- Email: [email protected]
INTRAOPERATIVE FROZEN SECTION ANALYSIS DURING NERVE SPARING ROBOTIC ASSISTED LAPAROSCOPIC PROSTATECTOMY
Vol. 179, No. 4, Supplement, Wednesday, May 21, 2008
treated with a curative or palliative intent. However, the effect of nutrition intake on health-related quality of life (HRQoL) in prostate cancer patients is not known. In this cross-sectional study, we tested the hypothesis that adherence to a healthy diet pattern was associated with a better HRQoL LQSDWLHQWVLQLWLDOO\GLDJQRVHGZLWKORFDOL]HGSURVWDWHFDQFHU METHODS: The more than 13000 men enrolled in CaPSURETM, a national prostate cancer registry, were invited to SDUWLFLSDWH LQ WKLV QXWULWLRQ VWXG\ PHQ ZHUH HQUROOHG ,QFOXVLRQ FULWHULDIRUWKLVDQDO\VLVZHUHWRKDYHORFDOL]HGGLVHDVHDWGLDJQRVLV and have completed the mailed food frequency questionnaire (FFQ) and +54R/PHDVXUHPHQWVZLWKLQPRQWKV+HDOWK\GLHWSDWWHUQZDVGH¿QHG as the upper quartile of intake for fruits and vegetables, and legumes, DQGDVWKHORZHUTXDUWLOHIRUUHGPHDWDQGUH¿QHGJUDLQV7RDVVHVVWKH association between adherence to a healthy diet pattern and HRQoL, we used analysis of variance and adjusted for the following variables: age, race, education and income levels, living with partner, BMI, smoking status, PSA, Gleason sum, clinical T stage all at diagnosis, cancer risk category and treatment type. RESULTS: Amongst the 1807 men included for analysis, the median time between prostate cancer diagnosis and completion of FFQ was 3 years. Overall, 322 patients met the criteria for the healthy diet pattern. In univariate analyses, the physical component domain of SF-36 questionnaire, and the bowel function domain of the UCLA 3URVWDWH&DQFHU,QGH[ 3&, ZHUHVWDWLVWLFDOO\VLJQL¿FDQWO\DVVRFLDWHG with healthy diet pattern (p<0.030). Sexual and urinary function domains (PCI), and mental component domain summary (SF-36) were not VLJQL¿FDQW ,Q WKH PXOWLYDULDWH DQDO\VLV RQO\ WKH SK\VLFDO FRPSRQHQW VXPPDU\GRPDLQUHPDLQHGVWDWLVWLFDOO\VLJQL¿FDQW S CONCLUSIONS: Regardless of other factors known to LQÀXHQFHSK\VLFDOZHOOEHLQJVXFKDVVPRNLQJ%0,DQGGLVHDVHVWDJH PHQGLDJQRVHGZLWKORFDOL]HGSURVWDWHFDQFHUZKRPDLQWDLQHGKHDOWKLHU diets were able engage more in physical activities, experienced less pain and discomfort, and felt healthier than those who ate less healthily. Prospective evaluation of dietary pattern and HRQoL after prostate cancer diagnosis is warranted. Source of Funding: Bourse McLaughlin du doyen de l’Universite Laval.
