Robotic Assisted Laparoscopic Salvage Prostatectomy for Radiation Resistant Prostate Cancer
Salvage prostatectomy is associated with the highest biochemical cure rate following radiation failure for prostate cancer. However, this approach is technically difficult and associated with tremendous potential morbidity including massive blood loss, urinary incontinence, erectile dysfunction and bowel injury. It is unclear whether a laparoscopic approach provides a less morbid treatment. Eandi et al (page 133) from Duarte, California report the results of salvage robotic assisted laparoscopic prostatectomy in 18 patients with a mean followup of 18 months. Previous treatment included brachytherapy in 8, external beam radiation in 8 and proton beam therapy in 2 patients. Mean time to surgery following primary treatment with radiation was 79 months. Median parameters for operative blood loss, operating time and hospital stay were 150 ml, 2.6 hours and 2 days, respectively. Of the patients 67% were free of biochemical progression at followup and a third was continent. There were no rectal injuries in this series. The authors suggest that robotic assisted laparoscopic prostatectomy can be used for salvage prostatectomy with minimal morbidity compared with open salvage surgery, although a direct comparison was not performed.
A Combination of Multiple Molecular Markers Can Improve Prognostication of Bladder Cancer
Many single institution series have shown that molecular markers can be used to increase predictive capabilities for failure of bladder cancer treatment. However, such use of these markers is poor when they are subjected to large clinical trials at multiple institutions. Shariat et al (page 68) tested a combination of cell cycle regulators (p53, pRB, p21 and p27) in combination in a large multi-institutional collaboration of patients with pT3-4N0 or pTany Npositive bladder cancer. Whereas individual biomarkers failed to improve predictive accuracy, the combination of all 4 molecular markers demonstrated a significantly higher predictive accuracy than any single biomarker. For the entire cohort of patients predictive accuracy was increased by 69.9% for disease recurrence and by 71.1% for cancer specific survival. The authors conclude that a panel using 4 well established regulatory molecular markers improved prognostic accuracy by a clinically significant margin.
Repeat Synthetic Mid Urethral Sling Procedure for Women With Recurrent Stress Urinary Incontinence
Stav et al (page 241) from Victoria, Australia compared the outcome of a repeat mid urethral sling (MUS) procedure with a primary MUS for stress urinary incontinence in a retrospective study of 1,112 patients, of whom 77 (7%) underwent the repeat procedure to achieve relief from persistent incontinence. The repeat procedures comprised a retropubic sling in 48 cases and a transobturator sling in 29. The overall subjective cure rate in the primary MUS group was 86% vs 62% in the repeat MUS group. The overall subjective success rate in the repeat group was higher with the retropubic sling (71%) vs the transobturator approach (48%). The authors demonstrate that repeat MUS has a significantly lower cure rate than primary procedures, although should a repeat procedure be necessary the retropubic sling was associated with a higher success rate than the transobturator sling. Of interest, urge incontinence was also higher with repeat MUS.
Long-Term Durability of Percutaneous Tibial Nerve Stimulation for Overactive Bladder
It is well-known that only a third of patients on antimuscarinics continue to take them due to lack of efficacy or side effects. Newer, especially nonpharmacological, treatments are needed. MacDiarmid et al (page 234) analyze the results of a multi-institutional randomized trial comparing percutaneous tibial nerve stimulation (PTNS) to extended-release tolterodine to determine efficacy beyond the predetermined end point. Of the subjects 87 completed the trial (PTNS 44 and tolterodine 43). Statistically significant improvement or cure over baseline overactive bladder symptoms was significantly higher in the PTNS group (79.5%) compared to the tolterodine group (54.8%). After 6 months urinary frequency decreased from a baseline of 12.6 to 9.4, nocturia decreased from 2.6 to 1.6, and daily urge incontinence episodes decreased from 2.4 to 0.8. Adjusted values at 6 months were durable at 12 months. However, a substantial dropout of patients occurred after completion of the study at 3, 6 and 12 months. It is unclear whether the results would have been so optimistic with longer followup including intent to treat.
