Is body mass index associated with pathological outcomes after radical prostatectomy in Korean men?

Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? Today, controversies continue with regards to the potential impact of obesity or increased body mass index (BMI) on actual pathological features of prostate cancer and/or clinical outcome after radical prostatectomy (RP). Moreover, a paucity of relevant data exist in the literature regarding Asian or Korean men. For the first time to our knowledge, the study demonstrated that although higher BMI was significantly associated with extracapsular extension of tumour, BMI did not significantly enhance ability to preoperatively predict extracapsular extension of tumour and was not significantly associated with PSA outcome as well as other objective pathological outcomes in Korean men undergoing RP, who are generally leaner than Western counterparts.

OBJECTIVE

? To investigate the impact of increased body mass index (BMI) on pathological features after radical prostatectomy (RP) in Korean patients.

PATIENTS AND METHODS

? We reviewed the records of 1000 Korean patients who underwent RP for prostate cancer and assessed the differences in pathological outcomes and biochemical recurrence‐free survival after RP according to BMI of subjects via univariate and multivariate analyses. ? A multivariate logistics regression model, the performance of which was analysed from a receiver operator characteristics curve, was applied to assess the predictive capacity of variables shown to be significant predictors of adverse pathological outcome.

RESULTS

? Among our subjects, only 17 (1.7%) men had BMI ≥30 kg/m². After adjusting for various clinical variables, BMI (highest quartile vs others) was shown to be significantly associated with extracapsular extension of tumour (P= 0.014) and positive surgical margin (P= 0.019), but not with high pathological Gleason score (P= 0.912) and seminal vesicle invasion (P= 0.191). ? Meanwhile, the addition of BMI to a multivariate model devised for preoperatively predicting extracapsular extension of tumour did not significantly increase predictive accuracy of the model (P= 0.319). On multivariate analysis, BMI was not shown to be a significant predictor of biochemical recurrence‐free survival (P= 0.201).

CONCLUSION

? Although higher BMI was significantly associated with extracapsular extension of tumour, BMI did not significantly enhance the ability to preoperatively predict extracapsular extension of tumour and was not significantly associated with PSA outcome or with other objective pathological outcomes in Korean men undergoing RP, who are generally leaner than their western counterparts.     

Tumour length of the largest focus predicts prostate‐specific antigen‐based recurrence after radical prostatectomy in clinically localized prostate cancer

OBJECTIVE

To investigate the possible significance of tumour dimensional variables, including maximum tumour diameter (MTD), maximum tumour area (MTA) and total tumour volume (TTV), with standard prognostic factors for predicting prostate‐specific antigen (PSA) recurrence after radical prostatectomy (RP).

PATIENTS AND METHODS

Serial whole sections of the prostate from 164 patients who had RP for localized prostate cancer were investigated. Cox proportional hazards regression models were used for univariate and multivariate analyses to test the relationships between biochemical failure and clinicopathological factors, including tumour dimensional variables. The results were analysed retrospectively to develop a prognostic factor‐based model for risk stratification.

RESULTS

In the univariate Cox proportional hazard model, pathological T stage, Gleason score, perineural invasion, microvascular invasion, positive surgical margins, MTD, MTA and TTV were significantly associated with biochemical failure. In the multivariate Cox proportional hazard model using a stepwise inclusion of these factors, Gleason score, positive surgical margins and MTD were independent indices in association with biochemical failure. Using the three statistically significant variables, the relative risk of biochemical failure could be calculated.

CONCLUSION

These results imply that MTD is possibly one of the most important prognostic factors for predicting biochemical recurrence after RP. As calculating the MTD on the section a rapid, simple and objective method, it can be used instead of the TTV calculation. The prognostic factor‐ based risk stratification might help clinicians to predict biochemical failure after RP.     

