Publications

2015
Muralidhar V, Mahal BA, Nezolosky MD, Beard CJ, Feng FY, Martin NE, Efstathiou JA, Choueiri TK, Pomerantz MM, Sweeney CJ, et al. Association between very small tumor size and increased cancer-specific mortality following radical prostatectomy in node-positive prostate cancer. BJU Int. 2015.Abstract
OBJECTIVE: To determine whether very small prostate cancers present in patients who also have lymph node (LN) metastases represent a particularly aggressive disease variant compared to larger node-positive tumors. SUBJECTS/PATIENTS AND METHODS: We identified 37,501 patients diagnosed with prostate cancer between 1988 and 2001 treated with radical prostatectomy within the Surveillance, Epidemiology, and End Results database. The primary study variables were tumor size by largest dimension (stratified into: (1) microscopic focus only or 1 mm; (2) 2-15 mm; (3) 16-30 mm; (4) greater than 30 mm), regional LN involvement, and the corresponding interaction term. We evaluated the risk of 10-year prostate cancer-specific mortality (PCSM) using the Fine-Gray model for competing risks after controlling for race, tumor grade, T stage, receipt of radiation, number of dissected LNs, number of positive LNs, year of diagnosis, and age at diagnosis. RESULTS: Median follow-up was 11.8 years. There was a significant interaction between tumor size and LN involvement (P-interaction < 0.001). In the absence of LN involvement (N=36,561), the risk of 10-year PCSM increased monotonically with increasing tumor size. Among patients with LN involvement (N=940), those with the smallest tumors had increased 10-year PCSM compared to patients with tumors sized 2-15 mm (24.7% vs. 11.8%; adjusted hazard ratio [AHR] = 2.84; 95% confidence interval [CI], 1.21 to 6.71; P = 0.017) or 16-30 mm (24.7% vs. 15.5%; AHR = 3.12; 95% CI, 1.51 to 6.49; P = 0.002) and similar 10-year PCSM compared to those with tumors greater than 30 mm (24.7% vs. 24.9%; P = 0.156). CONCLUSION: In prostate cancer patients with LN involvement, very small tumor size may predict for higher PCSM compared with some larger tumors, even after controlling for other prognostic variables. These tumors might be particularly aggressive, beyond what is captured by pathological assessment of tumor grade and stage. This article is protected by copyright. All rights reserved.
Ziehr DR, Chen M-H, Zhang D, Braccioforte MH, Moran BJ, Mahal BA, Hyatt AS, Basaria SS, Beard CJ, Beckman JA, et al. Association of androgen-deprivation therapy with excess cardiac-specific mortality in men with prostate cancer. BJU Int. 2015;116 (3) :358-65.Abstract
OBJECTIVES: To determine if androgen-deprivation therapy (ADT) is associated with excess cardiac-specific mortality (CSM) in men with prostate cancer and no cardiovascular comorbidity, coronary artery disease risk factors, or congestive heart failure (CHF) or past myocardial infarction (MI). PATIENTS AND METHODS: In all, 5077 men (median age 69.5 years) with cT1c-T3N0M0 prostate cancer were treated with brachytherapy with or without neoadjuvant ADT (median duration 4 months) between 1997 and 2006. Fine and Gray competing risks analysis evaluated the association of ADT with CSM, adjusting for age, year of brachytherapy, and ADT treatment propensity score among men in groups defined by cardiac comorbidity. RESULTS: After a median follow-up of 4.8 years, no association was detected between ADT and CSM in men with no cardiac risk factors (1.08% at 5 years for ADT vs 1.27% at 5 years for no ADT, adjusted hazard ratio (AHR) 0.83; 95% confidence interval (CI), 0.39-1.78; P = 0.64; n = 2653) or in men with diabetes mellitus, hypertension, or hypercholesterolaemia (2.09% vs 1.97%, AHR 1.33; 95% CI 0.70-2.53; P = 0.39; n = 2168). However, ADT was associated with significantly increased CSM in men with CHF or MI (AHR 3.28; 95% CI 1.01-10.64; P = 0.048; n = 256). In this subgroup, the 5-year cumulative incidence of CSM was 7.01% (95% CI 2.82-13.82%) for ADT vs 2.01% (95% CI 0.38-6.45%) for no ADT. CONCLUSION: ADT was associated with a 5% absolute excess risk of CSM at 5 years in men with CHF or prior MI, suggesting that administering ADT to 20 men in this potentially vulnerable subgroup could result in one cardiac death.