1775 THE CHANGING TRENDS OF PROSTATE CANCER TREATMENT IN ROCHESTER, NY Dragan J Golijanin*, Joy Knopf, Hani Rashid, Guan Wu, John Valvo, Louis Eichel, Ralph R Madeb. Rochester, NY. INTRODUCTION AND OBJECTIVE: Robotic surgery has been incorporated in urology in Rochester, NY since 2001. Over the last few years, Rochester urologists have been increasingly embracing robotic technology and have quickly been included in the residency FXUULFXOXP:HUHWURVSHFWLYHO\DQDO\]HGWKHVHFKDQJHVRYHUWKHODVW several years witht he incoporation of the robotic platform. METHODS: We retrospectively reviewed the operating room case logs for all surgeons performing open and robotic prostatectomies in all hospitals in Rochester New York in 2003-2006. We also assessed other modalities of therapy including brachytherapy and cryotherapy DQGORRNHGDWWKHLQÀXHQFHWKDWURERWLFSURVWDWHFWRP\KDGRQWKHRWKHU modalities of treatment for prostate cancer. The only oncologic parameter XVHGWRDVVHVVSUR¿FLHQF\ZDVVXUJLFDOPDUJLQVWDWXV7KHVXUJLFDOORJV of the graduating chief residents with respect to open and robotic case numbers were also reviewed. RESULTS: There are 20 surgeons in Rochester, NY that regularly perform radical prostatectomy in 4 hospitals in the Rochester area. Two of the 4 hospitals have robotic systems. In 2003-2004 there were 30 open radical prosatatectomies performed each month and less than 10 performed via the robotic approach. In 2006, the trend was VLJQL¿FDQWO\UHYHUVHGZLWKURERWLFFDVHVSHUIRUPHGHDFKPRQWKDQG less than 10 performed via the open approach(P<.05). The break point ZDV0DUFKRI VHH*UDSK 7KHUDWHRIEUDFK\WKHUDS\ÀXFWXDWHG over-time and increased in centers that did not have a surgical robot. The trend of open prostatectomies performed in centers that did not KDYHDURERWVLJQL¿FDQWO\GURSSHGZLWKOHVVWKDQFDVHVSHUIRUPHGSHU year(P<.05). Surgeons that had experience with both open and robotic prostatectomies were able to halve there positive margin rate with this
THE JOURNAL OF UROLOGY®
609
QHZ WHFKQRORJ\ 3 0RUH FRQFHUQLQJ LV WKH VLJQL¿FDQW GHFUHDVH in the number of open prostatecomies performed by graduating chief residents between 2003-2006. &21&/86,216 6LJQL¿FDQW FKDQJHV KDYH EHHQ VHHQ LQ surgical outcomes, individual and group practice patterns, training of residents, and consumer satisfaction as robotic surgery has become the standard of care in this community. Robotic systems will continue to be an important asset in the urologist surgical armamentarium.
Source of Funding: None
1776 INTRAOPERATIVE FROZEN SECTION ANALYSIS DURING NERVE SPARING ROBOTIC ASSISTED LAPAROSCOPIC PROSTATECTOMY Brian A Link*, Rebecca A Nelson, David Y Josephson, Laura E Crocitto, Timothy G Wilson. Duarte, CA. INTRODUCTION AND OBJECTIVE: The oncologic safety of sparing the cavernous nerves during robotic assisted laparoscopic SURVWDWHFWRP\ 5$/3 PD\EHPRQLWRUHGE\WDNLQJLQWUDRSHUDWLYHIUR]HQ section (IFS) analysis of the regions of the neurovascular bundles. We reviewed our experience with IFS to determine its effectiveness in SUHGLFWLQJWKH¿QDOVXUJLFDOPDUJLQ METHODS: We reviewed the charts of 168 patients who underwent RALP with IFS at the City of Hope from July 2003 to July 2007. An IFS was performed at the discretion of the operating surgeon by judging the risk of local tumor progression based on preoperative parameters and intraoperative judgment. The tissue taken was from the lateral margin of the prostate during antegrade dissection of the neurovascular bundles away from the lateral prostatic fascia. When the pathologist reported carcinoma on IFS during the procedure, additional tissue was taken from the NVB until a negative result was obtained or the entire NVB was resected on that side. Preoperative clinical parameters including PSA, clinical stage and Gleason’s score as well as IFS report RIQHXURYDVFXODUEXQGOH 19% ELRSVLHV¿QDOUHSRUWRI19%ELRSVLHV DQG¿QDOVXUJLFDOPDUJLQVZHUHDQDO\]HG RESULTS: The clinical disease state was T1 in 26 patients, T2 in 124 patients and T3 in 18 patients. The median preoperative PSA was 5.9. The Gleason’s sum was 6, 7, or 8-10 in 57, 86 and 25 patients, respectively. The IFS results of the NVB biopsy were identical WRWKRVHREWDLQHGRQWKH¿QDOSHUPDQHQWVHFWLRQRIWKHELRSV\WLVVXH in 162 (96.4%). The IFS results were reported positive in 10 cases (6.0%) and all demonstrated adenocarcinoma in the biopsy tissue on WKH¿QDOSHUPDQHQWVHFWLRQV2IWKHFDVHVZLWKDQHJDWLYH,)6 later demonstrated adenocarcinoma in the biopsy tissue on permanent VHFWLRQV,QFDVHVWKH¿QDOVXUJLFDOPDUJLQZDVSRVLWLYHGHVSLWHD negative IFS creating a false negative rate of 13% (21/158). Nonetheless, ,)6RIWKH19%FRUUHFWO\SUHGLFWHGDVLGHVSHFL¿FQHJDWLYHPDUJLQLQ 131 of 158 cases thereby potentially saving a patient with high-risk clinical features from a wide resection of the NVB. The positive and QHJDWLYHSUHGLFWLYHYDOXHVIRU,)6WRSUHGLFWWKH¿QDOVXUJLFDOPDUJLQ were therefore 100% (10/10) and 71% (112/158), respectively.
