Publications by authors named "Fernando Secin"

40 Publications

Pelvic lymph node dissection in high-risk prostate cancer.

Int Braz J Urol 2022 Feb 11;48. Epub 2022 Feb 11.

Discipline of Urology, Universidad de Buenos Aires, Argentina.

Introduction: The therapeutic role of pelvic lymph node dissection (PLND) in prostate cancer (PCa) is unknown due to absence of randomized trials.

Objective: to present a critical review on the therapeutic benefits of PLND in high risk localized PCa patients.

Materials And Methods: A search of the literature on PLND was performed using PubMed, Cochrane, and Medline database. Articles obtained regarding diagnostic imaging and sentinel lymph node dissection, PLND extension, impact of PLND on survival, PLND in node positive "only" disease and PLND surgical risks were critically reviewed.

Results: High-risk PCa commonly develops metastases. In these patients, the possibility of presenting lymph node disease is high. Thus, extended PLND during radical prostatectomy may be recommended in selected patients with localized high-risk PCa for both accurate staging and therapeutic intent. Although recent advances in detecting patients with lymph node involvement (LNI) with novel imaging and sentinel node dissection, extended PLND continues to be the most accurate method to stage lymph node disease, which may be related to the number of nodes removed. However, extended PLND increases surgical time, with potential impact on perioperative complications, hospital length of stay, rehospitalization and healthcare costs. Controversy persists on its therapeutic benefit, particularly in patients with high node burden.

Conclusion: The impact of PLND on biochemical recurrence and PCa survival is unclear yet. Selection of patients may benefit from extended PLND but the challenge remains to identify them accurately. Only prospective randomized study would answer the precise role of PLND in high-risk pelvis confined PCa patients.
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http://dx.doi.org/10.1590/S1677-5538.IBJU.2020.1063DOI Listing
February 2022

[Epidemiology, etiology and prevention of bladder cancer.]

Arch Esp Urol 2020 12;73(10):872-878

Docente autorizado de Urología. UBA. Argentina.

Bladder cancer is the seventh most frequent cancer on male population and eleventh within the whole inhabitants. Differences in incidence and mortality between countries and regions exist. Those differences depend on variables including epidemiological data, social and cultural features and economics amongst the several populations that are exposed to different risk factors and treatment approaches. Smoking is the strongest risk factor for bladder cancer, representing approximately 50% of the cases. Its alternative, the electronic cigarette does not seem to providea decrease in risk of bladder cancer. Employment exposure to aromatic amines, aromatic polycyclic hydrocarbons and chlorate hydrocarbons, are still important risk factors. Water consumption with high levels of arsenic has also shown an increased risk of bladder cancer. Fast acetylators or genetic predisposition would be tentative risk factors. Some medical treatments with chemotherapy oradiation therapy increase bladder cancer risk. Identifying all these factors allows for progress in the field of prevention and early detection. The main objective is to decrease incidence and mortality related to bladder cancer.
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December 2020

Small renal masses in Latin-American population: characteristics and prognostic factors for survival, recurrence and metastasis - a multi-institutional study from LARCG database.

BMC Urol 2020 Jul 2;20(1):85. Epub 2020 Jul 2.

Puigvert Foundation, Barcelona, Spain.

Background: To evaluate demographic, clinical and pathological characteristics of small renal masses (SRM) (≤ 4 cm) in a Latin-American population provided by LARCG (Latin-American Renal Cancer Group) and analyze predictors of survival, recurrence and metastasis.

Methods: A multi-institutional retrospective cohort study of 1523 patients submitted to surgical treatment for non-metastatic SRM from 1979 to 2016. Comparisons between radical (RN) or partial nephrectomy (PN) and young or elderly patients were performed. Kaplan-Meier curves and log-rank tests estimated 10-year overall survival. Predictors of local recurrence or metastasis were analyzed by a multivariable logistic regression model.

Results: PN and RN were performed in 897 (66%) and 461 (34%) patients. A proportional increase of PN cases from 48.5% (1979-2009) to 75% (after 2009) was evidenced. Stratifying by age, elderly patients (≥ 65 years) had better 10-year OS rates when submitted to PN (83.5%), than RN (54.5%), p = 0.044. This disparity was not evidenced in younger patients. On multivariable model, bilaterality, extracapsular extension and ASA (American Society of Anesthesiologists) classification ≥3 were predictors of local recurrence. We did not identify significant predictors for distant metastasis in our series.

Conclusions: PN is performed in Latin-America in a similar proportion to developed areas and it has been increasing in the last years. Even in elderly individuals, if good functional status, sufficiently fit to surgery, and favorable tumor characteristics, they should be encouraged to perform PN. Intending to an earlier diagnosis of recurrence or distant metastasis, SRM cases with unfavorable characteristics should have a more rigorous follow-up routine.
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http://dx.doi.org/10.1186/s12894-020-00649-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7331283PMC
July 2020

Priorities in testis cancer care during Covid-19 Pandemic.

Authors:
Fernando P Secin

Int Braz J Urol 2020 07;46(suppl.1):79-85

Discipline of Urology, University of Buenos Aires School of Medicine, Buenos Aires, Argentina.

Introduction: There is little information on how to prioritize testis cancer (TC) patients' care during COVID-19 pandemic in order to relieve its pressure on the health care systems.

Objective: To describe the recommendations for diagnosis, treatment and follow-up of patients with TC amidst COVID- 19 pandemic.

Material And Methods: Pubmed search and review of the main urological association guidelines on TC.

Results: The biology of TC requires immediate care of patients during diagnosis, initial surgical therapy and management of recurrent disease. Active surveillance is the first choice of management and should be offered to all compliant clinical stage I TC patients provided they understand the need to self-isolate. Active surveillance may also help decrease the demand for intensive care unit beds, ventilators, personal protective equipment, and other critical hospital and human resources by minimizing surgeries without compromising patient outcomes. Complications of therapy and symptomatic patients represent medical emergencies and should be treated immediately. Telemedicine may be useful during follow-up periods.

Conclusions: Most stages of testis cancer require urgent care; however, all recommendations must be adapted to local health care priorities considering that most of these patients are at low risk of severe COVID-19 infection.
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http://dx.doi.org/10.1590/S1677-5538.IBJU.2020.S109DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7719997PMC
July 2020

Biochemical recurrence-free conditional probability after radical prostatectomy: A dynamic prognosis.

