Gregory Zagaja - Profile on Academia.edu (original) (raw)
Papers by Gregory Zagaja
International Braz J Urol, Jul 1, 2011
Background and Purpose: Laparoscopic cryoablation (LCA) has emerged as an alternative to conventi... more Background and Purpose: Laparoscopic cryoablation (LCA) has emerged as an alternative to conventional surgery for the management of a T(1) renal mass; however, only few data are available on its functional outcomes. We assessed renal function changes after LCA in patients with normal renal function (NRF) and preexisting chronic renal insufficiency (CRI). Patients and Methods: Data of consecutive patients who were undergoing LCA between 2000 and 2008 at Duke University Medical Center were analyzed. Renal function parameters were obtained preoperatively, at discharge, and at 6, 12, and 24 months postoperatively. Serum creatinine (sCr) levels and estimated glomerular filtration rates (eGFR) were compared over a 2-year follow-up. Results: Of 67 patients, 22 (33%) had CRI at baseline. These patients were older, had larger tumors (2.5 vs 2.0 cm, P = 0.039), and a higher incidence of multiple lesions (22.7% vs 4.4%, P=0.034). Compared with baseline, sCr was significantly increased and eGFR declined at discharge, 6, 12, and 24 months in both NRF and CRI groups. Median sCr increase was 0.1 mg/mL, eGFR declined by 4.2 mg/mL/1.73 m(2) in the CRI cohort and up to 8.8 mg/mL/1.73m(2) in NRF patients (all P < 0.05) during the follow-up. Compared with baseline, however, no significant changes were noted in the distribution of CRI categories at any time (all P > 0.05). Conclusions: A minimal decline in renal function can be appreciated in patients undergoing LCA at midterm follow-up. This decline is no higher in CRI than in NRF patients. LCA offers excellent renal function outcomes at 2 years follow-up. Specifically, in patients with CRI, LCA offers excellent preservation of renal function.
Journal of Endourology, Apr 1, 2007
Purpose: Several experienced practitioners of open surgery with limited or no laparoscopic backgr... more Purpose: Several experienced practitioners of open surgery with limited or no laparoscopic background have adopted robot-assisted laparoscopic radical prostatectomy (RLRP) as an alternative to open radical prostatectomy (RRP), demonstrating outcomes comparable to those in large RRP and laparoscopic prostatectomy series. Thus, the significance of prior laparoscopic skills seems unclear. The learning curve, with respect to operative time and complications, in the hands of a devoted laparoscopic surgeon has not been critically assessed. We evaluated the learning curve of a highly experienced laparoscopic surgeon in achieving expertise with RLRP. Patients and Methods: We prospectively evaluated 150 consecutive patients undergoing RLRP by a single surgeon between March 2003 and September 2005. The first 25 cases were performed with the assistance of a surgeon experienced in open RRP. Data were compared for the first, second, and third groups of 50 cases. Demographic data were similar for the three groups. Urinary and sexual function data were evaluated subjectively and objectively using the RAND-36v2 Survey and the UCLA PCI preoperatively and at 3, 6, and 12 months postoperatively. Results: The mean operative time, blood loss, and conversion rate decreased significantly with increasing experience. All open conversions occurred during the first 25 cases. Intraoperative and postoperative complication rates were similar among groups. Although the differences were not significant, urinary and sexual function recovery improved with experience. Conclusion: The RLRP learning curve for a fellowship-trained laparoscopic surgeon seems to be similar to that of laparoscopically naive yet experienced practitioners of open RRP. The RLRP is safe and reproducible and even during the learning curve can produce results similar to those reported in large RRP series. The importance of assistance by an experienced open RRP surgeon during the learning curve cannot be overemphasized.