610
THE JOURNAL OF UROLOGY®
CONCLUSIONS: We found that IFS at the time of RALP FDQUHOLDEO\SUHGLFWWKH¿QDOVXUJLFDOPDUJLQLQVHOHFWHGSDWLHQWV7KLV WHFKQLTXH PD\ DOORZ IRU GHFUHDVHG PRUELGLW\ ZKLOH QRW VDFUL¿FLQJ oncologic outcomes when performing nerve-sparing surgery. Source of Funding: None
1777 TOTAL RECONSTRUCTION TECHNIQUE OF THE VESICOURETHRAL JUNCTION AND IMPACT ON EARLY RETURN OF CONTINENCE FOLLOWING ROBOTIC PROSTATECTOMY Jay K Jhaveri*, Sandhya Rao, Rajiv Yadav, Robert A Leung, Georg Bartsch, E Darracott Vaughan, Ashutosh K Tewari. New York, NY, and Innsbruck, Austria. INTRODUCTION AND OBJECTIVE: Robotic prostatectomy KDVEHFRPHDZLGHO\DFFHSWHGWUHDWPHQWIRUFOLQLFDOO\ORFDOL]HGSURVWDWH cancer. Unfortunately urinary incontinence is a disabling side effect and a variety of strategies are proposed in order to hasten the time to continence. We describe our surgical technique to shorten duration of incontinence and present our continence outcomes herein. METHODS: We have incorporated new tactics to our previous PRGL¿FDWLRQVWRSURGXFHDXQLTXHDQDVWRPRVLV7KLVDQDVWRPRVLVLV completely supported by anatomic structures resulting in low tension and high bladder neck suspension. Our surgical technique includes preservation of the puboprostatic ligaments and arcus tendineus ZLWK GLVVHFWLRQ RI D ÀDS EHKLQG WKH EODGGHU QHFN UHIHUUHG WR DV WKH retrotrigonal layer. We ligate the dorsal venous complex using a puboprostatic ligament sparing stitch. After prostatectomy we plicate the posterior bladder neck to funnel it and to reinforce the bladder posteriorly. We then suture the retrotrigonal layer to Denonvillier’s fascia to include WKHPHGLDQ¿EURXVUDSKHDQG¿QDOO\WKHFHQWUDOWHQGRQRIWKHSHULQHXP completing the posterior reconstruction and restoring the functional and anatomic length of the rhabdosphincter. The anterior reconstruction is performed by attaching the arcus tendineus to the bladder thus creating ODWHUDODQGDQWHULRUVXSSRUWWRWKHDQDVWRPRVLV:HWKHQXWLOL]HYDOLGDWHG health-related quality of life questionnaires in addition to third party telephone interviews at 1, 6, 12 and 24 weeks post-operatively to record FRQWLQHQFHRXWFRPHV&RQWLQHQFHLVGH¿QHGDVXVLQJQRSDGVSHUGD\ or using 1 dry security liner. 5(68/76 :H HPSOR\HG WKHVH WHFKQLFDO PRGL¿FDWLRQV LQ the last 260 consecutive patients, 17 were unavailable for follow-up via questionnaires or phone interviews. For the remaining 243, at 1,6,12 and 24 weeks, the continence rates are 36%,75%, 88%, 96% respectively. CONCLUSIONS: With this anatomic restoration of the vesicourethral junction, we observe that due to a good degree of bladder neck suspension, a reinforced anastomosis and restoration of the functional length of the sphincter, we have noticed an improvement in early continence as well as overall continence rates.