Int J Urol 2019 07 18;26(7):725-730. Epub 2019 Apr 18.

Department of Urology, Institute Mutualiste Montsouris, Université Paris-Descartes, Paris, France.

Objective: To estimate the conditional biochemical recurrence-free probability and to develop a predictive model according to the disease-free interval for men with clinically localized prostate cancer treated with minimally invasive radical prostatectomy.

Methods: The study population consisted of 3576 consecutive patients who underwent laparoscopic radical prostatectomy and 2619 men treated with robotic radical prostatectomy in the past 15 years at Institute Mutualiste Montsouris, Paris, France. Biochemical recurrence was defined as serum prostate-specific antigen ≥0.2 ng/dL. Univariable and multivariable survival analyses were carried out to identify the prognostic factors for overall free-of-biochemical recurrence probability and conditional survival with respect to the years from surgery without recurrence. A detailed nomogram for the static and dynamic prognosis of biochemical recurrence was developed and internally validated.

Results: The median follow-up period was 8.49 years (interquartile range 4.01-12.97), and 1148 (19%) patients experienced biochemical recurrence. Significant variables associated with biochemical recurrence in the multivariable model included preoperative prostate-specific antigen, positive surgical margins, extracapsular extension, pathological Gleason ≥4 + 3 and laparoscopic surgery (all P < 0.001). Conditional survival probability decreased with increasing time without biochemical recurrence from surgery. When stratified by prognosis factors, the 5- and 10-year conditional survival improved in all cases, especially in men with worse prognosis factors. The concordance index of the nomogram was 0.705.

Conclusions: Conditional survival provides relevant information on how prognosis evolves over time. The risk of recurrence decreases with increasing number of years without disease. An easy-to-use nomogram for conditional survival estimates can be useful for patient counseling and also to optimize postoperative follow-up strategies.
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http://dx.doi.org/10.1111/iju.13982DOI Listing
July 2019

Robotic surgery in public hospitals of Latin-America: a castle of sand?

World J Urol 2018 Apr 19;36(4):595-601. Epub 2018 Feb 19.

Hospital Universitario de Caracas, Caracas, Venezuela.

Introduction: There is no information about the evolution of robotic programs in public hospitals of Latin-America.

Objective: To describe the current status and functioning of robotic programs in Latin-American public hospitals since their beginning to date.

Methods: We conducted a survey among leading urologists working at public hospitals of Latin-America who had acquired the Da Vinci laparoscopic-assisted robotic system. Questions included: date the program started, its utilization by other services, number and kind of surgeries, surgery paying system, surgery related deaths, occurrence and reasons of robotic program interruptions and its use for training purposes. Medians and 25-75 centiles (IQR) were estimated.

Results: Since 2009, there are ten public hospitals of four Latin-American countries that acquired the Da Vinci robotic system. The median number of months robotic programs has been functioning without considering transitory interruption: 43 (IQR 35, 55). Median number of urologic and total surgeries performed: 140 (IQR 94, 168) and 336 (IQR 292, 621), respectively. The corresponding median number of urologic and total surgeries performed per month: 3 (IQR 2, 5) and 8 (IQR 5, 11). Median number of total surgeries performed per year per institution was 94 (IQR 68,123). The median proportion of urologic cases was 40% (IQR 31, 48), ranging from 24 to 66%. Five of ten institutions had their urology programs transitory or definitively closed due to the high burden costs.

Conclusion: Adoption and development of robotic surgery in some public hospitals of Latin-America have been hindered by high costs.
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http://dx.doi.org/10.1007/s00345-018-2227-5DOI Listing
April 2018

[Current status of urological training in Latin America.]

Arch Esp Urol 2018 Jan;71(1):23-33

Bowman Gray School of Medicine. Wake Forest University. Winston Salem. North Carolina. EEUU.

Objective: Achieving residents' medical training of quality is a constant concern in the Confederación Americana de Urología (CAU), the third Urological Society worldwide. We aim to analyze the diversity of state training programs, with the intention to identify opportunities for global improvement within them and also to analyse the professional reality in different countries.

Methods: Data from 2nd and 3rd Foro Educativo CAU regarding postgraduate training and labour implications are reviewed. This information is complemented by the opinion of representatives involved with the academic training in Confederación Americana de Urología, who have analyzed the reality and current status of the urological training through a 10-question survey that describes different aspects of residency program in the countries confederated in CAU.

Results: A total of 3,000 graduate doctors train as residents in Urology at the CAU environment. Each year 670 residents begin their training program in Latin America, Spain and Portugal, a territory that serves nearly 650 million people, with an active professional force of around 16.800 professionals. Detailed data on training, employment and supporting reality in the countries that comprise the CAU are presented. We also discuss the proportion of residents who carry out research and doctorate during the residency program. Finally, we examine the proportion of professionals who receive specific training at the end of their residence, the relative importance of this training and what are the most popular environments to carry it out.

Conclusions: Current postgraduate training in CAU environment is heterogeneous in their programs, as well as in the modes of accreditation and recertification. Academic activities do not seem to be properly valued. However, specific training offers better expectations of professional development.
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January 2018

Comparative Analysis of Partial Gland Ablation and Radical Prostatectomy to Treat Low and Intermediate Risk Prostate Cancer: Oncologic and Functional Outcomes.

J Urol 2018 01 18;199(1):140-146. Epub 2017 Aug 18.

Department of Urology, Institut Mutualiste Montsouris, Université Paris-Descartes, Paris, France.

Purpose: We analyzed the oncologic and functional outcomes of partial gland ablation compared with robot-assisted radical prostatectomy in patients with low and intermediate risk prostate cancer.

Materials And Methods: A total of 1,883 patients underwent robot-assisted radical prostatectomy and 373 underwent partial gland ablation from July 2009 to September 2015. We selected 1,458 of these participants for analysis, including 1,222 and 236 treated with robot-assisted radical prostatectomy and partial gland ablation, respectively. Patients had a Gleason score of 3 + 3 or 3 + 4, clinical stage T2b or less, prostate specific antigen 15 ng/dl or less, unilateral disease and life expectancy greater than 10 years. Propensity score matching analysis (1:2) was applied in the overall robot-assisted radical prostatectomy sample, which selected 472 patients for comparison. For partial gland ablation 188 men underwent high intensity focused ultrasound and 48 underwent cryotherapy. Oncologic outcomes were analyzed in terms of the need for salvage treatment. Partial gland ablation failure was defined as any positive control biopsy after treatment. Functional outcomes were assessed by validated questionnaires.