Journal of Endourology, Apr 1, 2011
Background and Purpose: Patients with Gleason (GL) 6 prostate cancer in one or two biopsy cores c... more Background and Purpose: Patients with Gleason (GL) 6 prostate cancer in one or two biopsy cores can be upgraded and=or upstaged at the time of surgery, which may adversely impact long-term outcome. A novel model for prediction of adverse pathologic outcomes was developed using preoperative characteristics. Patients and Methods: Between 2003 and 2007, 1159 patients underwent robot-assisted radical prostatectomy (RARP) at our institution. GL 6 prostate cancer in one or two biopsy cores was identified in 416 (36%) patients. Logistic regression analyses were used to assess the rate of GL 7 and=or extraprostatic extension at RARP. Covariates consisted of age, body mass index (BMI), number of positive cores, greatest percent of cancer in a core (GPC), clinical stage, and preoperative prostate-specific antigen (PSA) level. After backward variable selection, the developed model was internally validated using the area under the curve and subjected to methods of calibration. Results: Respectively, 278 (67%) and 138 (33%) patients had one or two positive biopsy cores. At RARP, 90 (22%) patients were upgraded to GL 7 and 37 (9%) had extraprostatic extension. The novel model relied on age, BMI, preoperative PSA level, and GPC for prediction of adverse pathologic outcomes and was 69% accurate. Calibration plot revealed a virtually perfect relationship between predicted and observed probabilities. Conclusions: In patients with GL 6 prostate cancer in one or two biopsy cores, 25% have more ominous pathology at RARP. The model provides an individual assessment of adverse outcomes at surgery. Consequently, it may be considered when counseling patients regarding their management options.
Continued improvement of perioperative, pathological and continence outcomes during 700 robot-assisted radical prostatectomies
PubMed, Aug 1, 2009
Background: Several robot-assisted radical prostatectomy (RARP) series have reviewed the impact o... more Background: Several robot-assisted radical prostatectomy (RARP) series have reviewed the impact of the initial learning curve on perioperative outcomes. However, little is known about the impact of experience on urinary and sexual outcomes. Herein, we review the perioperative, pathological and functional outcomes of our initial 700 consecutive procedures with at least 1 year follow up. Methods: From 2003-2006, 700 consecutive men underwent RARP at a single, academic institution. Perioperative data and pathologic outcomes were prospectively collected. Validated, UCLA-PCI-SF36v2 quality-of-life questionnaires were also obtained at 1, 3, 6 and 12 months following surgery. Outcomes between groups (cases 1-300, 301-500, and 501-700) were compared. Results: Mean operative time (OT) and blood loss significantly decreased during the experience (286, 198, 190 min; p <or= 0.001; 266, 190, 169 ml; p <or=0.001). Positive surgical margin (PSM) rate decreased in pT2 patients (15% versus 10% versus 7%; p = 0.03) despite operating on men with higher grade disease (biopsy GS>or=7 in 24%, 40%, 44%; p <or= 0.001). At 12 months postRARP, pad free continence rate was 81% when self reported and 62% when assessed by the UCLA-PCI-SF36v2 questionnaire in the initial group. Continence rates improved to 93% and 75%, respectively, for cases 501-700 (p <or= 0.05). Furthermore, significant improvement in continence rates between consecutive case groups was observed at all postoperative time points. Potency rate was 83% (bilateral nerve preservation) and 56% (unilateral nerve preservation) at 12 months when self reported and 63% and 37% respectively by the UCLA-PCI-SF36v2. No significant differences in sexual function were noted with increased experience. Conclusions: A prolonged learning curve is observed for EBL, OT and pT2-PSM. In addition, to the best of our knowledge, this is first series demonstrating a continued improvement in urinary continence with increased RARP experience.
The Journal of Urology, Apr 1, 2008
INTRODUCTION AND OBJECTIVE: With increasing experience, surgeons have tackled more complex roboti... more INTRODUCTION AND OBJECTIVE: With increasing experience, surgeons have tackled more complex robotic assisted laparoscopic prostatectomies (RALP), including those with prior transurethral procedures for symptomatic BPH (TURP). Concern has been raised over outcomes in these patients, particularly with respect to of patients with respect to their perioperative data, oncologic outcomes, sexual function and urinary control pre-and postoperatively. METHODS: Data was collected from prospective RALP databases at 2 institutions. All patients who indicated a history of a prior TURP were included. Preoperative information, operative statistics and pathologic data were prospectively collected and retrospectively data were reviewed. RESULTS: 48 patients underwent RALP after TURP. There were no conversions or transfusions required. PSMs were seen in 15/48 (31.3%) patients. PSMs were seen in 3/26 (11.5%) and 12/22 (54.5%) patients with pT2 and pT3 tumors, respectively. Overall, 22/47 (46.8%)
Urology, Nov 1, 2008
We evaluated trifecta outcomes (continence, potency and undetectable PSA) for preoperatively cont... more We evaluated trifecta outcomes (continence, potency and undetectable PSA) for preoperatively continent and potent men following robotic laparoscopic radical prostatectomy (RLRP) with bilateral nerve sparing technique. Materials and Methods: The prospective RLRP database was analyzed for patients with Ն1 year follow up. Continence and potency were evaluated using both UCLA-PCI questionnaire (no pads, erections sufficient for intercourse) and as reported at patient-surgeon encounter. Trifecta rates were calculated for both definitions. PSAϾ0.05 ng/ml was defined as biochemical recurrence. Results: Out of 1348 RLRP patients operated between February 2003 and January 2008, 380 were continent and potent preoperatively (per UCLA-PCI) and had at least 1 year follow up. The subjective (per patient-surgeon encounter) and objective (per UCLA-PCI) trifecta rates were 34% vs. 16%, 52% vs. 31%, 71% vs. 44% and 76% vs. 44% at 3,6,12 and 24 months, respectively. The differences between the values are statistically significant (pϽ0.0001). Conclusions: Trifecta rates following RLRP are similar to previously reported but vary significantly depending upon definitions applied for postoperative continence and potency.