Source of Funding: None
Vol. 179, No. 4, Supplement, Wednesday, May 21, 2008
1778 ROBOTIC VS. OPEN RADICAL PROSTATECTOMY: A SINGLE INSTITUTION, SINGLE SURGEON COMPARISON OF OUTCOME Michael O Koch*, William Smith. Indianapolis, IN. INTRODUCTION AND OBJECTIVE: Several centers have attempted to compare oncologic outcomes with open radical prostatectomy to laparoscopic prostatectomy. These studies have compared the outcomes of different surgeons and/or had selection GLIIHUHQFHVVLJQL¿FDQWO\OLPLWLQJWKHYDOLGLW\RIFRQFOXVLRQV,QWKLVVWXG\ we compare the results of a single surgeon with open and robotic laparoscopic prostatectomy over a ten year period. METHODS: 787 consecutive male patients underwent open radical prostatectomy (n=367) or robotic assisted laparoscopic SURVWDWHFWRP\ Q IRUSDWKRORJLFDOO\FRQ¿UPHG7DWR7ESURVWDWH cancer. All prostatectomies were performed by a single surgeon and ZHUHDQDO\]HGE\DVLQJOHSDWKRORJLVWXVLQJDZKROHPRXQWWHFKQLTXHDW Indiana University between 5/12/98 - 9/18/07. No patients were excluded because of a learning curve. The primary outcome parameters were positive margin rate and margin site. RESULTS: 19 patients were excluded from study due to inability to access complete medical records. Open positive margin rates were: pT2a-2%, pT2b-12.4%, pT2c-50%, pT3a-30.8%, pT3b-54.5%. Robotic positive margin rates were pT2a-2.2%, pT2b-10.4%, pT2c-7.7%, pT3a-25.3%, pT3b-24.1%. The most common positive margin site for both open and robotic prostatectomy was apex. No differences existed LQPHDQDQGPHGLDQDJHSURVWDWHVL]HSUHVHQWDWLRQ36$WRWDO*OHDVRQ score, or tumor volume at any stage between the groups. CONCLUSIONS: Robotic assisted laparoscopic prostatectomy is associated with equal or superior pathologic outcomes compared to RSHQSURVWDWHFWRP\LQRXUH[SHULHQFH8OWLPDWHO\WUXHRQFRORJLFHI¿FDF\ will have to be based upon long term follow-up comparing disease free and overall survival. Source of Funding: None
1779 PREDICTORS OF URINARY CONTINENCE AFTER CONTEMPORARY RADICAL PROSTATECTOMY Jaspreet S Sandhu*, Theresa M Koppie, Angel M Cronin, Kinjal C Vora, Farhang Rabbani, Karim Touijer, Bertrand D Guillonneau, Andrew J Vickers, James A Eastham, Peter T Scardino. New York, NY, and Sacramento, CA. INTRODUCTION AND OBJECTIVE: Urinary incontinence after radical prostatectomy (RP) occurs in a large minority of patients. Multiple risk factors are known and proposed. We sought pre-operative, intra-operative and peri-operative risk factors associated with urinary incontinence in a contemporary series of patients undergoing RP. METHODS: An Institutional Review Board approved retrospective study was performed. 2416 patients underwent RP by RQHRI¿YHVXUJHRQVEHWZHHQ-XO\ DQG-XQHSDWLHQWV had adequate continence follow-up. Univariate and multivariable logistic regression was used to determine variables associated with continence \HDU IROORZLQJ 53 9DULDEOH DQDO\]HG LQFOXGHG LQFOXGH DJH 36$ body mass index (BMI), American Society of Anesthesiologists class (ASA), MRI estimated prostate volume, history of TURP, clinical stage, biopsy Gleason grade, neoadjuvant therapy, operative time, estimated blood loss, nerve sparing status, surgeon opinion of vesicourethral anastomosis, presence of a urine leak 2 or more days after RP, and anastomotic stricture needing intervention within a year of RP. Restricted cubic splines were used when evaluating MRI volume to relax linearity assumptions. All variables were included in the multivariable model H[FHSW05,YROXPHDQGXULQHOHDNIRUZKLFKZHKDGVLJQL¿FDQWPLVVLQJ GDWD&RQWLQHQFHZDVGH¿QHGDVWKHQHHGIRUQRSDGVIRUXULQDU\FRQWURO at 1 year post RP. RESULTS: 1351 (83%) were continent at 1 year following RP. On univariate analysis, men younger at surgery (p<0.0005) and with lower BMI (p=0.006), ASA (p=0.001), or MRI volume (p=0.005) ZHUH VLJQL¿FDQWO\ PRUH OLNHO\ WR EH FRQWLQHQW DW \HDU IROORZLQJ 53 those having nerves resected (p=0.011), with a urine leak (p=0.005) RU DQDVWRPRWLF VWULFWXUH S ZHUH VLJQL¿FDQW OHVV OLNHO\ WR EH continent at 1 year following RP. Since older men tend to have larger prostates, we examined the effect of preoperative MRI volume on