The need for, and utilization of prostate-bed radiotherapy after radical prostatectomy for patients with prostate cancer in British Columbia

Introduction:

Three randomized trials have demonstrated that post-radical prostatectomy (RP) radiotherapy decreases biochemical relapse for those with adverse pathology. Our purpose was to describe the incidence of pathologic risk factors for recurrence in a contemporary series of patients treated with RP and to describe the use of post-RP radiotherapy.

Methods:

All incident prostate cancers diagnosed between January 2005 and December 2007 were identified from the tumour registry. Cases were then linked to radiotherapy records which included dose and modality (external beam radiotherapy and brachytherapy). The pathology reports in the tumour registry were reviewed for pathologic stage, grade and margin status.

Results:

We identified 9223 patients with prostate cancer. Overall, 36.3% of patients treated with RP had positive margins, and may have benefited from adjuvant radiotherapy. After RP, 332 (15%) patients had radiotherapy to the prostate bed; of these, only 25 (1.1%) received truly adjuvant radiotherapy (delivered within 6 months with a prostate-specific antigen of <0.2 ng/mL). Of the 2181 patients treated with RP, 270 (12%) were seen by a radiation oncologist within 6 months of RP. Of the 1015 patients (47%) with adverse RP pathology (positive margins, extracapsular extension or seminal vesicle invasion), 230 (23%) were seen by a radiation oncologist within 6 months of RP.

Conclusion:

Not all patients with adverse prostatectomy pathology were seen by a radiation oncologist post-prostatectomy, and very few received adjuvant radiotherapy despite almost half of them having risk factors for relapse. See related article on page 95.     

The impact of nerve sparing on incidence and location of positive surgical margins in radical prostatectomy

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Nerve sparing radical prostatectomy has been associated with increased risk of positive surgical margins due to the close anatomical relationship of the neurovascular bundle to the posterolateral aspect of the prostatic fascia. Our study of 945 men who underwent radical prostatectomy be one experienced surgeon found no increased risk of positive surgical margins, whether the cancer was organ confined or extracapsular extension was present.

OBJECTIVE

• ? To examine whether nerve‐sparing surgery (NSS) is a risk factor for positive surgical margins (PSMs) in patients with either organ‐confined prostate cancer or extracapsular extension (ECE).

PATIENTS AND METHODS

• ? Clinicopathological outcome data on 945 consecutive patients treated with radical prostatectomy (RP) were prospectively collected.
• ? All patients underwent RP (bilateral, unilateral or non‐NSS) by one surgeon between 2002 and 2007.
• ? Risk of PSMs and their locations with respect to NSS was determined by multivariate logistic regression analysis adjusting for preoperative risk factors for PSMs within pT2, pT3a and pT3b tumours.

RESULTS

• ? Overall a PSM was identified in 19.6% of patients in an unscreened population with mean prostate‐specific antigen (PSA) level of 8.1 ng/mL.
• ? There was no significant difference in rates of PSMs between NSS groups on multivariate analysis (P= 0.147).
• ? There was no significant difference in pT2 (P= 0.880), pT3a (P= 0.175) or pT3b (P= 0.354) tumours.
• ? The only significant predictor of PSMs was preoperative PSA level (risk ratio 1.289, P= 0.006).
• ? There was no significant difference in the location of PSMs except for the pT3a group, where the patients that had bilateral NSS were at higher risk of a posterolateral PSM (P= 0.028).

CONCLUSIONS

• ? With appropriate selection of patients, NSS does not increase the risk of PSMs, whether the cancer is organ confined or ECE is present.
• ? The adverse impact of the NSS procedure in the hands of an experienced surgeon is minimal and is a realistic compromise to obtain the increase in health‐related quality of life offered by NSS.

     

Robot‐assisted laparoscopic prostatectomy is not associated with early postoperative radiation therapy

OBJECTIVE

To compare open radical prostatectomy (RP) and robot‐assisted laparoscopic prostatectomy (RALP), and to determine whether RALP is associated with a higher risk of features that determine recommendations for postoperative radiation therapy (RT).