Leow JJ, Trinh QD. Delivering better care and value in urological procedures. Can J Urol. 2015;22 (4) :7857.
Allard CB, Meyer CP, Gandaglia G, Chang SL, Chun FKH, Gelpi-Hammerschmidt F, Hanske J, Kibel AS, Preston MA, Trinh Q-D. The Effect of Resident Involvement on Perioperative Outcomes in Transurethral Urologic Surgeries. J Surg Educ. 2015;72 (5) :1018-25.Abstract
OBJECTIVE: To conduct the first study of intra- and postoperative outcomes related to intraoperative resident involvement in transurethral resection procedures for benign prostatic hyperplasia and bladder cancer in a large, multi-institutional database. DESIGN: Relying on the American College of Surgeons National Surgical Quality Improvement Program Participant User Files (2005-2012), we abstracted all cases of endoscopic prostate surgery (EPS) for benign prostatic hyperplasia and transurethral resection of bladder tumors (TURBTs). Multivariable logistic regression models were constructed to assess the effect of trainee involvement (postgraduate year [PGY] 1-2: junior, PGY 3-4: senior, PGY ≥ 5: chief or fellow) vs attending only on operative time and length of hospital stay, as well as 30-day complication, reoperation, and readmission rates. RESULTS: In all, 5093 EPS and 3059 TURBTs for a total of 8152 transurethral resection procedures were performed during the study period for which data on resident involvement were available. In multivariable analyses, resident involvement in EPS or TURBT was associated with increased odds of prolonged operative times and hospital readmissions in 30 days independent of resident level of training. Resident involvement was not associated with overall complications or reoperation rates. CONCLUSIONS: Resident involvement in lower urinary tract surgeries is associated with increased readmissions. Strategies to optimize resident teaching of these common urologic procedures in order to minimize possible risks to patients should be explored.
Dinh KT, Mahal BA, Ziehr DR, Muralidhar V, Chen Y-W, Viswanathan VB, Nezolosky MD, Beard CJ, Choueiri TK, Martin NE, et al. Incidence and Predictors of Upgrading and Up Staging among 10,000 Contemporary Patients with Low Risk Prostate Cancer. J Urol. 2015;194 (2) :343-9.Abstract
PURPOSE: We determined the incidence of pathological upgrading and up staging for contemporary, clinically low risk patients, and identified predictors of having occult, advanced disease to inform the selection of patients for active surveillance. MATERIALS AND METHODS: We studied 10,273 patients in the SEER database diagnosed with clinically low risk disease (cT1c/T2a, prostate specific antigen less than 10 ng/ml, Gleason 3+3=6) in 2010 to 2011 and treated with prostatectomy. The primary outcome was the incidence of upgrading to pathological Gleason score 7-10 or up staging to pathological T3-T4/N1 disease. Multivariable logistic regression of cases with complete biopsy data (5,581) identified significant predictors of upgrading or up staging, which were then used to create a risk stratification table. RESULTS: At prostatectomy 44% of cases were upgraded and 9.7% were up staged. Multivariable analysis of 5,581 patients showed age, prostate specific antigen and percent positive cores (all p <0.001) but not race were associated with occult, advanced disease. With these variables dichotomized at the median, age older than 60 years (AOR 1.39), prostate specific antigen greater than 5.0 ng/ml (AOR 1.28) and more than 25% positive cores (AOR 1.76) were significantly associated with upgrading (all p <0.001). Similarly, age older than 60 years (AOR 1.42), prostate specific antigen greater than 5.0 ng/ml (AOR 1.44) and more than 25% positive cores (AOR 2.26) were associated with up staging (all p <0.001). Overall 60% of 5,581 low risk cases with prostate specific antigen 7.5 to 9.9 ng/ml and more than 25% positive cores were upgraded. This study is limited by possible bias introduced by only using patients selected for prostatectomy. CONCLUSIONS: Nearly half of clinically low risk patients harbor Gleason 7 or greater, or pT3 or greater disease, and should be risk stratified by prostate specific antigen and percent positive cores for consideration of further testing before deciding on active surveillance.
