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THE JOURNAL OF UROLOGY®
Vol. 179, No. 4, Supplement, Sunday, May 18, 2008
416 LYMPHATIC SPARING MICROSCOPIC RETROPERITONEAL VARICOCELECTOMY Jean Wong*, Steven C Friedman, Michael L Blute, Sherman Chan. Brooklyn, NY. INTRODUCTION AND OBJECTIVE: Varicoceles are dilated and tortuous testicular veins of the pampiniform plexus of the spermatic cord that are found in approximately 15% of male adolescents. One of the common approaches for varicocelectomy in adolescents is the Palomo high retroperitoneal mass ligation technique. The classic Palomo technique is associated with a 7% hydrocele rate and a 2% recurrence UDWH:HUHSRUWDVLQJOHVXUJHRQ¶VH[SHULHQFHZLWKDPRGL¿FDWLRQRQ the Palomo technique in which an operating microscope is brought into WKH¿HOGDIWHUWKHYHVVHOVDUHLGHQWL¿HGLQWKHUHWURSHULWRQHXP3ULRUWR OLJDWLRQWKUHHWRIRXUO\PSKDWLFVDUHLGHQWL¿HGDQGSUHVHUYHG%\VSDULQJ the lymphatics, we are attempting to reduce the hydrocele rate to levels achieved by the microscopic inguinal and subinguinal method. METHODS: Between Nov 2004 and Jun 2007, twenty boys with grade 3 left varicoceles underwent retroperitoneal gonadal vessel ligation with microscope assisted sparing of the lymphatics. The boys had a mean age of 15 years (range 12 to 19). Typical follow-up is at 1 week, 3 months, 6 months, 12 months and then annually. Follow-up ranged from three months to two years, with a mean follow-up of 7.7 months. One child was lost to follow-up. RESULTS: All boys who had the microscopic Palomo procedure had sparing of several lymphatics as identified by the microscope using high power. A clinical exam was performed to assess for recurrence and hydrocele. All boys who followed up had no hydroceles and no recurrences to date. No occurrences of testicular atrophy were noted. CONCLUSIONS: Although 29% of pediatric urologists do not XVHDQ\W\SHRIRSWLFDOPDJQL¿FDWLRQIRUYDULFRFHOHFWRP\WKHPLFURVFRSH is playing a larger role in varicocele surgery regardless of the approach. For example, the microscope has played a large role in inguinal and subinguinal approaches. However, this technique can take up to 2 hours and cases of testicular atrophy have been reported. We report no complications in our study and shorter operative time compared to the inguinal and subinguinal approaches. Patients undergo a muscle splitting incision, which has a short recovery time and does not require DQ RYHUQLJKW KRVSLWDO VWD\ 2XU WHFKQLTXH XVHV PDJQL¿FDWLRQ LQ WKH retroperitoneum and has not been described in the past. It combines the simplicity of the original Palomo technique with a short period of PLFURVFRSLFGLVVHFWLRQIRULGHQWL¿FDWLRQDQGVSDULQJRIWKHO\PSKDWLFV 7KLVPRGL¿FDWLRQRIWKH3DORPRWHFKQLTXHEHQH¿WVIURPDFRQWLQXHGKLJK success rate with a reduction in hydrocele rates postoperatively. Source of Funding: None
Prostate Cancer: Epidemiology and Natural History (II) Podium Session 13 Sunday, May 18, 2008
1:00 - 3:00 pm
417 WHICH IS THE MOST IMPORTANT RISK FACTOR FOR PROSTATE CANCER: RACE, FAMILY HISTORY, OR BASELINE PSA LEVEL? Dana M Mondo*, Kimberly A Roehl, Stacy Loeb, Sara N Gashti, &KULVWRSKHU5*ULI¿Q1RUP'6PLWK5REHUW%1DGOHU:LOOLDP- Catalona. Chicago, IL, Saint Louis, MO, and Baltimore, MD. INTRODUCTION AND OBJECTIVE: Prostate cancer (CaP) affects a disproportionate percentage of African Americans (AA). Additionally, men with a family history (FH) of CaP are at an increased risk of developing the disease. Recently, studies have suggested that DEDVHOLQH36$OHYHODERYHWKHDJHVSHFL¿FPHGLDQLVDOVRDVWURQJ predictor of future CaP risk. In men with both traditional risk factors (AA and +FH), the relationship between an initial screening PSA below the DJHVSHFL¿FPHGLDQDQGSURVWDWHFDQFHUULVNLVXQNQRZQ METHODS: A longitudinal PSA- and DRE- based CaP screening study enrolled 26,111 volunteers from 1991 to 2001. In study