PATIENTS AND METHODS

Patients undergoing RP from 2003 to 2007 were stratified into two groups: open RP and RALP. Preoperative (PSA level, T stage and Gleason score), pathological factors (T stage, Gleason score, extracapsular extension [ECE] and the status of surgical margins and seminal vesicle invasion [SVI]) and early treatment with RT or referral for RT within 6 months were compared between the groups. Multivariate analysis was used to control for selection bias in the RALP group.

RESULTS

In all, 904 patients were identified; 368 underwent RALP and 536 underwent open RP (retropubic or perineal). Patients undergoing open RP had a higher pathological stage with ECE present in 24.8% vs 19.3% in RALP (P = 0.05) and SVI in 10.3% vs 3.8% (P < 0.001). In the RALP vs open RP group, there were positive surgical margins in 31.5% vs 31.9% (P = 0.9) and there were postoperative PSA levels of ³ 0.2 ng/mL in 5.7% vs 6.3% (P = 0.7), respectively. On multivariate analysis to control for selection bias, RALP was not associated with indication for RT (odds ratio (OR) 1.10, P = 0.55), or referral for RT (OR 1.04, P = 0.86).

CONCLUSION

RALP was not associated with an increase in either indication or referral for early postoperative RT.     

The outcome of patients with pathological Gleason score >or=8 prostate cancer after radical prostatectomy

OBJECTIVE

To analyse the outcome of patients undergoing radical prostatectomy (RP) for Gleason 8–10 clinically localized prostate cancer, and to evaluate the prognostic value of well‐known predictors of progression.

PATIENTS AND METHODS

In all, 1480 patients had RP between 1988 and 2006, of whom 180 had pathological Gleason score ≥8 and negative lymph nodes. Biochemical progression‐free survival was determined using the Kaplan‐Meier method. The effect of preoperative prostate‐specific antigen (PSA) level, pathological stage and margin status was assessed with univariate and multivariate analyses.

RESULTS

Of the 180 patients, the Gleason score in the RP specimen was 8, 9 or 10 in 70%, 27% and 3%, respectively; 24% had stage pT2 disease, 30% stage pT3a, 25% stage pT3b and 20% stage pT4a. The 5‐ and 7‐year biochemical progression‐free survival was 73 and 65% for stage pT2, 40% and 27% for stage pT3a, and 30% for stage pT3b (log rank test, P < 0.001). In the univariate model, preoperative PSA level, pathological stage and surgical margins were predictors of survival. In the multivariate analysis, preoperative PSA level and extracapsular extension predicted biochemical progression‐free survival.

CONCLUSION

Gleason 8–10 tumours have a poor prognosis. Patients with a PSA level of <10 ng/mL and stage pT2 disease have the greatest likelihood of having a longer progression‐free survival after RP.     

Correlation of diffusion‐weighted magnetic resonance data with cellularity in prostate cancer

OBJECTIVE

To assess the relationship between the apparent diffusion coefficient (ADC) on magnetic resonance imaging (MRI) and cell density (CD) obtained from radical prostatectomy (RP) specimens.

PATIENTS AND METHODS

In all, 36 patients with prostate cancer were recruited; T2‐weighted and diffusion‐weighted MRI was obtained axially using a 3.0 T scanner. Patients then proceeded to RP; the prostate was whole‐mounted and sectioned axially. Slices (3 µm) were cut from the surface of each section and stained with haematoxylin and eosin (H&E). Five randomly positioned areas from the tumour and normal peripheral zone (PZ) were examined by light microscopy at × 200, then digitally photographed and analysed to obtain automatic CD. ADC values were determined from the MRI data using the H&E slides as a reference. ADC and CD values were measured in both malignant lesions and the PZ, and the correlation between ADC and CD assessed.