Meyer C, Sukumar S, Sood A, Hanske J, Vetterlein M, Elder JS, Fisch M, Trinh Q-D, Friedman AA. Inpatients hypospadias care: Trends and outcomes from the American nationwide inpatient sample. Korean J Urol. 2015;56 (8) :594-600.Abstract
PURPOSE: Hypospadias is the most common congenital penile anomaly. Information about current utilization patterns of inpatient hypospadias repair as well as complication rates remain poorly evaluated. MATERIALS AND METHODS: The Nationwide Inpatient Sample was used to identify all patients undergoing inpatient hypospadias repair between 1998 and 2010. Patient and hospital characteristics were attained and outcomes of interest included intra- and immediate postoperative complications. Utilization was evaluated temporally and also according to patient and hospital characteristics. Predictors of complications and excess length of stay were evaluated by logistic regression models. RESULTS: A weighted 10,201 patients underwent inpatient hypospadias repair between 1998 and 2010. Half were infants (52.2%), and were operated in urban and teaching hospitals. Trend analyses demonstrated a decline in incidence of inpatient hypospadias repair (estimated annual percentage change, -6.80%; range, -0.51% to -12.69%; p=0.037). Postoperative complication rate was 4.9% and most commonly wound-related. Hospital volume was inversely related to complication rates. Specifically, higher hospital volume (>31 cases annually) was the only variable associated with decreased postoperative complications. CONCLUSIONS: Inpatient hypospadias repair have substantially decreased since the late 1990's. Older age groups and presumably more complex procedures constitute most of the inpatient procedures nowadays.
Hueber P-A, Bienz MN, Valdivieso R, Lavigueur-Blouin H, Misrai V, Rutman M, Te AE, Chughtai B, Barber NJ, Emara AM, et al. Photoselective Vaporization of the Prostate for Benign Prostatic Hyperplasia Using the 180 Watt System: Multicenter Study of the Impact of Prostate Size on Safety and Outcomes. J Urol. 2015;194 (2) :462-9.Abstract
PURPOSE: We evaluated photoselective vaporization of the prostate using the GreenLight™ XPS™ 180 W system for benign prostatic hyperplasia treatment in a large multi-institutional cohort at 2 years. We particularly examined safety, outcomes and the re-treatment rate in larger prostates, defined as a prostate volume of 80 cc or greater, to assess the potential of photoselective vaporization of the prostate as a size independent procedure. MATERIALS AND METHODS: A total of 1,196 patients were treated at 6 international centers in Canada, the United States, France and England. All parameters were collected retrospectively, including complications, I-PSS, maximum urinary flow rate, post-void residual urine, prostate volume, prostate specific antigen and the endoscopic re-intervention rate. Subgroup stratified comparative analysis was performed according to preoperative prostate volume less than 80 vs 80 cc or greater on transrectal ultrasound. RESULTS: Median prostate size was 50 cc in 387 patients and 108 cc in 741 in the prostate volume groups less than 80 and 80 cc or greater, respectively. The rate of conversion to transurethral prostate resection was significantly higher in the 80 cc or greater group than in the less than 80 cc group (8.4% vs 0.6%, p <0.01). I-PSS, quality of life score, maximum urinary flow rate and post-void residual urine were significantly improved compared to baseline at 6, 12 and 24 months of followup without significant differences between the prostate size groups. The re-treatment rate at 2 years reported in 5 of 411 patients was associated with the delivery of decreased energy density (2.1 vs 4.4 kJ/cc) in the group without re-treatment. CONCLUSIONS: Photoselective vaporization of the prostate using the XPS 180 W system is safe and efficacious, providing durable improvement in functional outcomes at 2 years independent of prostate size when treated with sufficient energy.