Results: Matching was successful across the 2 groups, although men treated with partial gland ablation were older (p <0.001). Mean followup in the partial gland ablation group was 38.44 months. Partial gland ablation failure was observed in 68 men (28.8%), including 53 (28.1%) treated with high intensity focused ultrasound and 15 (31.2%) treated with cryotherapy. Partial gland ablation was associated with a higher risk of salvage treatment (HR 6.06, p <0.001). Complications were comparable between the groups (p = 0.06). Robot-assisted radical prostatectomy was associated with less continence recovery and a lower potency rate 3, 6 and 12 months after surgery (p <0.001).

Conclusions: In select patients with organ confined prostate cancer partial gland ablation offered good oncologic control with fewer adverse effects that required additional treatments. Potency and continence appeared to be better preserved after partial gland ablation.
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http://dx.doi.org/10.1016/j.juro.2017.08.076DOI Listing
January 2018

Learning curve of minimally invasive radical prostatectomy: Comprehensive evaluation and cumulative summation analysis of oncological outcomes.

Urol Oncol 2017 04 20;35(4):149.e1-149.e6. Epub 2017 Jan 20.

Department of Urology, Institut Mutualiste Montsouris, Paris, France.

Background And Objective: The primary objective was to evaluate the learning curve of minimally invasive radical prostatectomy (MIRP) in our institution and analyze the salient learning curve transition points regarding oncological outcomes.

Methods: Clinical, pathologic, and oncological outcome data were collected from our prospectively collected MIRP database to estimate positive surgical margin (PSM) and biochemical recurrence (BCR) trends during a 15-year period from 1998 to 2013. All the radical prostatectomies (laparoscopic prostatectomy [LRP]/robot-assisted laparoscopic radical prostatectomy [RARP]) were performed by 9 surgeons. PSM was defined as presence of cancer cells at inked margins. BCR was defined as serum prostate-specific antigen >0.2ng/ml and rising or start of secondary therapy. Surgical learning curve was assessed with the application of Kaplan-Meier curves, Cox regression model, cumulative summation, and logistic model to define the "transition point" of surgical improvement.

Results: We identified 5,547 patients with localized prostate cancer treated with MIRP (3,846 LRP and 1,701 RARP). Patient characteristics of LRP and RARP were similar. The overall risk of PSM in LRP was 25%, 20%, and 17% for the first 50, 50 to 350, and>350 cases, respectively. For the same population, the 5-year BCR rate decreased from 30% to 16.7%. RARP started 3 years after the LRP program (after approximately 250 LRP). The PSM rate for RARP decreased from 21.8% to 20.4% and the corresponding 5-year BCR rate decreased from 17.6% to 7.9%. The cumulative summation analysis showed significantly lower PSM and BCR at 2 years occurred at the transition point of 350 cases for LRP and 100 cases for RARP. In multivariable analysis, predictors of BCR were prostate-specific antigen, Gleason score, extraprostatic disease, seminal vesicle invasion, and number of operations (P<0.05). Patients harboring PSM showed higher BCR risk (23% vs. 8%, P< 0.05).

Conclusions: Learning curve trends in our large, single-center experience show correlation between surgical experience and oncological outcomes in MIRP. Significant reduction in PSM and BCR risk at 2 years is noted after the initial 350 cases and 100 cases of LRP and RARP, respectively.
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http://dx.doi.org/10.1016/j.urolonc.2016.10.015DOI Listing
April 2017

Questionable oncologic benefits of degarelix.

Authors:
Fernando P Secin

Urol Oncol 2016 10 28;34(10):423-6. Epub 2016 Jun 28.

Urologic Oncology, CEMIC University Hospital, Buenos Aires, Argentina. Electronic address:

Introduction: Luteinizing hormone releasing hormone (LhRh) antagonist degarelix has been approved by the Food and Drug Administration (FDA) for the treatment of advanced prostate cancer in 2008. However, the studies that followed such initial approval have several limitations.

Objective: To make a critical review of those publications.

Methods: Literature search on degarelix.

Results: The studies supporting the use of degarelix are criticized on the basis of selection bias in regards to the heterogeneous populations described, ad hoc analyses with low statistical merit, and the presentation of selected data that would appear to be favorable to the evaluated medication. In addition, those studies still have not shown that any of the data that they point out have any association with clinical benefit.

Conclusion: The flawed methodology of these publications makes the evidence to support the use of degarelix rather weak.
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http://dx.doi.org/10.1016/j.urolonc.2016.05.029DOI Listing
October 2016

American Confederation of Urology (CAU) experience in minimally invasive partial nephrectomy.

World J Urol 2017 Jan 30;35(1):57-65. Epub 2016 Apr 30.

La Raza Hospital, Mexico city, Mexico.

Purpose: To describe the perioperative and oncology outcomes in a series of laparoscopic or robotic partial nephrectomies (PN) for renal tumors treated in diverse institutions of Hispanic America from the beginning of their minimally invasive (MI) PN experience through December 2014.

Methods: Seventeen institutions participated in the CAU generated a MI PN database. We estimated proportions, medians, 95 % confidence intervals, Kaplan-Meier curves, multivariate logistic and Cox regression analyses. Clavien-Dindo classification was used.

Results: We evaluated 1501 laparoscopic (98 %) or robotic (2 %) PNs. Median age: 58 years. Median surgical time, warm ischemia and intraoperative bleeding were 150, 20 min and 200 cc. 81 % of the lesions were malignant, with clear cell histology being 65 % of the total. Median maximum tumor diameter is 2.7 cm, positive margin is 8.2 %, and median hospitalization is 3 days. One or more postoperative complication was recorded in 19.8 % of the patients: Clavien 1: 5.6 %; Clavien 2: 8.4 %; Clavien 3A: 1.5 %; Clavien 3B: 3.2 %; Clavien 4A: 1 %; Clavien 4B: 0.1 %; Clavien 5: 0 %. Bleeding was the main cause of a reoperation (5.5 %), conversion to radical nephrectomy (3 %) or open partial nephrectomy (6 %). Transfusion rate is 10 %. In multivariate analysis, RENAL nephrometry score was the only variable associated with complications (OR 1.1; 95 % CI 1.02-1.2; p = 0.02). Nineteen patients presented disease progression or died of disease in a median follow-up of 1.37 years. The 5-year progression or kidney cancer mortality-free rate was 94 % (95 % CI 90, 97). Positive margins (HR 4.98; 95 % CI 1.3-19; p = 0.02) and females (HR 5.6; 95 % CI 1.7-19; p = 0.005) were associated with disease progression or kidney cancer mortality after adjusting for maximum tumor diameter.

