Nicholas T. Karanikolas

Survival Rates After Resection for Localized Kidney Cancer: 1989 to 2004

Mortality rates from kidney cancer have continued to rise despite increases in the detection of smaller renal tumors and rates of renal surgery. To explore the factors associated with this treatment‐outcome discrepancy, the authors evaluated how changes in tumor size have affected disease progression in patients after nephrectomy for localized kidney cancer, and they sought to identify the factors associated with disease progression and overall patient survival after resection for localized kidney cancer.

Characterization and outcomes of small cell carcinoma of the bladder using the surveillance, epidemiology, and end results database.

Objective:To utilize the Surveillance, Epidemiology, and End Results Database to analyze clinical features, treatment, and survival outcomes of patients with small cell carcinoma of the bladder in a large population-based sample. Because of its rarity, prior reports are primarily limited to small single-institution studies. Methods:We identified patients of any age who were diagnosed with small cell carcinoma of the bladder between 1988 and 2007. Kaplan-Meier and Cox regression analysis were used to compare overall survival (OS) and urinary bladder-specific survival. Results:A total of 663 patients were identified. Most patients had either stage II (38.8%) or stage IV (35.4%) disease. The median OS for all patients was 12 months [95% confidence interval (CI), 10.9-13.1]. After excluding those patients who presented with distant metastatic disease or for whom it was unknown whether or not they received any treatment, there were no significant differences in survival between those that received cystectomy (median survival, 21 mo; 95% CI, 14.3-27.7) compared with those who underwent external beam radiation (median survival, 17 mo; 95% CI, 13.4-20.6). On multivariate analysis, both cystectomy (hazard ratio, 0.53; 95% CI, 0.4-0.71; P < 0.001) and radiation (hazard ratio, 0.66; 95% CI, 0.5-0.88; P=0.005) were associated with improved survival. Conclusions:Small cell carcinoma of the bladder is a rare but aggressive malignancy with poor OS. For those who present without widespread metastatic disease, treatment with either cystectomy or radiation appears to improve survival. Further prospective studies are needed to determine the best approach for treatment of these patients.

MP60-16 THE RELATIONSHIP OF BASELINE PROSTATE SPECIFIC ANTIGEN LEVELS AND RISK OF FUTURE PROSTATE BIOPSY POSITIVE FOR ADENOCARCINOMA AND ITS VARIANCE BY RACE

METHODS: We examined serum total PSA (tPSA) and %fPSA annually in a prostate cancer-screening cohort since July 2001. Men with tPSA > 4.0 ng/mL or tPSA ranging from 2.0 4.0 ng/mL with % fPSA 12% were screened as positive and were recommended to undergo biopsy. The study population consisted of 6,368 men aged 40 79 years who had tPSA 4.0 ng/mL at initial screening and who subsequently underwent one or more screenings. We calculated cumulative risk and hazard ratio of prostate cancer stratified by initial % fPSA groups as quartiles of prostate cancer patients. RESULTS: During a median follow-up of 36 months, 119 men were diagnosed with prostate cancer. The lowest quartile of %fPSA (<13.3%) was associated with a 21.2-fold higher risk of having prostate cancer when compared with the highest quartile (>22.2%). For the subset with initial tPSA 1.0 ng/mL, all men diagnosed with cancer had initial %fPSA 33.3% (median). For the subset with tPSA>1.0 ng/mL, men with %fPSA 23.0% (median) had significantly higher risk for cancer than those with %fPSA>23.0% (p<0.0001). Of the 114 subjects with prostate cancer in whom pathological findings were available, 79 (69.3%) had a Gleason score 3þ41⁄47. CONCLUSIONS: Low %fPSA is a strong predictor of subsequent diagnosis of prostate cancer among men with tPSA levels 4.0 ng/mL. Measurement of fPSA might enhance detection of high-grade cancer that warrants aggressive treatment.

Laparoscopic Radical Prostatectomy: Techniques and Complications

Laparoscopic radical prostatectomy (LRP) has gained increasing importance in the laparoscopic urologic oncology field and has become an established treatment for localized prostate cancer. The indications for laparoscopic radical prostatectomy are the same as those for the open technique. The advantages of the laparoscopic approach are a magnified view of the anatomic structures and a decreased venous bleeding in the surgical field allowing an accurate dissection of the prostate and neurovascular bundles. The LRP technique is well standardized. Five trocars are used; the patient is placed in the Trendelenburg position. The different steps of the operation are: dissection of the seminal vesicles, via a direct approach, after incising the peritoneum above Douglas’ cul-de-sac; creation of a space between the rectum and prostate behind Denonvilliers’ fascia; release of the bladder to approach the space of Retzius; opening of the endopelvic fascia and intracorporeal ligature of the dorsal vascular complex; dissection of the prostate from the bladder, by close dissection of the bladder neck; control of the pedicles and dissection of the neurovascular bundles; sectioning of the urethra and removal of the prostate in a bag, urethrovesical anastomosis performed with interrupted intracorporeal sutures, Foley catheter installation; placement of an aspiration drain; and closure. Knowledge of the prostatic anatomy, advanced laparoscopic skills, and expertise in surgical oncology are essential to provide optimal oncologic outcomes while maintaining the highest standards of life quality.

ANATOMY AND PRESERVATION OF ACCESSORY PUDENDAL ARTERIES IN LAPAROSCOPIC RADICAL PROSTATECTOMY

OBJECTIVE The incidence of laparoscopically diagnosed accessory pudendal arteries (APAs) varies depending on how proactive the surgeon is to find them. Their preservation depends on their calibre and location. Our objective was to provide a detailed description of how to identify, dissect, and preserve APAs during laparoscopic radical prostatectomy (LRP). METHODS Between January 2003 and January 2005, we treated 377 men with LRP; 325 met inclusion criteria for this study. We defined an APA as any artery located within the periprostatic region running parallel to the dorsal vascular complex and extending caudally towards the anterior perineum, other than cavernous arteries, corona mortis, and satellite arteries to the superficial and deep vascular complex. Two distinct varieties of APAs were identified: (1) lateral APAs course along the lateral aspect of the prostate and branch off any of the terminal branches of the hypogastric artery; and (2) apical APAs emerge through the levator ani fibres near the apical region of the prostate and most likely branch off the pudendal artery or corresponds to an aberrant course of the pudendal artery itself. We present a video depicting the laparoscopic anatomy of APAs and the technique to preserve them. RESULTS Ninety-six of 325 men (30%) were found to have 125 separate APAs. Using the depicted surgical technique, we were able to preserve 83% of all APAs. Forty-nine of 55 lateral APAs (89%) and 55 of 70 apical APAs (79%) were preserved. Thirty-five of 38 large-calibre APAs (92%) and 70 of 87 small-calibre APAs (80%) were spared. The side-specific incidence of PSMs were 3% and 6% when APAs were preserved and not preserved, respectively (p=0.5). CONCLUSIONS APAs are frequently identified during laparoscopic prostatectomy. Their preservation is feasible in LRP without increasing the risk of causing a PSM. It is reasonable to integrate APA preservation as part of the modern radical prostatectomy, although their role in functional outcomes still needs to be prospectively established.