Alenizi AM, Valdivieso R, Rajih E, Meskawi M, Toarta C, Bienz M, Azizi M, Hueber PA, Lavigueur-Blouin H, Trudeau V, et al. Factors predicting prolonged operative time for individual surgical steps of robot-assisted radical prostatectomy (RARP): A single surgeon's experience. Can Urol Assoc J. 2015;9 (7-8) :E417-22.Abstract
INTRODUCTION: We evaluated the average time required to complete individual steps of robotic-assisted radical prostatectomy (RARP) by an expert RARP surgeon. The intent is to help establish a time-based benchmark to aim for during apprenticeship. In addition, we aimed to evaluate preoperative patient factors, which could prolong the operative time of these individual steps. METHODS: We retrospectively identified 247 patients who underwent RARP, performed by an experienced robotic surgeon at our institution. Baseline patient characteristics and the duration of each step were recorded. Multivariate analysis was performed to predict factors of prolonged individual steps. RESULTS: In multivariable analysis, obesity was a significant predictor of prolonged operative time of: docking (odds ratio [OR] 1.96), urethral division (OR 3.13), and vesico-urethral anastomosis (VUA) (OR 2.63). Prostate volume was also a significant predictor of longer operative time in dorsal vein complex ligation (OR 1.02), bladder neck division (OR 1.03), pedicle control (OR 1.04), urethral division (OR 1.02), and VUA (OR 1.03). A prolonged bladder neck division was predicted by the presence of a median lobe (OR 5.03). Only obesity (OR 2.56) and prostate volume (OR 1.04) were predictors of a longer overall operative time. CONCLUSIONS: Obesity and prostate volume are powerful predictors of longer overall operative time. Furthermore, both can predict prolonged time of several individual RARP steps. The presence of a median lobe is a strong predictor of a longer bladder neck division. These factors should be taken into consideration during RARP training.
Ghatalia P, Je Y, Nguyen PL, Trinh Q-D, Choueiri TK, Sonpavde G. Fatigue with vascular endothelial growth factor receptor tyrosine kinase inhibitors and mammalian target of rapamycin inhibitors in patients with renal cell carcinoma (RCC) and other malignancies: A meta-analysis of randomized clinical trials. Crit Rev Oncol Hematol. 2015;95 (2) :251-63.Abstract
A trial-level meta-analysis of randomized phase II/III controlled trials in renal cell carcinoma (RCC) and other malignancies was conducted to systematically determine the relative risk (RR) of fatigue, a common side effect associated with single agent therapy with vascular endothelial growth factor receptor (VEGFR) tyrosine kinase inhibitors (TKI) and mammalian target of rapamycin inhibitors (mTORi). The RR of all grade fatigue and high grade fatigue in 7304 patients from 19 trials was 1.35 (95% CI 1.22-1.49, p<0.001) and 1.33 (95% CI 0.97-1.82, p=0.08), respectively in patients receiving VEGFR TKIs or mTORi. The summary incidence of all grade and high grade fatigue in the drug arm was 38.2% (95% CI 31.8-45.1) and 4.0% (95% CI 2.8-5.7), respectively. The type of drug (VEGFR TKI vs. mTORi), line of therapy, age, type of tumor (RCC vs. others) and median duration of therapy did not affect the risk of all-grade fatigue.
Mahal BA, Muralidhar V, Chen Y-W, Choueiri TK, Hoffman KE, Hu JC, Sweeney CJ, Yu JB, Feng FY, Trinh Q-D, et al. Gleason 5 + 3 = 8 Prostate Cancer: Much More like Gleason 9?. BJU Int. 2015.Abstract
OBJECTIVE: To determine whether patients with Gleason score 5+3=8 prostate cancer have outcomes more similar to other patients with Gleason 8 disease or to patients with Gleason 9 disease. PATIENTS AND METHODS: The SEER database was used to study 40,533 men diagnosed with N0M0 Gleason 8 or 9 prostate cancer from 2004 - 2011. Using Gleason 4+4=8 as the referent, Fine and Gray competing risks regression analyses modeled the association between Gleason score and prostate cancer-specific mortality (PCSM). RESULTS: Five-year PCSM rates for patients with Gleason 4+4=8, Gleason 3+5=8, Gleason 5+3=8, and Gleason 9 disease were 6.3%, 6.6%, 13.5%, and 13.9%, respectively (P<0.001). Patients with Gleason 5+3=8 or Gleason 9 disease had up to a two-fold increased risk for PCSM ([Adjusted Hazard Ratio (AHR) 1.89; 95% CI 1.50 - 2.38; P<0.001] and [AHR 2.17; 95% CI 1.99 - 2.36; P<0.001], respectively) compared to the referent group of patients (Gleason 4+4=8). There was no difference in PCSM between patients with Gleason 5+3=8 versus 9 disease (P=0.25). CONCLUSIONS: Gleason 8 disease represents a heterogeneous entity with PCSM outcomes distinguishable by the primary Gleason pattern. The PCSM of Gleason 3+5=8 and Gleason 4+4=8 disease are similar, but patients with Gleason 5+3=8 have a risk of PCSM that is twice as high as other patients with Gleason 8 disease and should be considered to have similar poor prognosis as patients with Gleason 9 disease. Such patients should be allowed onto trials seeking the highest-risk patients in which to test novel aggressive treatment strategies. This article is protected by copyright. All rights reserved.