participants, we examined the relative importance of the baseline PSA level for the prediction of CaP risk between AA and Caucasian © men, DIWHUVWUDWL¿FDWLRQIRU)+VWDWXV RESULTS: Of the 329 participants who were both AA and KDGD)+RI&D3 KDGDQLQLWLDO36$EHORZWKHDJHVSHFL¿F median. They were divided into three age groups, 40s, 50s, and 60s+ with a mean follow-up time of 19.5, 71, and 81 months, respectively. None of the men in their 40s or 50s were diagnosed with prostate cancer during follow-up. In men age 60 or older, 3 (14%) men were eventually diagnosed with prostate cancer. Table 1 compares prostate cancer detection rates between these men and 3 lower risk groups. With a PSA EHORZWKHDJHVSHFL¿FPHGLDQWKH&D3GHWHFWLRQUDWHZDVVLPLODUO\ORZ regardless of race or FH status. However, among men with a baseline 36$OHYHODERYHWKHDJHVSHFL¿FPHGLDQUDFHDQG)+ZHUHVLJQL¿FDQW predictors of CaP risk. CONCLUSIONS: AA men with a +FH were unlikely to develop &D3 LI WKHLU EDVHOLQH 36$ OHYHO ZDV EHORZ WKH DJHVSHFL¿F PHGLDQ The National Comprehensive Cancer Network currently recommends a baseline PSA test at age 40, after which the screening protocol may EHLQGLYLGXDOL]HGEDVHGXSRQWKHUHODWLRQVKLSRIWKLVOHYHOWRWKHDJH VSHFL¿FPHGLDQ2XUUHVXOWVGHPRQVWUDWHWKDWWKHHIIHFWRIWKHEDVHOLQH PSA level on future CaP risk is so robust that the correlation holds true HYHQIRUPHQZLWKRWKHUVLJQL¿FDQWULVNIDFWRUV7KXVRWKHURUJDQL]DWLRQV may similarly consider recommending a baseline PSA test at a young age for risk assessment. 7DEOH3URVWDWH&DQFHU'HWHFWLRQ5DWHV6WUDWL¿HGE\%DVHOLQH36$9DOXH5DFHDQG Family Fistory. Age Demographics PSA Below Median PSA Above Median AA/+FH 0% 8% AA/-FH 0% 4% 40s C/+FH 1% 3% C/-FH 0% 0% p-value p=0.52 p<0.0001 AA/+FH 0% 16% AA/-FH 1% 11% 50s C/+FH 1% 10% C/-FH 1% 8% p-value p=0.49 p=0.03 AA/+FH 14% 30% AA/-FH 3% 28% 60s+ C/+FH 3% 23% C/-FH 2% 19% p-value p=0.06 p<0.0001
Source of Funding: Beckman Coulter Incorporated and Urological Researach Foundation.
418 PREDICTORS OF CLINICAL METASTASES IN PROSTATE CANCER PATIENTS ON ANDROGEN DEPRIVATION THERAPY Robert Abouassaly*, Alan Paciorek, Eric A Klein, Charles J Ryan, Peter R Carroll. Cleveland, OH, and San Francisco, CA. INTRODUCTION AND OBJECTIVE: Virtually all patients with prostate cancer on androgen deprivation therapy (ADT) will ultimately develop evidence of resistance to treatment. The prognosis for patients who develop metastatic disease on ADT is poor, with overall survival estimated to be 24 to 36 months. Our aim is to identify predictors of clinical disease progression in patients with prostate cancer on ADT. METHODS: Of the 13,740 men with biopsy proven prostate cancer enrolled in the CaPSURE database from 1995-present, we LGHQWL¿HGPHQWUHDWHGZLWK$'7DIWHUGLDJQRVLVZLWKRXWHYLGHQFHRI metastases at treatment initiation. These men were followed for a median of 3.7 years, with the primary endpoint being the development of bone metastases. Other treatments combined with ADT (radical prostatectomy vs radiation vs none), age, clinical risk category at diagnosis, percent of biopsies positive, BMI, race and number of comorbidities were compared between patients who developed metastases and those that did not using &KLVTXDUHWHVWVLQD&R[SURSRUWLRQDOKD]DUGVUHJUHVVLRQPRGHO RESULTS: In addition to ADT, 1397(35%) were treated with radiation, 653(16%) with RP, 89(2%) were treated with both, and 1869(47%) were treated with ADT alone. The majority of men were either high (43%) or moderate risk (34%) at diagnosis. Mean age of the men in the cohort was 70 years (range 39-94 years). One hundred and ninety-six men (4.9%) progressed to metastatic disease a median of 18 months from the start of ADT (range 1-139 months). On both univariate