Functional Outcomes in African-Americans After Robot-Assisted Radical Prostatectomy
Journal of Endourology, Aug 1, 2012
World Journal of Urology, Feb 21, 2015
4, p = 0.02) were predictors of BCR on multivariate analysis. Conclusion Among men with positive ... more 4, p = 0.02) were predictors of BCR on multivariate analysis. Conclusion Among men with positive lymph nodes at time of robotic prostatectomy, those with two or fewer positive nodes and Gleason <8 exhibited favorable biochemical-free survival without adjuvant therapy.
Journal of Robotic Surgery, Jan 24, 2007
We sought to evaluate post-operative return of urinary and sexual function in men undergoing robo... more We sought to evaluate post-operative return of urinary and sexual function in men undergoing robotic-assisted laparoscopic radical prostatectomy (RLRP). Prospective assessment of urinary continence and sexual function was performed in patients undergoing RLRP. Subjective assessment involved the use of the validated RAND-36 Item Health Survey/ UCLA Prostate Cancer Index questionnaire. Questionnaires were completed pre-operatively and at 1, 3, 6 and 12 months post-operatively. Subset analyses were performed to assess the effect of age on functional outcomes. A total of 338 consecutive patients underwent RLRP between February 2003 and August 2005. Included patients for evaluation comprised of 21, 129, and 150 patients, aged <50, 50-59, and ‡60 years old, respectively. Kaplan-Meier curve analysis demonstrated that younger men (<60 years) achieved subjective continence significantly earlier than older age group ( ‡60 years) (P = 0.02). Continence rates, however, equalized among all age groups at 1 year follow-up. Younger men (<50 years) also demonstrated a quicker and greater return of sexual function (P = 0.01), which persisted through assessment at 1 year post-operatively. Our results suggest that younger men may have an earlier return of continence and potency when compared to men > 60 years. Despite this finding, continence outcomes appear to be equal among age groups after 1 year of follow-up. Moreover, men < 60 years continue to report superior potency outcomes compared to men > 60 years at 1 year post-operatively. Such findings are valuable in counseling patients undergoing RLRP.
Early Removal of Urethral Catheter with Suprapubic Tube Drainage Versus Urethral Catheter Drainage Alone after Robot-Assisted Laparoscopic Radical Prostatectomy
The Journal of Urology, Jul 1, 2014
Retrospective single institution data suggest that postoperative pain after robot-assisted laparo... more Retrospective single institution data suggest that postoperative pain after robot-assisted laparoscopic radical prostatectomy is decreased by early removal of the urethral catheter with suprapubic tube drainage. In a randomized patient population we determined whether suprapubic tube drainage with early urethral catheter removal would improve postoperative pain compared with urethral catheter drainage alone. Men with a body mass index of less than 40 kg/m(2) who had newly diagnosed prostate cancer and elected robot-assisted laparoscopic radical prostatectomy were included in analysis. Block randomization by surgeon was used and randomization assignment was done after completing the urethrovesical anastomosis. In patients assigned to suprapubic tube drainage the urethral catheter was removed on postoperative day 1 and all catheters were removed on postoperative day 7. Visual analog pain scale and satisfaction questionnaires were administered on postoperative days 0, 1 and 7. A total of 29 patients were randomized to the urethral catheter vs 29 to the suprapubic tube plus early urethral catheter removal at the time of interim futility analysis. Mean visual analog pain scale scores did not differ between the groups at any time point and a similar percent of patients cited the catheter as the greatest bother with nonsignificant differences in treatment related satisfaction. Complications during postoperative week 1 did not vary between the groups. Based on interim results the trial was terminated due to lack of effect. Patients randomized to suprapubic tube vs urethral catheter drainage for the week after prostatectomy had similar pain, catheter related bother and treatment related satisfaction in the perioperative period. We no longer routinely offer suprapubic tube drainage with early urethral catheter removal at our institution.