Schmid M, Sood A, Campbell L, Kapoor V, Dalela D, Klett DE, Chun FK-H, Kibel AS, Sammon JD, Menon M, et al. Impact of smoking on perioperative outcomes after major surgery. Am J Surg. 2015;210 (2) :221-229.e6.Abstract
BACKGROUND: To investigate the impact of smoking on perioperative outcomes in patients undergoing one of the 16 major cardiovascular, orthopedic, or oncologic surgical procedures. METHODS: We relied on the American College of Surgeons National Surgical Quality Improvement Program database (2005 to 2011). Procedure-specific multivariable logistic regression models assessed the association between smoking status (non, former, or current smokers) and risk of 30-day morbidity and mortality. RESULTS: Overall, 141,802 patients were identified. A total of 12.5%, 14.6%, and 14.9% of non, former, and current smokers, respectively, experienced at least one complication (P < .001). In multivariable models, current smokers had higher odds of overall, pulmonary, wound, and septic/shock complications following most cardiovascular and oncologic surgeries compared with nonsmokers. The odds of experiencing such adverse outcomes were significantly lower in former smokers compared with current smokers, but still higher compared with nonsmokers. CONCLUSIONS: The effect of smoking on perioperative outcomes is procedure dependent. Current and, even though mitigated, former smoking negatively influence outcomes following cardiovascular or oncologic procedures. Patients undergoing major procedures should be encouraged to discontinue tobacco smoking to achieve optimal procedural outcomes.
Pucheril D, Dalela D, Sammon J, Sood A, Sun M, Trinh Q-D, Menon M, Abdollah F. The influence of physician recommendation on prostate-specific antigen screening. Urol Oncol. 2015.Abstract
PURPOSE: Prostate-specific antigen (PSA) screening is controversial, and little is known regarding a physician's effect on a patient's decision to undergo screening. This study's objective was to evaluate the effect of a patient's understanding of the risks and benefits of screening compared to the final recommendation of the provider on the patient's decision to undergo PSA screening. MATERIALS AND METHODS: Using the 2012 Behavioral Risk Factor Surveillance System, men older than 55 years who did not have a history of prostate cancer/prostate "problem" and who reported a PSA test within the preceding year were considered to have undergone screening. The percentages of men informed and not informed of the risks and benefits of screening and the percentage men receiving recommendations for PSA screening from their provider were reported. Multivariable complex-sample logistic regression calculated the odds of undergoing screening. RESULTS: In all, 75% of men were informed of screening benefits; however, 32% were informed of screening risks. After being informed of both, 56% of men opted for PSA screening if the provider recommended it, compared with only 21% when not recommended. Men receiving a recommendation to undergo PSA testing had higher odds of undergoing screening (odds ratio [OR] = 4.98, 95% CI: 4.53-5.48) compared with those who were only informed about screening benefits (OR = 2.40, 95% CI: 2.18-2.65) or risks (OR = 0.92, 95% CI: 0.86-0.98). Significant limitations include recall and nonresponse bias. CONCLUSIONS: Patients' decision to undergo or forgo PSA screening is heavily influenced by the recommendation of their physician; it is imperative that physicians are cognizant of their biases and facilitate a shared decision-making process.