Conclusion: Laparoscopic PN in these centers of Hispanic America seem to have acceptable perioperative complications and short-term oncologic outcomes.
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http://dx.doi.org/10.1007/s00345-016-1837-zDOI Listing
January 2017

First off-time treatment prostate-specific antigen kinetics predicts survival in intermittent androgen deprivation for prostate cancer.

Prostate 2016 Jan 26;76(1):13-21. Epub 2015 Oct 26.

Department of Urology, Institut Mutualiste Montsouris, Paris, France.

Background: Prostate-specific antigen (PSA) doubling time is relying on an exponential kinetic pattern. This pattern has never been validated in the setting of intermittent androgen deprivation (IAD). Objective is to analyze the prognostic significance for PCa of recurrent patterns in PSA kinetics in patients undergoing IAD.

Methods: A retrospective study was conducted on 377 patients treated with IAD. On-treatment period (ONTP) consisted of gonadotropin-releasing hormone agonist injections combined with oral androgen receptor antagonist. Off-treatment period (OFTP) began when PSA was lower than 4 ng/ml. ONTP resumed when PSA was higher than 20 ng/ml. PSA values of each OFTP were fitted with three basic patterns: exponential (PSA(t) = λ.e(αt)), linear (PSA(t) = a.t), and power law (PSA(t) = a.t(c)). Univariate and multivariate Cox regression model analyzed predictive factors for oncologic outcomes.

Results: Only 45% of the analyzed OFTPs were exponential. Linear and power law PSA kinetics represented 7.5% and 7.7%, respectively. Remaining fraction of analyzed OFTPs (40%) exhibited complex kinetics. Exponential PSA kinetics during the first OFTP was significantly associated with worse oncologic outcome. The estimated 10-year cancer-specific survival (CSS) was 46% for exponential versus 80% for nonexponential PSA kinetics patterns. The corresponding 10-year probability of castration-resistant prostate cancer (CRPC) was 69% and 31% for the two patterns, respectively. Limitations include retrospective design and mixed indications for IAD.

Conclusion: PSA kinetic fitted with exponential pattern in approximately half of the OFTPs. First OFTP exponential PSA kinetic was associated with a shorter time to CRPC and worse CSS.
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http://dx.doi.org/10.1002/pros.23098DOI Listing
January 2016

The learning curve of robotic assisted laparoscopic radical prostatectomy: what is the evidence?

Authors:
Fernando P Secin

Arch Esp Urol 2011 Oct;64(8):830-8

CEMIC University Hospital, City of Buenos Aires, Argentina.

Objective: The robotic technique has been associated with a decreased LC for radical prostatectomy. The objective is to review the literature in search of any evidence that the RALP is able to shorten the learning curve for radical prostatectomy compared to the open and pure laparoscopic techniques.

Methods: A Medline search of the English-language literature was performed to identify all papers published relating to RALP and LC.

Results: There is substantial variability in the RALP literature regarding the number of cases a surgeon needs to achieve and sustain in time acceptable operative times and reasonable outcomes. The information on RALP LC comes from isolated single institution reports with questionable methodological analyses. There are no studies comparing the LC of RALP with open or pure laparoscopic techniques.

Conclusions: There is no reliable information to support the notion that RALP shortens the prostatectomy LC. The evidence is limited to case series, with a Level of Evidence 4.
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October 2011

Editorial comment.

Authors:
Fernando P Secin

J Urol 2011 May 21;185(5):1666. Epub 2011 Mar 21.

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http://dx.doi.org/10.1016/j.juro.2010.12.105DOI Listing
May 2011

The learning curve for laparoscopic radical prostatectomy: an international multicenter study.

J Urol 2010 Dec 16;184(6):2291-6. Epub 2010 Oct 16.

Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.

Purpose: It is not yet possible to estimate the number of cases required for a beginner to become expert in laparoscopic radical prostatectomy. We estimated the learning curve of laparoscopic radical prostatectomy for positive surgical margins compared to a published learning curve for open radical prostatectomy.

Materials And Methods: We reviewed records from 8,544 consecutive patients with prostate cancer treated laparoscopically by 51 surgeons at 14 academic institutions in Europe and the United States. The probability of a positive surgical margin was calculated as a function of surgeon experience with adjustment for pathological stage, Gleason score and prostate specific antigen. A second model incorporated prior experience with open radical prostatectomy and surgeon generation.

Results: Positive surgical margins occurred in 1,862 patients (22%). There was an apparent improvement in surgical margin rates up to a plateau at 200 to 250 surgeries. Changes in margin rates once this plateau was reached were relatively minimal relative to the CIs. The absolute risk difference for 10 vs 250 prior surgeries was 4.8% (95% CI 1.5, 8.5). Neither surgeon generation nor prior open radical prostatectomy experience was statistically significant when added to the model. The rate of decrease in positive surgical margins was more rapid in the open vs laparoscopic learning curve.

Conclusions: The learning curve for surgical margins after laparoscopic radical prostatectomy plateaus at approximately 200 to 250 cases. Prior open experience and surgeon generation do not improve the margin rate, suggesting that the rate is primarily a function of specifically laparoscopic training and experience.
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http://dx.doi.org/10.1016/j.juro.2010.08.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3397250PMC
December 2010

Surgery confounds biology: the predictive value of stage-, grade- and prostate-specific antigen for recurrence after radical prostatectomy as a function of surgeon experience.

Int J Cancer 2011 Apr 9;128(7):1697-702. Epub 2010 Jun 9.

Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.