treated with a curative or palliative intent. However, the effect of nutrition intake on health-related quality of life (HRQoL) in prostate cancer patients is not known. In this cross-sectional study, we tested the hypothesis that adherence to a healthy diet pattern was associated with a better HRQoL LQSDWLHQWVLQLWLDOO\GLDJQRVHGZLWKORFDOL]HGSURVWDWHFDQFHU METHODS: The more than 13000 men enrolled in CaPSURETM, a national prostate cancer registry, were invited to SDUWLFLSDWH LQ WKLV QXWULWLRQ VWXG\ PHQ ZHUH HQUROOHG ,QFOXVLRQ FULWHULDIRUWKLVDQDO\VLVZHUHWRKDYHORFDOL]HGGLVHDVHDWGLDJQRVLV and have completed the mailed food frequency questionnaire (FFQ) and +54R/PHDVXUHPHQWVZLWKLQPRQWKV+HDOWK\GLHWSDWWHUQZDVGH¿QHG as the upper quartile of intake for fruits and vegetables, and legumes, DQGDVWKHORZHUTXDUWLOHIRUUHGPHDWDQGUH¿QHGJUDLQV7RDVVHVVWKH association between adherence to a healthy diet pattern and HRQoL, we used analysis of variance and adjusted for the following variables: age, race, education and income levels, living with partner, BMI, smoking status, PSA, Gleason sum, clinical T stage all at diagnosis, cancer risk category and treatment type. RESULTS: Amongst the 1807 men included for analysis, the median time between prostate cancer diagnosis and completion of FFQ was 3 years. Overall, 322 patients met the criteria for the healthy diet pattern. In univariate analyses, the physical component domain of SF-36 questionnaire, and the bowel function domain of the UCLA 3URVWDWH&DQFHU,QGH[ 3&, ZHUHVWDWLVWLFDOO\VLJQL¿FDQWO\DVVRFLDWHG with healthy diet pattern (p<0.030). Sexual and urinary function domains (PCI), and mental component domain summary (SF-36) were not VLJQL¿FDQW ,Q WKH PXOWLYDULDWH DQDO\VLV RQO\ WKH SK\VLFDO FRPSRQHQW VXPPDU\GRPDLQUHPDLQHGVWDWLVWLFDOO\VLJQL¿FDQW S CONCLUSIONS: Regardless of other factors known to LQÀXHQFHSK\VLFDOZHOOEHLQJVXFKDVVPRNLQJ%0,DQGGLVHDVHVWDJH PHQGLDJQRVHGZLWKORFDOL]HGSURVWDWHFDQFHUZKRPDLQWDLQHGKHDOWKLHU diets were able engage more in physical activities, experienced less pain and discomfort, and felt healthier than those who ate less healthily. Prospective evaluation of dietary pattern and HRQoL after prostate cancer diagnosis is warranted. Source of Funding: Bourse McLaughlin du doyen de l’Universite Laval.
1775 THE CHANGING TRENDS OF PROSTATE CANCER TREATMENT IN ROCHESTER, NY Dragan J Golijanin*, Joy Knopf, Hani Rashid, Guan Wu, John Valvo, Louis Eichel, Ralph R Madeb. Rochester, NY. INTRODUCTION AND OBJECTIVE: Robotic surgery has been incorporated in urology in Rochester, NY since 2001. Over the last few years, Rochester urologists have been increasingly embracing robotic technology and have quickly been included in the residency FXUULFXOXP:HUHWURVSHFWLYHO\DQDO\]HGWKHVHFKDQJHVRYHUWKHODVW several years witht he incoporation of the robotic platform. METHODS: We retrospectively reviewed the operating room case logs for all surgeons performing open and robotic prostatectomies in all hospitals in Rochester New York in 2003-2006. We also assessed other modalities of therapy including brachytherapy and cryotherapy DQGORRNHGDWWKHLQÀXHQFHWKDWURERWLFSURVWDWHFWRP\KDGRQWKHRWKHU modalities of treatment for prostate cancer. The only oncologic parameter XVHGWRDVVHVVSUR¿FLHQF\ZDVVXUJLFDOPDUJLQVWDWXV7KHVXUJLFDOORJV of the graduating chief residents with respect to open and robotic case numbers were also reviewed. RESULTS: There are 20 surgeons