Abdollah F, Sammon JD, Reznor G, Sood A, Schmid M, Klett DE, Sun M, Aizer AA, Choueiri TK, Hu JC, et al. Medical androgen deprivation therapy and increased non-cancer mortality in non-metastatic prostate cancer patients aged ≥66 years. Eur J Surg Oncol. 2015.Abstract
PURPOSE: To examine the potential relationship between androgen deprivation therapy and other-cause mortality (OCM) in patients with prostate cancer treated with medical primary-androgen deprivation therapy, prostatectomy, or radiation. METHODS: A total of 137,524 patients with non-metastatic PCa treated between 1995 and 2009 within the Surveillance Epidemiology and End Results Medicare-linked database were included. Cox-regression analysis tested the association of ADT with OCM. A 40-item comorbidity score was used for adjustment. RESULTS: Overall, 9.3% of patients harbored stage III-IV disease, and 57.7% of patients received ADT. The mean duration of ADT exposure was 22.9 months (median: 9.1; IQR: 2.8-31.5). Mean and median follow-up were 66.9, and 60.4 months, respectively. At 10 years, overall-OCM rate was 36.5%; it was 30.6% in patients treated without ADT vs. 40.1% in patients treated with ADT (p < 0.001). In multivariable-analysis, ADT was associated with an increased risk of OCM (Hazard-ratio [HR]: 1.11, 95% Confidence-interval [95% CI]: 1.08-1.13). Patients with no comorbidity (10-year OCM excess risk: 9%) were more subject to harm from ADT than patients with high comorbidity (10-year OCM excess risk: 4.7%). CONCLUSIONS: In patients with PCa, treatment with medical ADT may increase the risk of mortality due to causes other than PCa. Whether this is a simple association or a cause-effect relationship is unknown and warrants further study in prospective studies.
Raup VT, Hess DS, Hanske J, Schmid M, Varda B, Das A, Trinh Q-D, Eswara JR. Patient Characteristics and Perioperative Outcomes of Female Urethral Diverticulectomy: Analysis of a Multi-Institutional Prospective Database. Urology. 2015.Abstract
OBJECTIVE: To assess the patient and perioperative characteristics of urethral diverticulectomy using a large multi-institutional prospectively collected database. METHODS: Female patients were identified using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant User Files (2007-2012) and Current Procedural Terminology (CPT) codes for urethral diverticulectomy (53230). Preoperative variables and 30-day complications were examined. RESULTS: One hundred twenty-two female urethral diverticulectomies were performed during the study period. The cohort was relatively healthy; 80% of patients had an ASA score of 1 or 2. The majority of procedures were performed in an outpatient setting (82%). The median procedure length was 77.5 minutes (IQR: 50.5-112.5), and the median length of stay was 0 days (IQR: 0-1). The overall 30-day complication rate was 3.3% (n=4): 3 patients developed UTIs and 1 patient developed both a UTI and a superficial wound infection. CONCLUSIONS: To our knowledge, our study represents the largest multi-institutional cohort of patients having undergone urethral diverticulectomy. The patients requiring this intervention were relatively healthy, and the procedure itself was short, allowing most patients to be discharged within 24 hours. The 30-day complication rate was very low, with UTI being the most common complication. Thus, patients can continue to be confidently counseled that urethral diverticulectomy is a safe procedure with very few perioperative complications.