Statistical models predicting cancer recurrence after surgery are based on biologic variables. We have shown previously that prostate cancer recurrence is related to both tumor biology and to surgical technique. Here, we evaluate the association between several biological predictors and biochemical recurrence across varying surgical experience. The study included two separate cohorts: 6,091 patients treated by open radical prostatectomy and an independent replication set of 2,298 patients treated laparoscopically. We calculated the odds ratios for biological predictors of biochemical recurrence-stage, Gleason grade and prostate-specific antigen (PSA)-and also the predictive accuracy (area under the curve, AUC) of a multivariable model, for subgroups of patients defined by the experience of their surgeon. In the open cohort, the odds ratio for Gleason score 8+ and advanced pathologic stage, though not PSA or Gleason score 7, increased dramatically when patients treated by surgeons with lower levels of experience were excluded (Gleason 8+: odds ratios 5.6 overall vs. 13.0 for patients treated by surgeons with 1,000+ prior cases; locally advanced disease: odds ratios of 6.6 vs. 12.2, respectively). The AUC of the multivariable model was 0.750 for patients treated by surgeons with 50 or fewer cases compared to 0.849 for patients treated by surgeons with 500 or more. Although predictiveness was lower overall for the independent replication set cohort, the main findings were replicated. Surgery confounds biology. Although our findings have no direct clinical implications, studies investigating biological variables as predictors of outcome after curative resection of cancer should consider the impact of surgeon-specific factors.
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http://dx.doi.org/10.1002/ijc.25502DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2970654PMC
April 2011

Surgical anatomy of radical prostatectomy: periprostatic fascial anatomy and overview of the urinary sphincters.

Arch Esp Urol 2010 May;63(4):255-66

Urology Section, CEMIC, Buenos Aires, Argentina.

Summary: Advances in the understanding of prostate and pelvic anatomy in recent years made a substantial contribution to improve the surgical technique for the treatment of prostate cancer (PC) with the potential preservation of anatomic structures responsible for erectile and urinary function postoperatively. Knowledge of these anatomic structures is key to achieve a complete removal of the prostate and seminal vesicles while preserving the best possible quality of life. The literature on prostate and pelvic anatomy has been reviewed and an updated notion of the surgical anatomy is herein provided.
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May 2010

The depth of the prostatic apex is an independent predictor of positive apical margins at radical prostatectomy.

BJU Int 2010 Sep;106(5):622-6

Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.

Objective: To determine the effect of a deep and narrow pelvis on apical positive surgical margins (PSM) at radical prostatectomy (RP), controlling for other clinical and pathological variables and surgical approach, i.e. open retropubic (RRP) vs laparoscopic (LRP), as apical dissection is expected to be more challenging at RP with a prostate situated deep in a narrow pelvis.

Patients And Methods: From July 2003 to January 2005, 512 consecutive patients with preoperative prostate magnetic resonance imaging (MRI) underwent RRP or LRP with no previous radio- or hormonal therapy. An additional 74 patients with preoperative MRI undergoing RP from December 2001 to June 2007 who had an apical PSM were also included, with 586 patients comprising the study population. Bony and soft-tissue pelvic dimensions, including interspinous distance (ISD), bony (BFW) and soft tissue (SW) pelvic width, apical prostate depth (AD) and symphysis pubis angle, were measured on preoperative MRI. The pelvic dimension index (PDI), bony width index (BWI) and soft-tissue width index (SWI) were defined as ISD/AD, BFW/AD and SW/AD, respectively. Multivariate logistic regression was used to assess the effect of pelvic dimensions on apical PSM, controlling for surgical approach and clinical and pathological variables.

Results: There was no significant difference in ISD, BFW, SW or symphysis angle between patients with and without apical PSM. The AD was significantly greater in men with an apical PSM and consequently PDI, BWI and SWI were significantly lower in men with an apical PSM. Each of PDI, AD, BWI and SWI was a significant independent predictor of apical PSM, independent of surgical approach, and other clinicopathological variables. The main limitations of the study were that it was retrospective, and the relatively few patients with apical PSM.

Conclusions: Apical prostate depth is an independent risk factor for apical PSM at RP. MRI pelvimetry might allow for preoperative planning of the approach to RP.
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http://dx.doi.org/10.1111/j.1464-410X.2009.09184.xDOI Listing
September 2010

Is it necessary to remove the seminal vesicles completely at radical prostatectomy? decision curve analysis of European Society of Urologic Oncology criteria.

J Urol 2009 Feb 13;181(2):609-13; discussion 614. Epub 2008 Dec 13.

Department of Urology, Sidney Kimmel Center for Prostate and Urologic Cancers and Department of Epidemiology and Biostatistics (AC, AJV), Memorial Sloan-Kettering Cancer Center, New York, New York.

Purpose: A publication on behalf of the European Society of Urological Oncology questioned the need for removing the seminal vesicles during radical prostatectomy in patients with prostate specific antigen less than 10 ng/ml except when biopsy Gleason score is greater than 6 or there are greater than 50% positive biopsy cores. We applied the European Society of Urological Oncology algorithm to an independent data set to determine its predictive value.

Materials And Methods: Data on 1,406 men who underwent radical prostatectomy and seminal vesicle removal between 1998 and 2004 were analyzed. Patients with and without seminal vesicle invasion were classified as positive or negative according to the European Society of Urological Oncology algorithm.

Results: Of 90 cases with seminal vesicle invasion 81 (6.4%) were positive for 90% sensitivity, while 656 of 1,316 without seminal vesicle invasion were negative for 50% specificity. The negative predictive value was 98.6%. In decision analytic terms if the loss in health when seminal vesicles are invaded and not completely removed is considered at least 75 times greater than when removing them unnecessarily, the algorithm proposed by the European Society of Urological Oncology should not be used.

Conclusions: Whether to use the European Society of Urological Oncology algorithm depends not only on its accuracy, but also on the relative clinical consequences of false-positive and false-negative results. Our threshold of 75 is an intermediate value that is difficult to interpret, given uncertainties about the benefit of seminal vesicle sparing and harm associated with untreated seminal vesicle invasion. We recommend more formal decision analysis to determine the clinical value of the European Society of Urological Oncology algorithm.
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http://dx.doi.org/10.1016/j.juro.2008.10.035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2777757PMC
February 2009

Oncologic outcome after laparoscopic radical prostatectomy: 10 years of experience.

Eur Urol 2009 May 6;55(5):1014-9. Epub 2008 Nov 6.

Department of Surgery, Service of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.

Background: While the published short-term oncologic outcomes after laparoscopic radical prostatectomy (LRP) are encouraging, intermediate and long-term data are lacking.

Objective: We analyzed the oncologic outcome after LRP based on 10 yr of experience.