Extrafascial Versus Interfascial Nerve-sparing Technique for Robotic-assisted Laparoscopic Prostatectomy: Comparison of Functional Outcomes and Positive Surgical Margins Characteristics
Urology, Sep 1, 2009
To evaluate the pathologic and functional outcomes of patients with bilateral interfascial (IF) o... more To evaluate the pathologic and functional outcomes of patients with bilateral interfascial (IF) or extrafascial nerve-sparing (EF-NSP) techniques. It is believed that the IF-NSP technique used during robotic-assisted radical prostatectomy (RARP) spares more nerve fibers, while EF dissection may lower the risk for positive surgical margins (PSM). A prospective database was analyzed for RARP patients with bilateral IF- or EF-NSP technique. Collected parameters included age, body mass index, prostate-specific antigen, clinical and pathologic Gleason score and stage, estimated blood loss, operative time, and PSM characteristics. Functional outcomes were evaluated with the use of the University of California Los Angeles Prostate Cancer Index questionnaire. Men receiving postoperative hormonal or radiation therapy were excluded from sexual function analysis. A total of 110 and 703 cases with bilateral EF- and IF-NSP, respectively, were analyzed. EF-NSP patients had higher prostate-specific antigen, clinical, pathologic stage, and pathologic Gleason score. PSM rate did not achieve statistically significant difference between groups. There was a trend toward lower pT3-PSM in the EF group (51% vs 28%; P = .08). Mid- and posterolateral PSM location were lower in the EF-NSP group, 11% vs 37% and 11% vs 29%, respectively (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). The IF-NSP group patients achieved statistically significant better sexual function (P = .02) and potency rates (P = .03) at 12 months after RARP. In lower risk patients, bilateral IF-NSP technique does not result in significantly higher PSM rates. EF-NSP appears to reduce posterolateral and mid-prostate PSM. Men with bilateral IF-NSP demonstrate significantly better sexual function outcomes.
The Journal of Urology, Apr 1, 2005
INTRODUCTION AND OBJECTIVE: TGF-13 is a multifunctional growth factor that is a potent inhibitor ... more INTRODUCTION AND OBJECTIVE: TGF-13 is a multifunctional growth factor that is a potent inhibitor of the immune response. Previously, it has been demonstrated that renal cell carcinoma cells express increased levels of expression of TGF-13 and a decreased level of expression ofTGF-13 receptors. In macrophages, TGF-13 is a potent inducer of cell death in a dose-dependent manner. In the present study, we test the hypothesis that macrophages that are rendered insensitive to TGF-13 will lead to an increased cytotoxic activity of macrophages on renal cell carcinoma cells. METHODS: Murine macrophage cell line, Raw 264.7, and murine renal cell carcinoma cell line, Renca, were routinely maintained in Dulbecco's Modified Eagle Medium (DMEM) supplemented with 10% fetal bovine serum (FBS). To generate TGF-13 resistant cells, Raw 264.7 was transfected with either control vector (GFP) or TGF-13 receptor type II dominant negative (TI3RIIDN) using lipofectamine. Subsequently transfected cells (Raw-TI3RIIDN) were co-cultured with Renca and percentage of apoptotic cells were determined by fluorescence assisted cell sorter (FACS) using Annexin V-PE assay kit. Anti-murine macrophage antibody was used to set the gate against Raw 264.7. Finally, Western blot and Elisa assays were used to measure inducible Nitric Oxide Synthetase (i-NOS), TNF-a, and Fas-Ligand. RESULTS: When co-cultured for 24 hours with Raw 264.7 parental cells, Raw-GFP, and Raw-TI3RIIDN cells, the percentage of apoptotic Renca cells was 6. 7%, 3.5%, and 65%, respectively. To determine whether the increased cytotoxic effect of Raw-TI3RIIDN is due to soluble factors , the two cell types were co-cultured but physically separated by a microporous membrane that allows soluble factors but not cells to cross the membrane. Again, the fraction of apoptotic Renca cells in the presence of Raw-TI3RIIDN cells was 47% (as compared to 11% in control). As an initial attempt to identify the soluble factor(s) secreted by Raw-TI3RIIDN cells that leads to apoptosis of Renca, Western blot analysis for iNOS and Elisa for TNF-a and Fas-Ligand were carried out. The results demonstrated a significant increase in the levels of iNOS and TNF-a in Raw-TI3RIIDN cells. CONCLUSIONS: Overexpression of TI3RIIDN in Raw 264.7 cells results in an enhanced cytotoxic effect on the murine renal cell carcinoma cell line, Renca. The mechanism may be, in part, due to soluble factors such as oxygen radicals and TNF-a.