Sammon JD, Abdollah F, Reznor G, Pucheril D, Choueiri TK, Hu JC, Kim SP, Schmid M, Sood A, Sun M, et al. Patterns of Declining Use and the Adverse Effect of Primary Androgen Deprivation on All-cause Mortality in Elderly Men with Prostate Cancer. Eur Urol. 2015;68 (1) :32-9.Abstract
BACKGROUND: Primary androgen deprivation therapy (pADT) is commonly used to treat elderly men diagnosed with localized prostate cancer (CaP), despite the lack of evidence supporting its use. OBJECTIVE: To examine the effect of pADT on mortality and to assess contemporary trends of pADT use in elderly men with CaP. DESIGN, SETTING, AND PARTICIPANTS: Men older than 65 yr residing in Surveillance, Epidemiology, and End Results (SEER) registry areas diagnosed with localized or locally advanced CaP between 1992 and 2009 and not receiving definitive therapy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Propensity score (PS)-weighted Cox proportional hazards models were used to estimate the effect of pADT use on overall survival among patients receiving pADT. The interaction between comorbidity-adjusted life expectancy (LE) and pADT use was assessed within the Cox and PS-weighted models. Contemporary (2004-2009) trends for pADT use were analyzed by linear regression. RESULTS AND LIMITATIONS: The primary cohort included 46 376 men, of whom 17 873 received pADT (39%). Patients with >10 yr LE had lower pADT utilization rates than patients with short LE. Between 2004 and 2009, the use of pADT in men with localized CaP decreased by 14% (from 36% to 22%). Relative to observation, pADT was associated with a survival disadvantage, with a hazard ratio for all-cause mortality of 1.37 (95% confidence interval 1.20-1.56). Limitations included biases not accounted for by the PS-weighted model, changes in CaP staging over the study period, the absence of prostate-specific antigen (PSA) data prior to 2004, and the limits of retrospective analysis to demonstrate causality. CONCLUSIONS: The use of pADT in elderly men with localized CaP has decreased over time. For men forgoing primary definitive therapy, the use of pADT is not associated with a survival benefit compared to observation, and denies men an opportunity for cure with definitive therapy. The deleterious effect of pADT is most pronounced in men with prolonged LE. PATIENT SUMMARY: In this report, we assessed the effect of primary androgen deprivation (pADT) on prostate cancer mortality and determined current trends in the use of pADT. We showed that use of pADT in men aged >65 yr with localized prostate cancer has decreased over time. We also found that pADT is detrimental to men with localized prostate cancer, and particularly men with longer life expectancy. Therefore, we conclude that ADT should not be used as a primary treatment for men with prostate cancer that has not spread beyond the prostate.
Bienz M, Hueber P-A, Trudeau V, Alenizi AM, Valdivieso R, Alom M, Balbay MD, Canda AE, Mouraviev V, Albala DM, et al. Prevalence and risk factors of contralateral extraprostatic extension in men undergoing radical prostatectomy for unilateral disease at biopsy: A global multi-institutional experience. Can Urol Assoc J. 2015;9 (7-8) :E434-8.Abstract
INTRODUCTION: We assessed the incidence of contralateral prostate cancer (cPCa), contralateral EPE (cEPE) and contralateral positive surgical margins (cPSM) in patients diagnosed preoperatively with unilateral prostate cancer and evaluated risk factors predictive of contralateral disease extension. METHODS: The occurrence of cPCa, cEPE and cPSM and the side-specific nerve-sparing technique performed were collected postoperatively from 327 men diagnosed with unilateral prostate cancer at biopsy. Parameters, such as the localization, proportion, and percentage of cancer in positive cores, were prospectively collected. RESULTS: Overall, 50.5% of patients had bilateral disease, and were at higher risk when associated with a positive biopsy core at the apex (p = 0.016). The overall incidence of ipsilateral EPE and cEPE were 21.4% and 3.4%, respectively (p < 0.001). Compared to cPCa, ipsilateral disease was at an almost 4-fold higher risk of extending out of the prostate (p < 0.001). None of the criteria tested were identified as useful predictors for cEPE. The low incidence of cEPE in our cohort could limit our ability to detect significance. The overall incidence of ipsilateral PSM and cPSM were 15.3% and 5.8%, respectively (p < 0.001). More aggressive nerve-sparing was not associated with a higher incidence of PSM. Prostate sides selected for more aggressive nerve-sparing were associated with younger patients (p < 0.001), a smaller prostate (p = 0.006), and a lower percentage of cancer in biopsy material (p = 0.008). CONCLUSION: Although the risk of cPCa is high in patients diagnosed with unilateral prostate cancer at biopsy, the risk of cEPE and cPSM is low, yet not insignificant. Contralateral aggressive nerve-sparing should be used with caution and should not compromise oncological outcome.
Sun M, Trinh Q-D. A Surveillance, Epidemiology and End Results (SEER) database malfunction: perceptions, pitfalls and verities. BJU Int. 2015.
Sun M, de Velasco G, Trinh Q-D, Choueiri TK. Assessing the Contemporary Role of Cytoreductive Nephrectomy in Metastatic Renal Cell Carcinoma: Another Step in the Right Direction. Eur Urol. 2015.