Design, Setting, And Participants: This retrospective analysis of data prospectively collected from 1998 to 2007 studies 1564 consecutive patients with clinically localized prostate cancer (cT1c-cT3a) who underwent LRP.

Intervention: LRP was performed by two surgeons at either L'Institut Mutualiste Montsouris (IMM) in Paris, France, or Memorial Sloan-Kettering Cancer Center (MSKCC) in New York City, USA.

Measurements: Progression of disease was defined as a prostate-specific antigen (PSA) of >or=0.1 ng/ml with confirmatory rise or initiation of secondary therapy. Patients were stratified as low, intermediate, or high risk based on the pretreatment prostate cancer nomogram progression-free probability of >90%, 89-71%, and <70%, respectively.

Results And Limitations: The overall 5-yr and 8-yr probability of freedom from progression (PFP) was 78% (95% confidence interval [CI], 74-82%) and 71% (95% CI, 63-78%), respectively. For low-, intermediate-, and high-risk cancer, the 5-yr PFP was 91% (95% CI, 85-95%), 77% (95% CI, 71-82%), and 53% (95% CI, 40-65%), respectively. Surgical margins (SMs) were positive in 13% of the cases. Nodal metastases were detected in 3% of the patients after limited pelvic lymph node dissection (PLND) and in 10% after a standard PLND (p<0.001). The 3-yr PFP for node-positive patients was 49%. There were 22 overall deaths and 2 deaths from prostate cancer.

Conclusions: LRP provided 5- and 8-yr cancer control in 78% and 71% of patients, respectively, with clinically localized prostate cancer and in 53% of those with high-risk cancer at 5 yr. A PLND limited to the external iliac nodal group is inadequate for detecting nodal metastases.
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http://dx.doi.org/10.1016/j.eururo.2008.10.036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2962532PMC
May 2009

Renal cell carcinoma in young and old patients--is there a difference?

J Urol 2008 Oct 15;180(4):1262-6; discussion 1266. Epub 2008 Aug 15.

Department of Surgery (Urology Service), Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA.

Purpose: Renal cell carcinoma is rare in patients younger than 40 years and conflicting data regarding presentation and outcome are present in the literature. We reviewed our experience with young patients with renal cell carcinoma and compared them to their older counterparts.

Materials And Methods: We identified 1,720 patients 18 to 79 years old who were treated with partial or radical nephrectomy for renal cell carcinoma between 1989 and 2005. Patients were grouped according to age and outcome analysis was performed.

Results: Of the 1,720 patients with renal cell carcinoma 89 (5%), 672 (39%) and 959 (56%) were younger than 40, 40 to 59 and 60 to 79 years old, respectively. There were no significant differences in sex, tumor size, TNM stage or multifocality by age group. However, patients younger than 40 years were significantly more likely to present with symptomatic tumors (p = 0.028). Additionally, there were significant differences in histology by age (p <0.001), that is chromophobe histology decreased while papillary histology increased with age. Despite similar tumor sizes in each age group the percent of patients treated with partial nephrectomy decreased with age. Of patients younger than 40 years 49% were treated with partial nephrectomy compared with 35% and 30% of those 40 to 59 and 60 to 79 years old, respectively (p <0.001). At a median followup of 2.6 years (range 0 to 14.5) we did not observe a significant difference in cancer specific survival according to age (p = 0.17).

Conclusions: Younger patients with renal cell carcinoma are more likely to have symptomatic tumors with chromophobe histology, although the prognosis appears similar across age groups. Older patients are more likely to be treated with radical nephrectomy, which requires careful scrutiny for current clinical practice.
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http://dx.doi.org/10.1016/j.juro.2008.06.037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2615196PMC
October 2008

Importance and limits of ischemia in renal partial surgery: experimental and clinical research.

Authors:
Fernando P Secin

Adv Urol 2008 :102461

Urology Section, CEMIC University Hospital, Buenos Aires C1431FWO, Argentina.

Introduction: The objective is to determine the clinical and experimental evidences of the renal responses to warm and cold ischemia, kidney tolerability, and available practical techniques of protecting the kidney during nephron-sparing surgery.

Materials And Methods: Review of the English and non-English literature using MEDLINE, MD Consult, and urology textbooks.

Results And Discussion: There are three main mechanisms of ischemic renal injury, including persistent vasoconstriction with an abnormal endothelial cell compensatory response, tubular obstruction with backflow of urine, and reperfusion injury. Controversy persists on the maximal kidney tolerability to warm ischemia (WI), which can be influenced by surgical technique, patient age, presence of collateral vascularization, indemnity of the arterial bed, and so forth.

Conclusions: When WI time is expected to exceed from 20 to 30 minutes, especially in patients whose baseline medical characteristics put them at potentially higher, though unproven, risks of ischemic damage, local renal hypothermia should be used.
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http://dx.doi.org/10.1155/2008/102461DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2467455PMC
August 2008

Comprehensive prospective comparative analysis of outcomes between open and laparoscopic radical prostatectomy conducted in 2003 to 2005.

J Urol 2008 May 18;179(5):1811-7; discussion 1817. Epub 2008 Mar 18.

Department of Surgery, Service of Urology, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.

Purpose: In a nonrandomized prospective fashion we compared the oncological, functional and morbidity outcomes after laparoscopic and retropubic radical prostatectomy.

Materials And Methods: Between January 2003 and December 2005 a total of 1,430 consecutive men with clinically localized prostate cancer underwent radical prostatectomy, laparoscopic in 612 and retropubic in 818. The surgical approach was selected by the patient. Preoperative staging, respective surgical techniques, pathological examination and followup were uniform. Functional outcome was measured by patient completed health related quality of life questionnaire.

Results: Positive surgical margin rates (11%) and freedom from progression (median followup 18 months) were comparable between laparoscopic and retropubic radical prostatectomy (HR 0.99 for laparoscopic vs retropubic radical prostatectomy, p = 0.9). We found no significant association between operation type and time to postoperative potency (HR 1.04 for laparoscopic vs retropubic radical prostatectomy; 95% CI 0.74, 1.46; p = 0.8). Patients who underwent laparoscopic radical prostatectomy were less likely to become continent than those treated with retropubic radical prostatectomy (HR 0.56 for laparoscopic vs retropubic radical prostatectomy; 95% CI 0.44, 0.70; p <0.0005). Laparoscopic radical prostatectomy was associated with less blood loss (mean ml +/- SD 315 +/- 186 vs 1,267 +/- 660) and lower overall transfusion rate (3% vs 49%). No significant difference was noted in cardiovascular, thromboembolic and urinary complications. Emergency room visits and readmissions were higher after laparoscopic radical prostatectomy (15% vs 11% and 4.6% vs 1.2%, respectively).

