William Berg

Delay from biopsy to radical prostatectomy influences the rate of adverse pathologic outcomes.

We sought to determine maximum wait times between biopsy diagnosis and surgery for localized prostate cancer, beyond which the rate of adverse pathologic outcomes is increased.

'Trifecta' after radical prostatectomy: Is there a standard definition?

To determine the extent of variability in the definitions of the ‘trifecta’ after radical prostatectomy (undetectable PSA, urinary continence and potency) to be found in the literature. To establish a consensus definition of the trifecta in an effort to standardize criteria and reporting.

A Pilot Study of Laparoscopic Doppler Ultrasound Probe to Map Arterial Vascular Flow within the Neurovascular Bundle during Robot-Assisted Radical Prostatectomy

Purpose. To report on the feasibility of a new Laparoscopic Doppler ultrasound (LDU) technology to aid in identifying and preserving arterial blood flow within the neurovascular bundle (NVB) during robotic prostatectomy (RARP). Materials and Methods. Nine patients with normal preoperative potency and scheduled for a bilateral nerve-sparing procedure were prospectively enrolled. LDU was used to measure arterial flow at 6 anatomic locations alongside the prostate, and signal intensity was evaluated by 4 independent reviewers. Measurements were made before and after NVB dissection. Modifications in nerve-sparing procedure due to LDU use were recorded. Postoperative erectile function was assessed. Fleiss Kappa statistic was used to evaluate inter-rater agreement for each of the 12 measurements. Results. Analysis of Doppler signal intensity showed maintenance of flow in 80% of points assessed, a decrease in 16%, and an increase in 4%. Plane of NVB dissection was altered in 5 patients (56%) on the left and in 4 patients (44%) on the right. There was good inter-rater reliability for the 4 reviewers. Use of the probe did not significantly increase operative time or result in any complications. Seven (78%) patients had recovery of erections at time of the 8-month follow-up visit. Conclusions. LDU is a safe, easy to use, and effective method to identify local vasculature and anatomic landmarks during RARP, and can potentially be used to achieve greater nerve preservation.

Prostate cancer disease characteristics for foreign-born South Asian men living in the United States

INTRODUCTION We report the largest known cohort of South Asian (SA) men treated by radical prostatectomy living in the United States. Our objective was to characterize this sub-population and compare them to our wider cohort of prostate cancer patients treated with radical prostatectomy in the United States. MATERIALS AND METHODS All patients who underwent radical prostatectomy at two high-volume United States academic institutions at separate geographic locations between 1990 and 2011 were identified. Demographic data, pre-operative Prostate Specific Antigen (PSA), biopsy Gleason score, pathology Gleason score, pathology Stage, margin status, and node status were collected. In addition to SA men, African American (AA) men were identified and used for comparative analysis as a high-risk cohort. RESULTS A total of 69 SA men were identified in Cohort 1 and 24 men were identified in Cohort 2. When comparing SA men against the entire cohort, no significant difference was found for age, year of surgery, biopsy Gleason score, or path Gleason score for either cohort. However, significant differences were found in pre-operative PSA (P = 0.01), pathologic stage (P<0.01), and positive node status (P = 0.04) for SA men in Cohort 1. Whereas in Cohort 2, SA men had a significantly higher proportion of positive surgical margins (P = 0.04). In all significant comparisons, characteristics were worse in SA men and similar to that of AA men. CONCLUSIONS SA men have worse pathologic disease profiles when compared to the general population of men undergoing radical prostatectomy. SA men living in the United States have pathologic disease profiles that are comparable to AA men.

Baseline Serum 25-Hydroxyvitamin D Levels in Men Undergoing Radical Prostatectomy: Is There An Association With Adverse Pathologic Features?

