prostate cancer (CaP) diagnosis. Numerous variables have shown associations with development of CaP. We present a nomogram that predicts the probability of detecting CaP on TRUSB. Methods: After obtaining institutional review board approval, all patients undergoing primary TRUSB for CaP detection at a single center at our institution between 2/2000 and 9/2007 were reviewed. Patients undergoing repeat biopsies were excluded, and only the first biopsy was included in the analysis. Variables included age at biopsy, race, clinical stage, prostate specific antigen (PSA), number of cores removed, TRUS prostate volume (TRUSPV), body mass index, family history of CaP, and pathology results. S-PLUS 2000 statistical software was utilized with p < 0.05 considered significant. Cox proportional hazards regression models with restricted cubic splines were utilized to construct the nomogram. Validation utilized bootstrapping, and the concordance index was calculated based on these predictions. Results: A total of 1,542 consecutive patients underwent primary TRUSB with a median age of 64.2 years (range 34.9–89.2 years), PSA of 5.7 ng/ml (range 0.3–3,900 ng/ml), number of cores removed of 8.0 (range 1– 22) and TRUSPV of 36.4 cm3 (range 9.6–212.0 cm3). CaP was diagnosed in 561 (36.4%) patients. A nomogram was constructed incorporating age at biopsy, race, PSA, body mass index, clinical stage, TRUSPV, number of cores removed, and family history of CaP. The concordance index when validated internally was 0.802. Conclusions: We have developed and internally validated a model predicting cancer detection in men undergoing TRUSB in a contemporary series. This model may assist clinicians in risk-stratifying potential candidates for TRUSB, potentially avoiding unnecessary or low-probability TRUSB.