RESULTS

ADC values were lower (P ≤ 0.001) in regions pathologically determined as tumour, with a mean (sd ) of 1.45 (0.26) × 10^?3 mm²/s, vs normal PZ, of 1.90 (0.33) × 10^?3 mm²/s. Similarly, the mean CD over the five fields was higher (P ≤ 0.001) in tumour than in normal PZ, with values of 18.89 (4.93)% vs 9.22 (3.23)%. There was a significant correlation between the ADC values and CD (r = ?0.50, P < 0.001) regardless of tissue type. CD values were high in cancer which had lower ADC values than normal PZ.

CONCLUSIONS

ADC values were correlated successfully with CD; this information cannot be obtained with conventional MRI and is useful in characterizing prostate cancer.     

The value of EZH2, p27kip1, BMI‐1 and MIB‐1 on biopsy specimens with low‐risk prostate cancer in selecting men with significant prostate cancer at prostatectomy

OBJECTIVE

To assess the additional prognostic value of the molecular markers EZH2, MIB‐1, p27^kip1 and BMI‐1 on needle biopsies from men with low‐risk prostate cancer, as this disease in needle biopsies shows a heterogeneous clinical outcome, and while it is known that the expression of these tissue markers is predictive of the clinical outcome after radical prostatectomy (RP) their value in prostate biopsies is largely unknown.

PATIENTS AND METHODS

The study included men participating in a screening study, diagnosed with low‐risk prostate cancer and subsequently treated with RP. Immunohistochemical staining for EZH2, MIB‐1, p27^kip1 and BMI‐1 on the needle biopsies were (semi)quantitatively scored and expression levels were related to significant disease at RP. Clinical low‐risk prostate cancer was defined as a prostate‐specific antigen (PSA) level of ≤10 ng/mL, clinical T‐stage ≤2, biopsy Gleason score ≤6, a PSA density of <0.20 ng/mL/g and two or fewer positive cores. Significant PC at RP was defined as presence of any of extracapsular extension, Gleason pattern 4/5, or tumour volume ≥0.5 mL.

RESULTS

In all, 86 biopsy specimens were included; there was high EZH2 expression (>1.0%) in 42% and a low p27^kip expression (<90%) in 63%. Significant disease was present in 44 (51%) RP specimens. A high EZH2 (odds ratio 3.19, P = 0.043) and a low p27^kip1 (4.69, P = 0.036) were independent predictors for significant prostate cancer at RP.

CONCLUSIONS

The determination of EZH2 and p27^kip1 on diagnostic needle biopsies supports the selection of men with indolent prostate cancer at RP. Especially p27^kip1 could improve the pretreatment risk assessment of patients with low‐risk prostate cancer.     

Accuracy of preoperative endorectal MRI in predicting extracapsular extension and influence on neurovascular bundle sparing in radical prostatectomy

Purpose

To evaluate the accuracy of presurgical endorectal MRI (eMRI) for local staging before radical prostatectomy (RP) and its influence on neurovascular bundle (NVB) resection during radical prostatectomy.

Patients and methods

A total of 385 patients with histologically proven prostate cancer (PCa) have been included in this retrospective study between 2004 and 2008. All patients underwent preoperative eMRI at 1.5 T before open RP. Staging results by eMRI were compared with the histopathological findings. The presence of positive surgical margins and extent of nerve-sparing procedure were evaluated. Subgroup analysis of low–risk group and intermediate to high-risk group based on D’Amico criteria was conducted.

Results

In 294 (76.4%) patients, pathological stage was correctly predicted, 69 patients (17.9%) were understaged and 22 (5.7%) overstaged. Overall sensitivity, specificity, negative and positive predictive value for predicting extracapsular extension (ECE) were 41.5, 91.8, 78.0 and 69.0%, respectively. One hundred and fifty-two (48.4%) of the patients classified as stage cT2 by eMRI underwent bilateral NVB sparing, whereas 14 (19.7%) patients with reported ECE underwent bilateral NVB sparing (P < 0.01). Overall positive surgical margin rate was 14.8%. Sensitivity of predicting ECE and positive predictive value were lower in the low-risk group than in the intermediate and high-risk group.

