Faculty Bibliography

Adenocarcinoma of the prostate is the second most common cancer in men in the United States (following only skin cancer) and accounts for 33% of all newly diagnosed male cancers. It is estimated that in 2007, 218,890 men will be diagnosed with prostate cancer and 27,050 will die from this disease. While most currently diagnosed prostate cancers are localized, radical prostatectomy remains a gold standard treatment. Since its original description, radical retropubic prostatectomy has evolved over the last three decades to a precise, sophisticated procedure with minimal mortality, and excellent surgical outcomes. However, despite its efficacy, open surgical treatment is inherently associated with blood loss and significant pain. Due to these reasons, many men have sought other, less invasive forms of treatment. With its development in the late 1990s, minimally invasive surgery has significantly and irrevocably changed the surgical treatment of prostate cancer. Robotic-assisted technology has further propelled the utilization of the laparoscopic approach for radical prostatectomy, particularly for non-laparoscopic trained surgeons. The implementation of robotic technology has been rapid. Presently, 7 years after its approval by the FDA, many hospitals have established for robotic-assisted radical prostatectomy programs. This trend will undoubtedly continue to grow as more surgeons become familiar with the procedure, more robotic systems become available, and increasingly mature data is published. Robotic-assisted laparoscopic radical prostatectomy allows patients the benefits of minimally invasive surgery with functional and oncological results comparable to those from open and standard laparoscopic procedures, we believe that this surgical approach will shortly evolve into the standard surgical approach for localized prostate cancer.

Management decisions for a patient with high grade (G3) T1 urothelial cancer of the bladder are critical. These tumors should not be classified as "superficial" since they are not confined to the urothelium. Patients with T1G3 bladder cancers are likely to have recurrence and the tumor will often progress, invade, metastasize, and cause death. Radical cystectomy as well as transurethral resection followed by intravesical BCG are acceptable initial therapies. This article reviews these treatment options and provides recommendations for management of high grade T1 tumors.

Radiofrequency ablation (RFA) has emerged as a minimally invasive nephron-sparing treatment for small (<4-cm) renal tumors. Post-RFA complications have been reported. We describe a patient who developed complete renal-pelvic obstruction after RFA. To our knowledge, this is the first such case to be reported and the second reported renal-unit loss as the result of collecting-system obstruction after RFA.

PURPOSE/OBJECTIVE:Prostate cancer Gleason score 3 + 3 = 6 is currently the most common score assigned on prostatic biopsies. We analyzed the clinical variables that predict the likelihood of a patient with biopsy Gleason score 6 to harbor a higher grade tumor. MATERIALS AND METHODS/METHODS:The study population consisted of 448 patients with a mean age of 59.1 years who underwent radical prostatectomy between February 2003 to October 2006 for Gleason score 6 adenocarcinoma. The effect of preoperative variables on the probability of a Gleason score upgrade on final pathological evaluation was evaluated using logistic regression, and classification and regression tree analysis. RESULTS:Gleason score upgrade was found in 91 of 448 patients (20.3%). Logistic regression showed that only serum prostate specific antigen and the greatest percent of cancer in a core were significantly associated with a score upgrade (p = 0.0014 and 0.023, respectively). Classification and regression tree analysis showed that the risk of a Gleason score upgrade was 62% when serum prostate specific antigen was higher than 12 ng/ml and 18% when serum prostate specific antigen was 12 ng/ml or less. In patients with serum prostate specific antigen lower than 12 ng/ml the risk of a score upgrade could be dichotomized at a greatest percent of cancer in a core of 5%. The risk was 22.6% and 10.5% when the greatest percent of cancer in a core was higher than 5% and 5% or lower, respectively. CONCLUSIONS:The probability of patients with a prostate biopsy Gleason score of 6 to conceal a Gleason score of 7 or higher can be predicted using serum prostate specific antigen and the greatest percent of cancer in a core. With these parameters it is possible to predict upgrade rates as high as 62% and as low as 10.5%.

OBJECTIVES/OBJECTIVE:The intraoperative complexity of laparoscopic partial nephrectomy (LPN) for upper pole renal tumors is recognized. We report on the technical feasibility and operative outcomes of LPN for upper pole tumors (UPLPN) and lower pole tumors (LPLPN), and open partial nephrectomy (UPOPN) for upper pole tumors. METHODS:We retrospectively reviewed our database of LPNs performed by a single surgeon from October 2002 to February 2006. All solitary, upper and lower pole tumors in patients with a normal contralateral kidney were included. The perioperative outcomes were assessed. UPOPNs performed in the same institution by a separate surgeon were analyzed and compared separately with the UPLPN group. RESULTS:Three groups, UPLPN (20 patients), LPLPN (33 patients), and UPOPN (24 patients), were analyzed. The UPLPN and LPLPN groups had similar perioperative outcomes. The intraoperative and postoperative major complications were also comparable between the UPLPN and LPLPN groups (17% versus 12%, P = 0.68 and 22% versus 6%, P = 0.07, respectively). The mean pathologic tumor size was larger (3.2 versus 2.3 cm, P = 0.05) and the mean operative time significantly shorter (187 versus 244 minutes, P = 0.02) in the UPOPN group than in the UPLPN group. The UPOPN group had a trend toward fewer intraoperative complications compared with the UPLPN group (4% versus 17%, P = 0.17). The final pathologic surgical margins were negative in all three groups. CONCLUSIONS:LPN for upper pole renal tumors is technically feasible and may have comparable outcomes to LPN for lower pole tumors. However, performing open nephron-sparing surgery is still the standard of care because it may offer fewer complications and reduce the risk of ischemic damage to the kidney.

Initial experience utilizing metal stents in the treatment of ureteroenteric anastomotic strictures has yielded promising results. However, the long-term efficacy of metal stent placement remains unknown. Further, there is a paucity of literature to describe the technical considerations associated with the surgical management of obstruction after metal stent failure. We report the case of a 67-year-old man undergoing bilateral ureteral metal stent removal and ileal conduit creation following stent failure and recurrent obstruction.