Conclusions: At our institution and during the study period laparoscopic radical prostatectomy and retropubic radical prostatectomy provided comparable oncological efficacy. Laparoscopic radical prostatectomy was associated with less blood loss and a lower transfusion rate, and higher postoperative hospital visits and readmission rate. While the recovery of potency was equivalent, that of continence was superior after retropubic radical prostatectomy.
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http://dx.doi.org/10.1016/j.juro.2008.01.026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3622224PMC
May 2008

Laparoscopic adrenalectomy for adrenal masses: does size matter?

Urology 2008 Jun 12;71(6):1138-41. Epub 2008 Mar 12.

Section of Endourology and Laparoscopic Urology, Clínica Santa María, Santiago de Chile, Chile.

Objectives: To examine the impact of adrenal tumor size on perioperative morbidity and postoperative outcomes in patients undergoing laparoscopic adrenalectomy.

Methods: A total of 227 laparoscopic adrenalectomies were divided in three groups according to size as estimated by pathologic specimen maximum diameter: less than 6 cm (group 1, n = 140), between 6 and 7.9 cm (group 2, n = 47), and equal to or larger than 8 cm (group 3, n = 40). We prospectively recorded and analyzed clinical and pathologic data.

Results: Average operative time was 60 minutes (range, 50 to 90 minutes) for group 1, 75 minutes (range, 65 to 105 minutes) for group 2, and 80 minutes (range, 65 to 120 minutes) for group 3. Estimated blood loss, median (interquartile range) was 50 mL (range, 20 to 100 mL), 100 mL (range, 48 to 225 mL), and 100 mL (range, 50 to 475 mL) for groups 1, 2, and 3, respectively. We observed a total of 10, 4, and 4 complications in groups 1, 2, and 3, respectively. Average hospital stay was 2 days (range, 2 to 3 days), 2 days (range, 2 to 3 days), and 3 days (range, 2 to 4 days), respectively, for groups 1, 2, and 3. Operative time, average blood loss, and mean hospital stay were significantly higher (P
Conclusions: Laparoscopic adrenalectomy in large adrenal masses (8 cm or greater) is associated with significantly longer operative time, increased blood loss, and longer hospital stay, without affecting perioperative morbidity.
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http://dx.doi.org/10.1016/j.urology.2007.12.019DOI Listing
June 2008

Artery sparing radical prostatectomy--myth or reality?

J Urol 2008 Mar 25;179(3):827-31. Epub 2008 Jan 25.

Department of Surgery, Urology Service, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.

Purpose: Not all patients in whom the neurovascular bundles are preserved recover erectile function after radical prostatectomy. A significant proportion of these men have vascular abnormalities that can impact erectile function recovery after radical prostatectomy. We describe the available evidence supporting the need to spare not only the nerves, but also the arteries to improve erectile function recovery after radical prostatectomy.

Materials And Methods: A literature review was done to determine the available evidence supporting vascular insufficiency as a contributor to erectile dysfunction after radical prostatectomy.

Results: There is no question that preservation of the cavernous nerves is key to erectile function recovery after radical prostatectomy. In addition, it is believed that erectile tissue requires oxygenation to maintain its integrity, which can be significantly affected if the arteries irrigating the cavernous bodies are damaged intraoperatively, such as the accessory pudendal arteries. In approximately 1 of every 4 patients undergoing laparoscopic radical prostatectomy accessory pudendal arteries of different calibers are identified. Thus, accumulating evidence supports the concept that the accessory pudendal arteries have a role in erectile function and its recovery after radical prostatectomy and, furthermore, supports the idea that preserving the accessory pudendal arteries may contribute to erectile function recovery.

Conclusions: Based on the evidence at hand we believe that it is appropriate to build on the notion of nerve sparing radical prostatectomy by introducing the urological community to the concept of artery sparing radical prostatectomy in an attempt to make the urological community aware of the potential need to spare the accessory pudendal arteries. The crux of the difficulty is in deciding which arteries should be preserved and which may be sacrificed. Thus, defining the role of the accessory pudendal arteries in erectile function recovery requires intraoperative analysis of the functional role of these vessels.
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http://dx.doi.org/10.1016/j.juro.2007.10.021DOI Listing
March 2008

Multi-institutional study of symptomatic deep venous thrombosis and pulmonary embolism in prostate cancer patients undergoing laparoscopic or robot-assisted laparoscopic radical prostatectomy.

Eur Urol 2008 Jan 11;53(1):134-45. Epub 2007 Jun 11.

Memorial Sloan-Kettering Cancer Center, Department of Urology, New York, NY 10021, USA.

Objectives: The true incidence of symptomatic deep venous thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing laparoscopic radical prostatectomy is unknown. Our aim was to determine the incidence of symptomatic DVT and PE and the risk factors for these complications.

Methods: Fourteen surgeons from 13 referral institutions from both Europe and the United States provided retrospective data for all 5951 patients treated with laparoscopic radical prostatectomy (LRP), with or without robotic assistance, since the start of their institution's experience. Symptomatic DVT and PE within 90 d of surgery were regarded as venous thromboembolism (VTE). DVT was diagnosed mostly by Doppler ultrasound or contrast venography and PE by lung ventilation/perfusion scan or chest computed tomography or both. Statistical analysis included evaluation of incidence of symptomatic DVT and PE and risk factors as determined by exact methods and logistic regression.

Results: Of 5951 patients in the study, 31 developed symptomatic VTE (0.5%; 95% confidence interval [CI], 0.4%, 0.7%). Among patients with an event, 22 (71%) had DVT only, 4 had PE without identified DVT, and 5 had both. Two patients died of PE. Prior DVT (odds ratio [OR]=13.5; 95%CI, 1.4, 61.3), current tobacco smoking (OR=2.8; 95%CI, 1.0, 7.3), larger prostate volume (OR=1.18; 95%CI, 1.09, 1.28), patient re-exploration (OR=20.6; 95%CI, 6.6, 54.0), longer operative time (OR=1.05; 95%CI, 1.02, 1.09), and longer hospital stay (OR=1.05; 95%CI, 1.01, 1.09) were associated with VTE in univariate analysis. Neoadjuvant therapy, body mass index, surgical experience, surgical approach, pathologic stage, perioperative transfusion, and heparin administration were not significant predictors.