in Rochester, NY that regularly perform radical prostatectomy in 4 hospitals in the Rochester area. Two of the 4 hospitals have robotic systems. In 2003-2004 there were 30 open radical prosatatectomies performed each month and less than 10 performed via the robotic approach. In 2006, the trend was VLJQL¿FDQWO\UHYHUVHGZLWKURERWLFFDVHVSHUIRUPHGHDFKPRQWKDQG less than 10 performed via the open approach(P<.05). The break point ZDV0DUFKRI VHH*UDSK 7KHUDWHRIEUDFK\WKHUDS\ÀXFWXDWHG over-time and increased in centers that did not have a surgical robot. The trend of open prostatectomies performed in centers that did not KDYHDURERWVLJQL¿FDQWO\GURSSHGZLWKOHVVWKDQFDVHVSHUIRUPHGSHU year(P<.05). Surgeons that had experience with both open and robotic prostatectomies were able to halve there positive margin rate with this
THE JOURNAL OF UROLOGY®
609
QHZ WHFKQRORJ\ 3 0RUH FRQFHUQLQJ LV WKH VLJQL¿FDQW GHFUHDVH in the number of open prostatecomies performed by graduating chief residents between 2003-2006. &21&/86,216 6LJQL¿FDQW FKDQJHV KDYH EHHQ VHHQ LQ surgical outcomes, individual and group practice patterns, training of residents, and consumer satisfaction as robotic surgery has become the standard of care in this community. Robotic systems will continue to be an important asset in the urologist surgical armamentarium.
Source of Funding: None
1776 INTRAOPERATIVE FROZEN SECTION ANALYSIS DURING NERVE SPARING ROBOTIC ASSISTED LAPAROSCOPIC PROSTATECTOMY Brian A Link*, Rebecca A Nelson, David Y Josephson, Laura E Crocitto, Timothy G Wilson. Duarte, CA. INTRODUCTION AND OBJECTIVE: The oncologic safety of sparing the cavernous nerves during robotic assisted laparoscopic SURVWDWHFWRP\ 5$/3 PD\EHPRQLWRUHGE\WDNLQJLQWUDRSHUDWLYHIUR]HQ section (IFS) analysis of the regions of the neurovascular bundles. We reviewed our experience with IFS to determine its effectiveness in SUHGLFWLQJWKH¿QDOVXUJLFDOPDUJLQ METHODS: We reviewed the charts of 168 patients who underwent RALP with IFS at the City of Hope from July 2003 to July 2007. An IFS was performed at the discretion of the operating surgeon by judging the risk of local tumor progression based on preoperative parameters and intraoperative judgment. The tissue taken was from the lateral margin of the prostate during antegrade dissection of the neurovascular bundles away from the lateral prostatic fascia. When the pathologist reported carcinoma on IFS during the procedure, additional tissue was taken from the NVB until a negative result was obtained or the entire NVB was resected on that side. Preoperative clinical parameters including PSA, clinical stage and Gleason’s score as well as IFS report RIQHXURYDVFXODUEXQGOH 19% ELRSVLHV¿QDOUHSRUWRI19%ELRSVLHV DQG¿QDOVXUJLFDOPDUJLQVZHUHDQDO\]HG RESULTS: The clinical disease state was T1 in 26 patients, T2 in 124 patients and T3 in 18 patients. The median preoperative PSA was 5.9. The Gleason’s sum was 6, 7, or 8-10 in 57, 86 and 25 patients, respectively. The IFS results of the NVB biopsy were identical WRWKRVHREWDLQHGRQWKH¿QDOSHUPDQHQWVHFWLRQRIWKHELRSV\WLVVXH in 162 (96.4%). The IFS results were reported positive in 10 cases (6.0%) and all demonstrated adenocarcinoma in the biopsy tissue on WKH¿QDOSHUPDQHQWVHFWLRQV2IWKHFDVHVZLWKDQHJDWLYH,)6 later demonstrated adenocarcinoma in the biopsy tissue on permanent VHFWLRQV,QFDVHVWKH¿QDOVXUJLFDOPDUJLQZDVSRVLWLYHGHVSLWHD negative IFS creating a false negative rate of 13% (21/158). Nonetheless, ,)6RIWKH19%FRUUHFWO\SUHGLFWHGDVLGHVSHFL¿FQHJDWLYHPDUJLQLQ 131 of 158 cases thereby potentially saving a patient with high-risk clinical features from a wide resection of the NVB. The positive and QHJDWLYHSUHGLFWLYHYDOXHVIRU,)6WRSUHGLFWWKH¿QDOVXUJLFDOPDUJLQ were therefore 100% (10/10) and 71% (112/158), respectively.