1339: Comparison of Validated Survey Evaluation Methods in the Determination of Post-Prostatectomy Sexual Function
The Journal of Urology, Apr 1, 2006
V343: Antegrade Nerve Preservation During Robotic Laparoscopic Radical Prostatectomy: The Video
The Journal of Urology, Apr 1, 2005
1068 Functional Outcomes in African-Americans After Robotic-Assisted Radical Prostatectomy
The Journal of Urology, Apr 1, 2010
Abstract Background and Purpose: Previous studies have demonstrated differences in surgical outco... more Abstract Background and Purpose: Previous studies have demonstrated differences in surgical outcomes after radical prostatectomy based on ethnicity. We compared sexual and urinary outcomes in African-American (AA) patients 6 and 12 months after robot-assisted radical prostatectomy (RARP) with those of non-AA patients. Patients and Methods: We reviewed our RARP database at our institution for patients with at least 12 months of follow-up. Erectile function was defined using the University of California, Los Angeles Prostate Cancer Index as erections “firm enough for masturbation and foreplay” or “firm enough for intercourse,” while urinary continence was defined as being “pad free.” Only patients who were potent and pad free preoperatively were included in the analysis. Multivariate logistic regression was used to compare postoperative potency and urinary pad-free status between AA and non-AA patients while controlling for pertinent demographic, clinical, and pathologic variables. Results: In the urinary c...
The Journal of Urology, Apr 1, 2008
respectively. 57% of Group1 and 88% of Group2 patients had bilateral (34%) had stage pT2c or grea... more respectively. 57% of Group1 and 88% of Group2 patients had bilateral (34%) had stage pT2c or greater disease. Tumor was limited to the posterior and mid prostate (MP) in 28.3% of Group1 cases. Anterior and posterior MP tumors were predominant in 86% of Group2 patients. The apex was involved in 37% and 58% of the Group1 and Group2 patients respectively and was the only site of tumor in 8% overall. MRI studies were positive in 43% of Group1 and 52% of Group2 cases (p=0.24). CONCLUSIONS: Current staging tools for predicting PCA behavior cannot distinguish patients with indolent cancer. Clinically based on preoperative data. Pathologically T2c or greater tumors were seen in 17% of cases overall. Patients considered for AS or FT would be inappropriately selected. These data support the development of a more accurate strategy for staging biopsy and imaging assessment of patients considered for AS or FT.
Journal of Pediatric Urology, Apr 1, 2009
Urology, Nov 1, 2008
Results: Demographic. Preoperative, operative and pathologic details are given in table 1. Mean h... more Results: Demographic. Preoperative, operative and pathologic details are given in table 1. Mean hospital stay was 1 day and mean catheter duration was 9.8 days (range 6-21 days). Only one patient required blood transfusion (0.01%). At a mean follow up of 78 weeks, 6 patients (4.8%) had biochemical recurrence compared to 14 (3.6%) in the non obese (Pϭ0.15). Three patients (2%) were using 2 pads per day compared to similar percentage among the non obese. Conclusions: Robotic surgery is feasible in the morbidly obese and can achieve good operative, post operative outcomes and oncologic control despite having larger prostates and a bad disease.
The Journal of Urology, Apr 1, 2007
International Braz J Urol, Jul 1, 2011
Background and Purpose: Laparoscopic cryoablation (LCA) has emerged as an alternative to conventi... more Background and Purpose: Laparoscopic cryoablation (LCA) has emerged as an alternative to conventional surgery for the management of a T(1) renal mass; however, only few data are available on its functional outcomes. We assessed renal function changes after LCA in patients with normal renal function (NRF) and preexisting chronic renal insufficiency (CRI). Patients and Methods: Data of consecutive patients who were undergoing LCA between 2000 and 2008 at Duke University Medical Center were analyzed. Renal function parameters were obtained preoperatively, at discharge, and at 6, 12, and 24 months postoperatively. Serum creatinine (sCr) levels and estimated glomerular filtration rates (eGFR) were compared over a 2-year follow-up. Results: Of 67 patients, 22 (33%) had CRI at baseline. These patients were older, had larger tumors (2.5 vs 2.0 cm, P = 0.039), and a higher incidence of multiple lesions (22.7% vs 4.4%, P=0.034). Compared with baseline, sCr was significantly increased and eGFR declined at discharge, 6, 12, and 24 months in both NRF and CRI groups. Median sCr increase was 0.1 mg/mL, eGFR declined by 4.2 mg/mL/1.73 m(2) in the CRI cohort and up to 8.8 mg/mL/1.73m(2) in NRF patients (all P < 0.05) during the follow-up. Compared with baseline, however, no significant changes were noted in the distribution of CRI categories at any time (all P > 0.05). Conclusions: A minimal decline in renal function can be appreciated in patients undergoing LCA at midterm follow-up. This decline is no higher in CRI than in NRF patients. LCA offers excellent renal function outcomes at 2 years follow-up. Specifically, in patients with CRI, LCA offers excellent preservation of renal function.