Conclusions: The incidence of symptomatic VTE after LRP is low. These data do not support the administration of prophylactic heparin to all patients undergoing LRP, especially those without risk factors for VTE.
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http://dx.doi.org/10.1016/j.eururo.2007.05.028DOI Listing
January 2008

Standard versus limited pelvic lymph node dissection for prostate cancer in patients with a predicted probability of nodal metastasis greater than 1%.

J Urol 2007 Jul 11;178(1):120-4. Epub 2007 May 11.

Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.

Purpose: We determined the yield of standard vs limited pelvic lymphadenectomy in patients with a predicted risk of lymph node metastasis greater than 1% according to the Partin tables predicted probability of pathological stage. We also determined the feasibility of laparoscopic standard pelvic lymph node dissection.

Materials And Methods: Of 1,269 patients with clinically localized prostate cancer undergoing radical prostatectomy, 648 had a Partin's table predicted probability of lymph node invasion greater than 1%. Of the 648 patients 177 underwent limited pelvic lymph node dissection performed laparoscopically (group 1), and 471 underwent standard pelvic lymph node dissection performed open (367) or laparoscopically (104) (group 2). Templates of limited pelvic lymph node dissection included the external iliac lymph nodes whereas standard pelvic lymph node dissection included the external iliac, obturator and hypogastric lymph nodes. Multivariate logistic regression analyses were performed to compare the node positivity rate between groups 1 and 2.

Results: On multivariate logistic regression analysis controlling for prostate specific antigen, biopsy Gleason sum, clinical stage and surgical approach, the odds of node positivity were 7.15-fold higher (95% CI 2.49-20.5, p<0.001) for standard vs limited pelvic lymph node dissection. The median (mean) number of nodes retrieved was 9 (10) and 14 (15) after limited and standard pelvic lymph node dissection, respectively (p<0.001). A similar impact was observed in patients treated laparoscopically with standard vs limited pelvic lymph node dissection (odds ratio 15.6, 95% CI 3.7-66.4, p<0.001).

Conclusions: Standard lymph node dissection yields positive nodes more frequently and retrieves a higher total nodal count than the often performed pelvic lymph node dissection limited to the external iliac nodes. Standard pelvic lymph node dissection is feasible through a transperitoneal laparoscopic approach.
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http://dx.doi.org/10.1016/j.juro.2007.03.018DOI Listing
July 2007

Bilateral cavernous nerve interposition grafting during radical retropubic prostatectomy: Memorial Sloan-Kettering Cancer Center experience.

J Urol 2007 Feb;177(2):664-8

Departments of Urology and Plastic Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.

Purpose: Cavernous nerve graft is an option for men requiring bilateral cavernous nerve resection for cancer control during radical prostatectomy. We determined the success rate and identified determinants of success of bilateral cavernous nerve grafting following resection of the 2 nerves during radical prostatectomy in patients who were potent preoperatively.

Materials And Methods: We retrospectively reviewed the records of 44 consecutive patients who underwent bilateral nerve grafting from 1999 to 2004. Postoperative erectile function was defined as the achievement of erections satisfactory for intercourse with or without oral medication. We calculated cumulative erectile function recovery rates using Kaplan-Meier curves. The log rank test was used to compare variables affecting erectile function recovery with p <0.0083 considered significant after adjusting for the number of variables evaluated using the Bonferroni correction.

Results: The overall 5-year cumulative recovery of erectile function permitting penetration was 34% and the rate of consistent penetration was 11%. None of the analyzed variables were significantly associated with recovery of postoperative erectile function, including patient age (p = 0.3), incomplete bilateral cavernous nerve resection (p = 0.045), sural nerve grafts compared to genitofemoral or ilioinguinal nerves as donor sites (p = 0.067), post-radiation salvage radical prostatectomy (p = 0.15), neoadjuvant hormone therapy (p = 0.7) and comorbidities (p = 0.15) or medications (p = 0.4) affecting EF.

Conclusions: Bilateral cavernous nerve grafts might be beneficial in select patients. A definitive answer awaits the performance of a multi-institutional, randomized, controlled trial.
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http://dx.doi.org/10.1016/j.juro.2006.09.035DOI Listing
February 2007

The anterior layer of Denonvilliers' fascia: a common misconception in the laparoscopic prostatectomy literature.

J Urol 2007 Feb;177(2):521-5

Department of Urology, Sidney Kimmel Center for Prostate and Urologic Cancers, New York, New York 10021, USA.

Purpose: Incision of the anterior layer of Denonvilliers' fascia is commonly cited as a key step in successful dissection of the vasa deferentia and seminal vesicles from the posterior bladder neck during laparoscopic radical prostatectomy. However, anatomical descriptions do not support the presence of Denonvilliers' fascia anterior to the seminal vesicles. To address this inconsistency we performed a detailed anatomical study of tissue planes encountered during laparoscopic dissection of the posterior bladder neck.

Materials And Methods: To grossly characterize the tissue planes encountered during laparoscopic posterior bladder neck dissection, ex vivo dissections were performed on 4 separate cystoprostatectomy specimens. Biopsies of the representative areas were obtained from 20 consecutive laparoscopic radical prostatectomy specimens by 2 dedicated uropathologists.

Results: Following incision into the posterior bladder neck mucosa, longitudinally oriented fibers were readily visualized, extending from bladder neck to prostate base. Histologically this anatomical landmark represents the fusion of 2 separate tissue layers, that is an inner lamella composed of longitudinally disposed smooth muscle fibers in continuation with the longitudinal fascia of the bladder detrusor (medial fascicle of the detrusor running in between the ureters) and an outer lamella composed of fibroadipose tissue in continuation with the bladder adventitia.

Conclusions: Our anatomical and histological analysis refutes the prevailing belief in the laparoscopic literature that the longitudinal muscle fibers identified during dissection of the posterior bladder neck represent the anterior layer of Denonvilliers' fascia. They correspond to the posterior longitudinal fascia of the detrusor muscle that is externally upholstered by the bladder adventitia.
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http://dx.doi.org/10.1016/j.juro.2006.09.028DOI Listing
February 2007