Ryan K. Berglund

Emergence of fluoroquinolone-resistant Escherichia coli as cause of postprostate biopsy infection: implications for prophylaxis and treatment.

OBJECTIVES To report the sensitivity and resistance of Escherichia coli in patients with infectious complications after prostate biopsy in a North American cohort. Increasing antibiotic-resistant E. coli has been observed worldwide. METHODS Data were available for 1446 patients who had undergone transrectal ultrasound-guided prostate biopsy from 2001 to 2010. Of the 1446 patients, 932 were administered 500 mg of ciprofloxacin 1 hour before prostate biopsy and 514 were administered a 3-day course of ciprofloxacin starting 1 day before biopsy plus an enema the night before. The sensitivity and resistance of E. coli were attained through the analysis of the blood and urine cultures of patients with suspected infection. RESULTS Of the 1446 patients, 40 (2.77%) developed an infection after biopsy. Of these 40 patients, 31 (2.14%) had a febrile urinary tract infection and 9 (0.62%) were diagnosed with sepsis requiring hospitalization. Of the 40 patients, 20 (50%) had urine cultures positive for E. coli. Of these 20 patients, 11 (55%) had fluoroquinolone-resistant infection and 9 had fluoroquinolone-sensitive E. coli. Of the remaining 20 patients, culture was not obtained for 9, and 5 had negative urine culture findings. Of the 7 patients (78%) with sepsis had blood cultures positive for E. Coli; 4 (57.1%) of which were fluoroquinolone-resistant and 3 were fluoroquinolone-sensitive. CONCLUSIONS In the present study, a significant risk of fluoroquinolone-resistant E. coli was observed in patients with both febrile urinary tract infection and sepsis after prostate biopsy. Alternative prophylactic antibiotics should be researched further, and postbiopsy infections developing after standard quinolone prophylaxis should be treated with cephalosporins until culture findings are available to guide therapy.

A nomogram for predicting upgrading in patients with low‐ and intermediate‐grade prostate cancer in the era of extended prostate sampling

Study Type – Diagnostic (exploratory cohort)
Level of Evidence 2b

A prospective comparison of transperitoneal and retroperitoneal laparoscopic nephrectomy in the extremely obese patient

Associate Editor

Porcine small intestinal submucosa as a percutaneous mid‐urethral sling: 2‐year results

To report the 2‐year follow‐up results on patients treated with a novel minimally invasive outpatient procedure for placing a mid‐urethral sling, using porcine small intestinal submucosa (SIS).

A practical guide to prostate cancer diagnosis and management.

Screening, diagnosis, and management of prostate cancer can be complicated, with no clear consensus about key issues. We present our approach, which reflects the guidelines of the American Urological Association (AUA). Screening, diagnosis, and management of prostate cancer can be complicated, with no clear consensus about key issues. Our approach refl ects the guidelines from the American Urological Association.

Ten-year follow-up of neoadjuvant therapy with goserelin acetate and flutamide before radical prostatectomy for clinical T3 and T4 prostate cancer: Update on southwest oncology group study 9109

OBJECTIVE To update the results with 10-year data of a phase II prospective trial of neoadjuvant hormonal therapy with goserelin acetate and flutamide followed by radical prostatectomy for locally advanced prostate cancer (SWOG 9109). The optimal management for clinical stage T3 and T4 N0,M0 prostate cancer is uncertain. MATERIALS AND METHODS Sixty-two patients with clinical stage T3 and T4 N0,M0 prostate cancer were enrolled. Cases were classified by stage T3 vs T4 and by volume of disease (bulky >4 cm and nonbulky ≤ 4 cm). RESULTS Fifty-five of 61 eligible patients completed the trial with radical prostatectomy after neoadjuvant androgen deprivation therapy (ADT). The median preoperative prostate-specific antigen value was 19.8 ng/mL, and 67% of patients had a Gleason score of ≥ 7. Among 41 patients last known to be alive, median follow-up is 10.6 years (range 5.1-12.6). In all, 38 patients have had disease progression (30/55, 55%) or died without progression (8/55, 15%) for a 10-year progression-free survival (PFS) estimate of 40% (95% CI 27-53). Median PFS was 7.5 years, and median survival has not been reached. The 10-year overall survival (OS) estimate is 68% (95% CI 56-80). CONCLUSIONS In this small, prospective phase II study, neoadjuvant hormonal therapy with goserelin acetate and flutamide followed by radical prostatectomy achieves long-term PFS and OS comparable with alternative treatments. This approach is feasible and may be an alternative to a strategy of combined radiation and ADT.