Conclusions

eMRI is effective in predicting extracapsular extension in an intermediate to high-risk group. Preoperative eMRI in patients with low-risk criteria is not recommended as a routine assessment modality. eMRI findings did appear to influence surgical strategy as patients with imaging findings suggesting >cT2 disease were less likely to undergo NVB sparing.     

Prostate cancer detection with real-time elastography using a bi-plane transducer: comparison with step section radical prostatectomy pathology

Purpose

To evaluate elastography using a bi-plane transducer for localizing prostate cancer (PCa) in patients scheduled for radical prostatectomy (RP), in comparison with step section pathological analysis.

Methods

Fifty-six consecutive PCa patients underwent real-time elastography examination with a bi-plane transducer before RP. Transverse elastographic images were obtained from the apex to the base by slightly compressing and releasing the prostate tissue using the probe. The diagnostic performance of elastography was evaluated in correlation with step section RP histopathology.

Results

In 56 PCa patients, gray-scale ultrasonography detected at least one lesion in 36 patients, whereas elastography detected at least one lesion in 53 patients (P = 0.001). The overall sensitivity, specificity and accuracy of elastography in depicting tumor lesions were 67.6, 89.5 and 82.7 %, respectively. The detection rate of a PCa lesion with elastography was best in the left posterior region, followed by the right posterior region. Elastography was more sensitive in detecting PCa lesions with higher Gleason scores, diameter >5 mm and extracapsular extension.

Conclusions

The additional use of elastography with the bi-plane transducer can improve PCa detection rate by providing more information about tissue stiffness within the prostate gland.     

Comparison of stage migration patterns between Europe and the USA: an analysis of 11 350 men treated with radical prostatectomy for prostate cancer

OBJECTIVE

To examine the stage migration patterns in patients treated with radical prostatectomy (RP) for prostate cancer in Europe and in the USA in the last 20 years.

PATIENTS AND METHODS

Between 1988 and 2005, RP was performed in 11 350 men: 5739 from Europe and 5611 from the USA. Independent‐samples t‐test and the chi‐square test were, respectively, used for comparisons of means and proportions. The trend test was used to test the statistical significance of trends in proportions over time.

RESULTS

Temporal patterns in patients’ age, stage and PSA level at presentation were similar on both continents. Conversely, temporal patterns in Gleason sum distribution differed. In the USA, the rate of biopsy Gleason sums of 2–5 decreased from 32.8% to 0.2% (P < 0.001), while the rate of Gleason sums of 7 and 8–10 increased (P < 0.001). Conversely, in Europe the rate of Gleason sums of 6 increased from 40% to 64% (P < 0.001) at the expense of all other Gleason sums. At RP, the rate of Gleason sums of 2–5 decreased on both continents and the rate of a Gleason sum of 7 increased in the USA. Moreover, no important differences in pathological stage trends (organ confinement, extracapsular extension and seminal vesicle invasion) distinguished either population. Finally, the rate of lymph node involvement increased in the USA but remained stable in Europe.

CONCLUSIONS

Stage and grade migration affected the USA and Europe to different extents. These differences should be accounted for when prediction tools or comparisons between the USA and Europe are considered.     

Validation of the current eligibility criteria for focal therapy in men with localized prostate cancer and the role of MRI

Purpose

To validate current eligibility criteria for focal therapy (FT) in prostate cancer men undergoing radical prostatectomy (RP) and to assess the role of magnetic resonance imaging (MRI).