Patient Perceived Effectiveness of the AdVance™ Sling for Post-Prostatectomy Incontinence
Gill et al (page 247) from Cleveland, Ohio performed a retrospective chart review and telephone survey of 33 patients who received an AdVance transobturator sling a mean of 35 weeks after prostatectomy. The success rate from medical records and followup was 51% but only 28% on the telephone survey. Of the 17 patients in whom the sling failed none was pad-free, 3 pursued further treatment with bulking agents and 3 experienced retention. Pad use decreased from 3.7 to 1.4 pads a day. These results indicate that the transobturator sling can provide improvement in properly selected patients, measured objectively with pad use and subjectively by patient global impression of improvement. However, overall results are modest in terms of pad-free rates.
Reduced Preoperative Prostate Specific Antigen Levels in Men Taking Statins
Previous studies have suggested that statins used to treat elevated lipids may improve prostate specific antigen (PSA) levels. In vitro, statins demonstrate antitumor effects. To determine the effect of statins on PSA levels in patients with prostate cancer Krane et al (page 118) from Detroit, Michigan performed a retrospective study on 3,828 patients undergoing radical prostatectomy from January 2001 to July 2008 and identified 1,031 taking statin medications. Compared to patients not on statins, mean PSA levels were significantly lower by 0.2 ng/ml. While this is interesting, its clinical significance is unclear and probably modest.
Renal Insufficiency is an Independent Risk Factor for Complications of Partial Nephrectomy
Serum creatinine alone is a poor marker for renal function and a better estimate of renal insufficiency is the MDRD (Modification of Diet in Renal Disease) formula. Hakimi et al (page 43) from Bronx, New York report that preoperative renal insufficiency, defined as MDRD less than 60 ml per minute per 1.73 m2, was predictive of increased hospital stay, subsequent renal dysfunction and increased morbidity after partial nephrectomy. Validation by larger studies at multiple centers is needed. Regardless, special caution should be exercised in patients presenting with reduced renal function which in turn is an indication for partial nephrectomy.
Orthotopic Neobladder Versus Indiana Pouch in Women: QOL Outcomes
Until recently neobladders have been used primarily in men. Large et al (page 201) from Chicago, Illinois retrospectively analyzed a single surgeon series of orthotopic neobladder vs continent urinary diversion with the Indiana pouch for health related quality of life outcomes. Of the patients 87% in the neobladder group and 93% in the pouch group were available for evaluation at a median followup of 34 and 24 months, respectively. No significant differences were found in tumor status or complications. The 5-year survival rates were higher in the orthotopic neobladder group (65% vs 58%). The authors believe that health related quality of life metrics were not significantly different between the groups. Either of these approaches is feasible to treat women with bladder cancer.
Chronic Testicular Pain as a Symptom of Pelvic Floor Dysfunction
Is there an association between chronic testicular pain and male pelvic pain syndrome? Planken et al (page 177) from Leiden, the Netherlands attempt to answer this question by retrospectively reviewing the records of 41 patients with chronic testicular pain using standard pelvic floor methodology. Methods included electromyography registration of the pelvic floor, and a questionnaire on complaints in the 3 domains of micturition, defecation and sexual function. Average patient age was 48 years, and 93% of the patients had at least 1 symptom suspicious for pelvic floor dysfunction. Complaints were reported in 1 domain by 22%, in 2 domains by 24% and in all 3 domains by 49% of the patients. Moreover, increased resting tone of pelvic floor electromyography activity was noted in 88% of men. It appears that chronic testicular pain was associated with pelvic floor overactivity in this population, especially in younger patients.
Evaluation of Renal Function Following Major Renal Injury
Tasian et al (page 196) from San Francisco, California analyzed whether staging renal trauma using the AASTI (American Association for the Surgery of Trauma Injury Scale) has any prognostic value. In their retrospective review of renal function following renal trauma they found a strong association between the severity of renal injury on the AASTI scale and reduction in renal function on dimercaptosuccinic acid scanning. Of note, this was a highly selected group with only a third of the patients treated nonoperatively and the majority having disproportionately higher stage injuries, explaining the followup scans. Grade V injuries resulted in about a 60% loss of renal function. Previous studies have shown that whether the renal scan is performed early or late does not affect the detected loss of renal function. The authors argue that nephrectomy may be appropriate for grade V injury since surgical salvage involves such a dramatic loss of renal function and a substantial complication rate.
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