Avoiding androgen deprivation therapy in men with high-risk prostate cancer: the role of radical prostatectomy as initial treatment.

OBJECTIVE To examine the ability of surgery as initial management in avoiding androgen deprivation therapy (ADT) in patients with high-risk localized prostate cancer. MATERIALS AND METHODS A total of 267 men were identified from a cohort of patients treated by radical prostatectomy (RP) between January 1998 and June 2004. Patients were included if they presented with clinical stage ≥T2b and/or prostate-specific antigen (PSA) ≥15 ng/mL, and/or Gleason score ≥8. Information on biochemical recurrence, distant metastasis, cancer-specific survival, and use of ADT was obtained from a prospectively maintained database. RESULTS The median follow-up was 6.7 years (range, 1-146 months). Biochemical recurrence (BCR), distant metastasis (DM), and prostate cancer-specific mortality (PCSM) were observed in 112 (42%), 28 (10%), and 15 (6%) patients, respectively. Salvage treatment was performed in 95 (85%) of 112 patients with BCR. Only 71 (27%) of 267 men were subjected to ADT. Overall, 8-year probabilities of freedom from BCR, DM, PCSM, and ADT were 46% (95% CI, 38-54), 87% (95% CI, 84-90), 93% (95% CI, 91-95), and 71% (95% CI, 65-77), respectively. CONCLUSIONS RP provides excellent long-term clinical outcomes for patients with high-risk localized prostate cancer and avoids the use of ADT in approximately 70% of these patients.

Laparoscopic radical cystoprostatectomy with bilateral nephroureterectomy: initial report

To present our experience with laparoscopic radical cystoprostatectomy and bilateral nephroureterectomy for organ‐confined, muscle‐invasive transitional cell carcinoma (TCC) of the bladder in two patients with dialysis‐dependent end‐stage renal disease (ESRD).

Intermediate-Term Outcomes for Men with Very Low/Low and Intermediate/High Risk Prostate Cancer Managed by Active Surveillance

Purpose: We compare intermediate term clinical outcomes among men with favorable risk and intermediate/high risk prostate cancer managed by active surveillance. Materials and Methods: A total of 635 men with localized prostate cancer have been on active surveillance since 2002 at a high volume academic hospital in the United States. Median followup is 50.5 months (IQR 31.1–80.3). Time to event analysis was performed for our clinical end points. Results: Of the cohort 117 men (18.4%) had intermediate/high risk disease. Overall 5 and 10‐year all cause survival was 98% and 94%, respectively. Cumulative metastasis‐free survival at 5 and 10 years was 99% and 98%, respectively. To date no cancer specific deaths had been observed. Overall freedom from intervention was 61% and 49% at 5 and 10 years, respectively. Overall cumulative freedom from failure of active surveillance, defined as metastasis or biochemical failure after local therapy with curative intent, was 97% and 91% at 5 and 10 years, respectively. Of the men 21 (9.9%) experienced biochemical failure after deferred treatment and the 5‐year progression‐free probability was 92%. Compared to men with favorable risk disease those with intermediate/high risk cancer experienced no difference in metastases, surveillance failure or curative intervention. However, patients at higher risk were at significantly increased risk for all cause mortality, likely reflecting patient selection factors. These conclusions may be limited by the small number of events and the duration of our study. Conclusions: Patients with localized prostate cancer who are on active surveillance demonstrated a low rate of active surveillance failure, prostate cancer specific mortality and metastases regardless of baseline risk.

PATHOLOGIC UPGRADING AND UPSTAGING WITH IMMEDIATE REPEAT BIOPSY FOR PATIENTS ELIGIBLE FOR ACTIVE SURVEILLANCE

Purpose AS is a treatment regimen used in patients with low-risk prostate cancer. Decision making is based on pre-treatment PSA, clinical stage, and prostate biopsy results. We review our experience with immediate repeat biopsy in patients eligible for AS.