Methods

Retrospective analysis of 217 RP patients (2009–2016) with preoperative MRI (almost all in external institutions) and fulfillment of different FT eligibility criteria: unilateral tumor, clinical tumor stage ≤ cT2a, prostate volume ≤ 60 mL and either biopsy Gleason 3 + 3 or ≤ 3 + 4 and PSA ≤ 10 or ≤ 15 ng/mL. Multivariable logistic regression analyses (MVA) assessed the role of MRI to predict the presence of significant contralateral tumor or extracapsular extension (ECE), including seminal vesicle invasion. To quantify model accuracy, Receiver Operating Characteristics-derived area under the curve (AUC) was used.

Results

Of 217 patients fulfilling widest biopsy criteria and 113 fulfilling additional MRI criteria, 64 (29.7%) and 37 (32.7%) remained eligible for FT according to histopathological results. In MVA, fulfillment of MRI criteria reached independent predictor status for prediction of contralateral tumor but not for ECE. Addition of MRI resulted in AUC gain (57.5–64.6%). Sensitivity, specificity, PPV and NPV for MRI to predict contralateral tumor were: 41.8, 71.6, 70.9 and 42.6%, respectively. Virtually the same results were recorded for Gleason 3 + 3 and/or PSA ≤ 10 ng/mL.

Conclusions

Patient eligibility criteria for FT using biopsy criteria remained insufficient with respect to contralateral tumor disease. Although, MRI improves accuracy, it cannot safely exclude or minimize chance of significant cancer on contralateral prostate side. To date, stricter eligibility criteria are needed to provide more diagnostic reliability.

     

Critical assessment of preoperative urinary prostate cancer antigen 3 on the accuracy of prostate cancer staging

Background

Knowledge about the staging significance of the prostate cancer antigen 3 (PCA3) score to better identify pathologic features after radical prostatectomy (RP) is limited and controversial.

Objective

Our aim was to study the clinical staging significance of PCA3 to identify pathologic favorable and/or unfavorable features in the RP specimen.

Design, setting, and participants

Complete retrospective clinical and pathologic data of consecutive men who had undergone RP from three tertiary referral centers including preoperative PCA3 scores (n = 305) and computer-assisted planimetrically measured tumor volume data (n = 160) were available.

Intervention

All patients were treated with RP.

Measurements

PCA3 scores were assessed using the PROGENSA assay (Gen-Probe, San Diego, CA, USA). Beyond standard risk factors (age, digital rectal examination, prostate-specific antigen, prostate volume, biopsy Gleason score, percentage of positive cores), five different PCA3 codings were used in logistic regression models to identify five distinct pathologic end points: (1) low-volume disease (<0.5 ml), (2) insignificant prostate cancer (PCa) according to the Epstein criteria, (3) extracapsular extension (ECE), (4) seminal vesicle invasion (SVI), and (5) aggressive disease defined as Gleason sum ≥7. Accuracy estimates of each end point were quantified using the area under the curve (AUC) of the receiver operator characteristic analysis in models with and without PCA3.

Results and limitations

PCA3 scores were significantly lower in low-volume disease and insignificant PCa (p ≤ 0.001). AUC of multivariable low-volume disease (+2.4 to +5.5%) and insignificant PCa models (+3 to +3.9%) increased when PCA3 was added to standard clinical risk factors. In contradistinction, regardless of its coding, PCA3 scores were not significantly elevated in pathologically confirmed ECE (p = 0.4) or SVI (p = 0.5), respectively. Higher PCA3 scores were associated with aggressive disease (p < 0.001). Importantly, the addition of PCA3 to multivariable intermediate- and high-grade models did not improve prediction. Despite reporting the largest pathologic PCA3 study, the main limitation resides in its small sample size.

Conclusions

PCA3 was confirmed as a valuable predictor of pathologically confirmed low-volume disease and insignificant PCa. Further exploration of its role as an additional marker to select patients for active surveillance may be warranted. In contradistinction, assessment of pathologically advanced or aggressive PCa is not improved using PCA3.     