610
THE JOURNAL OF UROLOGY®
CONCLUSIONS: We found that IFS at the time of RALP FDQUHOLDEO\SUHGLFWWKH¿QDOVXUJLFDOPDUJLQLQVHOHFWHGSDWLHQWV7KLV WHFKQLTXH PD\ DOORZ IRU GHFUHDVHG PRUELGLW\ ZKLOH QRW VDFUL¿FLQJ oncologic outcomes when performing nerve-sparing surgery. Source of Funding: None
1777 TOTAL RECONSTRUCTION TECHNIQUE OF THE VESICOURETHRAL JUNCTION AND IMPACT ON EARLY RETURN OF CONTINENCE FOLLOWING ROBOTIC PROSTATECTOMY Jay K Jhaveri*, Sandhya Rao, Rajiv Yadav, Robert A Leung, Georg Bartsch, E Darracott Vaughan, Ashutosh K Tewari. New York, NY, and Innsbruck, Austria. INTRODUCTION AND OBJECTIVE: Robotic prostatectomy KDVEHFRPHDZLGHO\DFFHSWHGWUHDWPHQWIRUFOLQLFDOO\ORFDOL]HGSURVWDWH cancer. Unfortunately urinary incontinence is a disabling side effect and a variety of strategies are proposed in order to hasten the time to continence. We describe our surgical technique to shorten duration of incontinence and present our continence outcomes herein. METHODS: We have incorporated new tactics to our previous PRGL¿FDWLRQVWRSURGXFHDXQLTXHDQDVWRPRVLV7KLVDQDVWRPRVLVLV completely supported by anatomic structures resulting in low tension and high bladder neck suspension. Our surgical technique includes preservation of the puboprostatic ligaments and arcus tendineus ZLWK GLVVHFWLRQ RI D ÀDS EHKLQG WKH EODGGHU QHFN UHIHUUHG WR DV WKH retrotrigonal layer. We ligate the dorsal venous complex using a puboprostatic ligament sparing stitch. After prostatectomy we plicate the posterior bladder neck to funnel it and to reinforce the bladder posteriorly. We then suture the retrotrigonal layer to Denonvillier’s fascia to include WKHPHGLDQ¿EURXVUDSKHDQG¿QDOO\WKHFHQWUDOWHQGRQRIWKHSHULQHXP completing the posterior reconstruction and restoring the functional and anatomic length of the rhabdosphincter. The anterior reconstruction is performed by attaching the arcus tendineus to the bladder thus creating ODWHUDODQGDQWHULRUVXSSRUWWRWKHDQDVWRPRVLV:HWKHQXWLOL]HYDOLGDWHG health-related quality of life questionnaires in addition to third party telephone interviews at 1, 6, 12 and 24 weeks post-operatively to record FRQWLQHQFHRXWFRPHV&RQWLQHQFHLVGH¿QHGDVXVLQJQRSDGVSHUGD\ or using 1 dry security liner. 5(68/76 :H HPSOR\HG WKHVH WHFKQLFDO PRGL¿FDWLRQV LQ the last 260 consecutive patients, 17 were unavailable for follow-up via questionnaires or phone interviews. For the remaining 243, at 1,6,12 and 24 weeks, the continence rates are 36%,75%, 88%, 96% respectively. CONCLUSIONS: With this anatomic restoration of the vesicourethral junction, we observe that due to a good degree of bladder neck suspension, a reinforced anastomosis and restoration of the functional length of the sphincter, we have noticed an improvement in early continence as well as overall continence rates.