INTRODUCTION/BACKGROUND The purpose of this study was to evaluate the prevalence of vitamin D (VitD) deficiency in men undergoing radical prostatectomy and determine whether an association exists between preoperative VitD levels and adverse pathologic features. PATIENTS AND METHODS Patients scheduled to undergo radical prostatectomy for clinically localized disease from January to August 2012 were prospectively followed and those with available preoperative serum 25-hydroxyvitamin D levels were included. Men with a known diagnosis of VitD deficiency or taking VitD supplementation were excluded. Cox regression analysis was performed to determine whether preoperative VitD level is predictive of adverse pathologic outcomes. RESULTS One hundred consecutive men were included. Mean age was 62 (range, 42-79) years and mean VitD level was 26 (range, 6-57) ng/mL. Overall, 65 men (65%) had suboptimal levels of VitD (< 30 ng/mL), and 32 (32%) had deficiency (< 20 ng/mL). There was no significant correlation between VitD and age (P = .5). In logistic regression analysis, VitD level was not predictive of pathologic Gleason (P = .11), pathologic stage (P = .7), or positive margin status (P = .8). CONCLUSION The association between VitD and prostate cancer has been controversial and data suggesting an increased risk of aggressive cancer in men with low levels of VitD have been inconsistent. We found that baseline preoperative VitD level was not associated with any adverse pathologic features. However, VitD deficiency is a common finding in this population, although unrelated to patient age. These results represent the first time the correlation between VitD and prostate cancer has been evaluated in a cohort of men undergoing radical prostatectomy.

Preliminary Evaluation of the endogo® HD Portable Cystoscopic Camera

Introduction: During office cystoscopy and hospital consultations urologists may only have direct visualization cystoscopy available. Field of view and usability are often characterized as suboptimal compared to video tower based camera models. The endogo® HD, a portable, battery powered cystoscopic camera that attaches to a standard cystoscope, was created to more closely mimic the usability of the normal cystoscopic camera that connects to the video tower. We objectively evaluated the usefulness of this new device. Methods: A total of 30 urology fellows, residents and students were consented and randomized to perform standard video tower cystoscopy, direct cystoscopy without a camera and cystoscopy with the endogo HD on a previously used Uro‐Scopic Trainer bladder model (Limbs & Things USA, Savannah, Georgia). Participants were timed and evaluated using the previously validated OSATS (Objective Structured Assessment of Technical Skills). Each participant then rated the usability of and preferences for each of the 3 systems. All participants completed the 3 types of cystoscopy. Results: Users found the field of view to be significantly better for the endogo HD than for direct cystoscopy (p = 0.03) and similar for the endogo HD and the tower (p = 0.7). Time needed to perform cystoscopy was significantly longer for endogo HD than for tower and direct cystoscopy (71.9 vs 43.3 and 46.8 seconds, respectively, p = 0.01). When comparing novices to experts (greater than 200 cases), experts completed all procedures more quickly regardless of camera type. Tower cystoscopy was significantly less difficult and more comfortable, and it was preferred by most participants. Conclusions: On objective and subjective measures the endogo HD portable cystoscopic camera received marks similar to those of other types of cystoscopy that are currently widely available. It required an average of a half minute longer to set up and overall participants preferred standard video tower cystoscopy. The endogo HD may be useful in the emergency department or office setting where no video tower is available. Further study of its usefulness as a teaching tool and the learning curve associated with its use will be performed in the future.

Findings of routine apical margin biopsy during robot-assisted radical prostatectomy.

INTRODUCTION Intraoperative biopsy of the apical margin during radical prostatectomy has been recommended as a way to reduce the positive margin rate at this location. However, the enhanced visibility of the apex during robot-assisted radical prostatectomy (RARP) may obviate this need, allowing for the preservation of maximal urethral length. We assessed pathologic findings of routine apical margin biopsy intraoperative frozen section (IFS) during RARP. PATIENTS AND METHODS The Columbia University Robotic Database was retrospectively reviewed to identify men who underwent RARP with biopsy of the apical soft tissue (urethroprostatic junction). Both IFS and permanent section samples were analyzed. The clinical characteristics associated with IFS and permanent section histological findings were assessed. RESULTS In total, 335 men underwent RARP with apical biopsy from December 2007 to August 2011. Of these, 329 had IFS available for analysis. Median age and prostate-specific antigen level were 60 years (range, 42-78 years) and 5.2 ng/mL (interquartile range, 4.1-6.9 ng/mL), respectively. Of the 329 apical IFS cases, cancer was detected in 9 patients (2.7%), benign prostatic glands in 135 (41%), and nonprostatic tissue in 185 (56.3%). On permanent section, cancer was seen in 9 patients (2.7%), benign prostatic glands in 125 (38%), and nonprostatic tissue in 195 (59.3%). False-positive and false-negative rates of detecting cancer on IFS were 33% (3/9) and 1% (3/320), respectively. The overall positive surgical margin rate was 11%. CONCLUSIONS Cancer is rarely detected by IFS analysis of routine biopsy of the apical margin during RARP. Although routine IFS may not be beneficial for all patients, selective utilization of IFS may be useful in directing apical dissection in men with apical tumors, allowing for the preservation of maximal urethral length.