Prognostic value of insulin-like growth factor II mRNA binding protein 3 in patients treated with radical prostatectomy

Study Type – Prognosis (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Insulin‐like growth factor II mRNA binding protein 3 (IMP3) is associated with poor outcomes in a variety of malignancies. The role of IMP3 in protate cancer remains poorly understood. IMP3 expression was associated with features of aggressive biology and aggressive prostate cancer recurrence after surgery. Although IMP3 is differentially expressed in patients with features of biologically aggressive prostate cancer, it does not have independent prognostic value in patients treated with RP.

OBJECTIVE

• ? To evaluate the association of insulin‐like growth factor II mRNA binding protein 3 (IMP3) with pathological features and outcomes in patients treated with radical prostatectomy (RP).

PATIENTS AND METHODS

• ? Immunohistochemical staining for IMP3 was performed on archival tissue microarray specimens from 232 consecutive patients treated with RP for clinically localized disease.
• ? None of the patients received neoadjuvant or adjuvant radiation or hormone therapy.
• ? IMP3 expression was histologically categorized as normal or abnormal.
• ? Disease recurrence was classified as aggressive if metastases were present, post‐recurrence prostate‐specific antigen (PSA) doubling time was less than 10 months, or if the patients failed to respond to salvage local radiation therapy.

RESULTS

• ? The median follow‐up was 69.8 months (interquartile range [IQR]: 40.1–99.5).
• ? IMP3 expression was abnormal in 42 (18.1%) of 232 patients.
• ? IMP3 expression was associated with extracapsular extension (P= 0.020), seminal vesicle invasion (P= 0.024), lymphovascular invasion (P= 0.036) and a high pathological Gleason score (P= 0.009).
• ? The 5‐year PSA recurrence‐free survival for IMP3‐negative patients was 83% (standard error [SE]= 3) vs 67% (SE = 8) in IMP3‐positive patients (log‐rank test, P= 0.015).
• ? In a multivariable analysis that adjusted for the effects of surgical margins, extracapsular extension and seminal vesicle invasion, PSA (hazard ratio [HR]: 1.04, P= 0.013), lymph node metastasis (HR: 16.7, P < 0.001) and a high pathological Gleason score (HR 4.3, P= 0.008) were significantly associated with PSA recurrence‐free survival, whereas IMP3 expression was not (P= 0.11). Similarly, IMP3 expression was only associated with aggressive recurrence (HR 3.2, P= 0.006).

CONCLUSION

• ? IMP3 expression is abnormal in approximately one‐fifth of prostate cancers. Although IMP3 is differentially expressed in patients with features of biologically aggressive prostate cancer, it does not have an independent prognostic value in patients treated with RP.

     

Expanding the indications for laparoscopic retroperitoneal adrenalectomy: experience with 81 resections

Background

Laparoscopic retroperitoneal (RP) adrenalectomy has gained popularity as the preferred approach over transabdominal (TA) method; however, surgeons have been reluctant to offer this operation to obese patients because of the concerns over inadequate working space and overall perceived higher rate of complications. The aim of the present study was to evaluate the feasibility and safety of RP adrenalectomy compared with TA adrenalectomy, specifically in morbidly obese patients.

Methods

All laparoscopic adrenalectomies performed at our institution between 2004 and 2012 were reviewed retrospectively. Presenting features, operative characteristics, and postoperative outcomes were evaluated. Complications were graded using Clavien system. Continuous variables were compared using Student t-test. Categorical variables were compared using χ²-test. Prediction models were constructed using linear or logistic regression as appropriate.

Results

Eighty-one RP and 130 TA procedures were performed, 26 (12.3%) and 60 (28.4%), respectively in obese patients (BMI > 30). Among the obese patients, operative time and estimated blood loss were less for RP (90 versus 130 min; P < 0.001 and 0 versus 50 mL; P < 0.001). Differences in the length of stay, overall mortality, incidence and severity of postoperative complications, and rates of readmission were not statistically significant between RP and TA procedures for all comers and in the obese patients. Controlling the operative characteristics and patient-specific factors, neither operative approach nor obesity was found to independently predict the postoperative complications.