Source of Funding: None
Vol. 179, No. 4, Supplement, Wednesday, May 21, 2008
1778 ROBOTIC VS. OPEN RADICAL PROSTATECTOMY: A SINGLE INSTITUTION, SINGLE SURGEON COMPARISON OF OUTCOME Michael O Koch*, William Smith. Indianapolis, IN. INTRODUCTION AND OBJECTIVE: Several centers have attempted to compare oncologic outcomes with open radical prostatectomy to laparoscopic prostatectomy. These studies have compared the outcomes of different surgeons and/or had selection GLIIHUHQFHVVLJQL¿FDQWO\OLPLWLQJWKHYDOLGLW\RIFRQFOXVLRQV,QWKLVVWXG\ we compare the results of a single surgeon with open and robotic laparoscopic prostatectomy over a ten year period. METHODS: 787 consecutive male patients underwent open radical prostatectomy (n=367) or robotic assisted laparoscopic SURVWDWHFWRP\ Q IRUSDWKRORJLFDOO\FRQ¿UPHG7DWR7ESURVWDWH cancer. All prostatectomies were performed by a single surgeon and ZHUHDQDO\]HGE\DVLQJOHSDWKRORJLVWXVLQJDZKROHPRXQWWHFKQLTXHDW Indiana University between 5/12/98 - 9/18/07. No patients were excluded because of a learning curve. The primary outcome parameters were positive margin rate and margin site. RESULTS: 19 patients were excluded from study due to inability to access complete medical records. Open positive margin rates were: pT2a-2%, pT2b-12.4%, pT2c-50%, pT3a-30.8%, pT3b-54.5%. Robotic positive margin rates were pT2a-2.2%, pT2b-10.4%, pT2c-7.7%, pT3a-25.3%, pT3b-24.1%. The most common positive margin site for both open and robotic prostatectomy was apex. No differences existed LQPHDQDQGPHGLDQDJHSURVWDWHVL]HSUHVHQWDWLRQ36$WRWDO*OHDVRQ score, or tumor volume at any stage between the groups. CONCLUSIONS: Robotic assisted laparoscopic prostatectomy is associated with equal or superior pathologic outcomes compared to RSHQSURVWDWHFWRP\LQRXUH[SHULHQFH8OWLPDWHO\WUXHRQFRORJLFHI¿FDF\ will have to be based upon long term follow-up comparing disease free and overall survival. Source of Funding: None
1779 PREDICTORS OF URINARY CONTINENCE AFTER CONTEMPORARY RADICAL PROSTATECTOMY Jaspreet S Sandhu*, Theresa M Koppie, Angel M Cronin, Kinjal C Vora, Farhang Rabbani, Karim Touijer, Bertrand D Guillonneau, Andrew J Vickers, James A Eastham, Peter T Scardino. New York, NY, and Sacramento, CA. INTRODUCTION AND OBJECTIVE: Urinary incontinence after radical prostatectomy (RP) occurs in a large minority of patients. Multiple risk factors are known and proposed. We sought pre-operative, intra-operative and peri-operative risk factors associated with urinary incontinence in a contemporary series of patients undergoing RP. METHODS: An Institutional Review Board approved retrospective study was performed. 2416 patients underwent RP by RQHRI¿YHVXUJHRQVEHWZHHQ-XO\ DQG-XQHSDWLHQWV had adequate continence follow-up. Univariate and multivariable logistic regression was used to determine variables associated with continence \HDU IROORZLQJ 53 9DULDEOH DQDO\]HG LQFOXGHG LQFOXGH DJH 36$ body mass index (BMI), American Society of Anesthesiologists class (ASA), MRI estimated prostate volume, history of TURP, clinical stage, biopsy Gleason grade, neoadjuvant therapy, operative time, estimated blood loss, nerve sparing status, surgeon opinion of vesicourethral anastomosis, presence of a urine leak 2 or more days after RP, and anastomotic stricture needing intervention within a year of RP. Restricted cubic splines were used when evaluating MRI volume to relax linearity assumptions. All variables were included in the multivariable model H[FHSW05,YROXPHDQGXULQHOHDNIRUZKLFKZHKDGVLJQL¿FDQWPLVVLQJ GDWD&RQWLQHQFHZDVGH¿QHGDVWKHQHHGIRUQRSDGVIRUXULQDU\FRQWURO at 1 year post RP. RESULTS: 1351 (83%) were continent at 1 year following RP. On univariate analysis, men younger at surgery (p<0.0005) and with lower BMI (p=0.006), ASA (p=0.001), or MRI volume (p=0.005) ZHUH VLJQL¿FDQWO\ PRUH OLNHO\ WR EH FRQWLQHQW DW \HDU IROORZLQJ 53 those having nerves resected (p=0.011), with a urine leak (p=0.005) RU DQDVWRPRWLF VWULFWXUH S ZHUH VLJQL¿FDQW OHVV OLNHO\ WR EH continent at 1 year following RP. Since older men tend to have larger prostates, we examined the effect of preoperative MRI volume on