Muralidhar V, Ziehr DR, Mahal BA, Chen Y-W, Nezolosky MD, Viswanathan VB, Choueiri TK, Sweeney CJ, Trinh Q-D, Nguyen PL. Association Between Older Age and Increasing Gleason Score. Clin Genitourin Cancer. 2015.Abstract
INTRODUCTION: In order to help inform the discussion about the risks versus benefits of prostate cancer screening among older men, we determined whether advanced age is associated with a higher probability of harboring high-grade or high-risk disease. PATIENTS AND METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was used to identify 383,039 men diagnosed with prostate cancer in 2004-2011. The percentage of patients diagnosed with low-, intermediate-, or high-risk disease or a Gleason score of 6, 7, or 8 to 10 was calculated by age range. As a secondary analysis, we examined whether this relationship was different in 2010-2011 versus 2007-2008 (before and after the 2009 publication of screening trials). RESULTS: The probability of Gleason score 8 to 10 or high-risk disease increased significantly with increasing age. The percentage of Gleason score 8 to 10 disease among men ages 50 to 54, 70 to 74, and 80 to 84 years was 8.9%, 16.2%, and 28.5%, respectively, and the percentage of high-risk disease was 14.3%, 22.4%, and 38.7% (P < .001). There were similar relationships among men with stage T1c disease. In addition, older men experienced a significant increase in the relative probability of high-risk or high-grade disease from 2007-2008 to 2010-2011. CONCLUSION: In this large US-based cohort, older men had a much higher probability of high-grade or high-risk prostate cancer. Physicians and patients should take into account the higher risk of more aggressive or advanced disease in older men when discussing the risks and benefits of prostate-specific antigen screening with healthy older men with a substantial life expectancy.
Rieken M, Shariat SF, Kluth LA, Fajkovic H, Rink M, Karakiewicz PI, Seitz C, Briganti A, Rouprêt M, Loidl W, et al. Association of Cigarette Smoking and Smoking Cessation with Biochemical Recurrence of Prostate Cancer in Patients Treated with Radical Prostatectomy. Eur Urol. 2015.Abstract
BACKGROUND: Cigarette smoking seems to be associated with prostate cancer (PCa) incidence and mortality. OBJECTIVE: To elucidate the association between pretreatment smoking status, cumulative smoking exposure, and time since smoking cessation and the risk of biochemical recurrence (BCR) of PCa in patients treated with radical prostatectomy (RP). DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of 6538 patients with pathologically node-negative PCa treated with RP between 2000 and 2011. Clinicopathologic and smoking variables, including smoking status, number of cigarettes per day (CPD), duration in years, and time since smoking cessation were collected. INTERVENTION: RP without neoadjuvant therapy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Univariable and multivariable Cox regression analyses assessed the association between smoking and risk of PCa BCR. RESULTS AND LIMITATIONS: Of 6538 patients, 2238 (34%), 2086 (32%), and 2214 (34%) were never, former, and current smokers, respectively. Median follow-up for patients not experiencing BCR was 28 mo (interquartile range 14-42). RP Gleason score (p=0.3), extracapsular extension (p=0.2), seminal vesicle invasion (p=0.8), and positive surgical margins (p=0.9) were comparable among the three groups. In multivariable Cox regression analysis, former smokers (hazard ratio [HR] 1.63, 95% confidence interval [CI] 1.30-2.04; p<0.001) and current smokers (HR 1.80, 95% CI 1.45-2.24; p<0.001) had a higher risk of PCa BCR compared with non-smokers. Smoking cessation for ≥10 yr mitigated the risk of BCR in multivariable analyses (HR 0.96, 95% CI 0.68-1.37; p=0.84). In multivariable analysis, no significant association between cumulative smoking exposure and risk of BCR could be detected. Limitations of the study include the retrospective design and potential recall bias regarding smoking history. CONCLUSION: Smoking seems to be associated with a higher risk of PCa BCR after RP. The effects of smoking appear to be mitigated by ≥10 yr of cessation. Smokers should be counseled regarding the detrimental effects of smoking on PCa prognosis. PATIENT SUMMARY: We investigated the effect of smoking on the risk of prostate cancer recurrence in patients with treated with surgery. We found that former smokers and current smokers were at higher risk of cancer recurrence compared to patients who never smoked; the detrimental effect of smoking was mitigated after 10 yr or more of smoking cessation. We conclude that smokers should be counseled regarding the detrimental effects on prostate cancer outcomes.

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