Conclusions

Laparoscopic RP adrenalectomy is a safe and feasible technique for obese patients. In the obese patients and for all comers, it offers shorter operative time, decreased estimated blood loss, with comparable length of stay and morbidity and mortality rates. We therefore recommend that this technique should be considered for patients undergoing adrenal resection.     

Is de novo stress incontinence after sacrocolpopexy related to anatomical changes and surgical approach?

Introduction and hypothesis

The objective was to investigate the relationship between new onset postoperative stress urinary incontinence (SUI) after sacrocolpopexy (SCP) and anatomical change/surgical approach.

Methods

We analyzed a retrospective cohort of patients with negative preoperative testing for SUI who underwent SCP from 2005 to 2012. Our primary outcome was new onset postoperative SUI. Logistic regression was used to examine the relationship among anatomical change, defined as ΔAa, ΔBa, ΔC, and ΔTVL, and surgical approach, categorized as abdominal (ASCP) for open cases and minimally invasive (MISCP) for laparoscopic and robot-assisted cases, and postoperative SUI.

Results

Of 795 cases, 33 ASCP (43%) and 44 MISCP (57%) met the inclusion criteria for analysis. New onset SUI was demonstrated by 15 patients (45%) of the ASCP group and 7 patients (15%) of the MISCP group (p?=?0.005). New onset SUI was significantly associated with route of SCP and ΔAa (p?=?0.006 and p?=?0.033 respectively). Controlling for ΔAa, the odds of new onset SUI were 4.4 times higher in the ASCP group compared with the MISCP group (OR 4.37, 95% CI 1.42, 13.48). Controlling for route of SCP, the odds of new onset SUI were 2.2 times higher with moderate ΔAa compared with low ΔAa (OR 2.16 95% CI 1.07, 4.38). The odds of new onset SUI was 4.7 times higher in those with high ΔAa than in those with low ΔAa (OR 4.67 95% CI 1.14, 19.22). ΔBa, ΔC, and ΔTVL were not associated with new onset SUI.

Conclusions

Greater reduction in point Aa and abdominal surgical route are risk factors for new onset postoperative SUI after SCP.     

Effect of prostate size on pathological outcome and biochemical recurrence after radical prostatectomy for prostate cancer: is it correlated with serum testosterone level?

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

OBJECTIVE

To examine whether prostate size is associated with pathological outcome and biochemical recurrence (BCR) after radical prostatectomy (RP) in patients with prostate cancer, and to evaluate whether it is correlated with serum testosterone level.

PATIENTS AND METHODS

The study comprised 579 men treated with RP for prostate cancer between June 1991 and March 2008, with a prostate‐specific antigen level of <20 ng/mL. We assessed the associations of prostate size (volume), measured using magnetic resonance imaging, and serum testosterone concentration, with adverse pathological outcomes and BCR.

RESULTS

There was a positive correlation between preoperative prostate volume and prostate weight (r= 0.685, P < 0.001). On multivariate analysis, prostate volume was inversely associated with the outcomes of high‐grade prostate cancer (P= 0.044), extracapsular extension (P= 0.011) and BCR (P= 0.016). There was also a positive correlation between serum testosterone level and prostate volume (r= 0.136, P= 0.043). Multivariate analysis showed that lower serum testosterone levels correlated with adverse pathological stage and a pathological Gleason score of ≥8 (P= 0.042). However, there was no relationship between serum testosterone level and BCR after adjusting for covariates.

CONCLUSIONS

Men with smaller prostates had unfavourable pathological findings and were at greater risk of progression after RP. Low serum testosterone levels were not associated with tumour progression. Therefore, another mechanism, aside from hormonal factors, might be involved in unfavourable outcomes in patients with a small prostate.