Journal of Endourology, Apr 1, 2007
Purpose: Several experienced practitioners of open surgery with limited or no laparoscopic backgr... more Purpose: Several experienced practitioners of open surgery with limited or no laparoscopic background have adopted robot-assisted laparoscopic radical prostatectomy (RLRP) as an alternative to open radical prostatectomy (RRP), demonstrating outcomes comparable to those in large RRP and laparoscopic prostatectomy series. Thus, the significance of prior laparoscopic skills seems unclear. The learning curve, with respect to operative time and complications, in the hands of a devoted laparoscopic surgeon has not been critically assessed. We evaluated the learning curve of a highly experienced laparoscopic surgeon in achieving expertise with RLRP. Patients and Methods: We prospectively evaluated 150 consecutive patients undergoing RLRP by a single surgeon between March 2003 and September 2005. The first 25 cases were performed with the assistance of a surgeon experienced in open RRP. Data were compared for the first, second, and third groups of 50 cases. Demographic data were similar for the three groups. Urinary and sexual function data were evaluated subjectively and objectively using the RAND-36v2 Survey and the UCLA PCI preoperatively and at 3, 6, and 12 months postoperatively. Results: The mean operative time, blood loss, and conversion rate decreased significantly with increasing experience. All open conversions occurred during the first 25 cases. Intraoperative and postoperative complication rates were similar among groups. Although the differences were not significant, urinary and sexual function recovery improved with experience. Conclusion: The RLRP learning curve for a fellowship-trained laparoscopic surgeon seems to be similar to that of laparoscopically naive yet experienced practitioners of open RRP. The RLRP is safe and reproducible and even during the learning curve can produce results similar to those reported in large RRP series. The importance of assistance by an experienced open RRP surgeon during the learning curve cannot be overemphasized.
Journal of Endourology, Apr 1, 2011
Background and Purpose: Patients with Gleason (GL) 6 prostate cancer in one or two biopsy cores c... more Background and Purpose: Patients with Gleason (GL) 6 prostate cancer in one or two biopsy cores can be upgraded and=or upstaged at the time of surgery, which may adversely impact long-term outcome. A novel model for prediction of adverse pathologic outcomes was developed using preoperative characteristics. Patients and Methods: Between 2003 and 2007, 1159 patients underwent robot-assisted radical prostatectomy (RARP) at our institution. GL 6 prostate cancer in one or two biopsy cores was identified in 416 (36%) patients. Logistic regression analyses were used to assess the rate of GL 7 and=or extraprostatic extension at RARP. Covariates consisted of age, body mass index (BMI), number of positive cores, greatest percent of cancer in a core (GPC), clinical stage, and preoperative prostate-specific antigen (PSA) level. After backward variable selection, the developed model was internally validated using the area under the curve and subjected to methods of calibration. Results: Respectively, 278 (67%) and 138 (33%) patients had one or two positive biopsy cores. At RARP, 90 (22%) patients were upgraded to GL 7 and 37 (9%) had extraprostatic extension. The novel model relied on age, BMI, preoperative PSA level, and GPC for prediction of adverse pathologic outcomes and was 69% accurate. Calibration plot revealed a virtually perfect relationship between predicted and observed probabilities. Conclusions: In patients with GL 6 prostate cancer in one or two biopsy cores, 25% have more ominous pathology at RARP. The model provides an individual assessment of adverse outcomes at surgery. Consequently, it may be considered when counseling patients regarding their management options.
Continued improvement of perioperative, pathological and continence outcomes during 700 robot-assisted radical prostatectomies
PubMed, Aug 1, 2009
Background: Several robot-assisted radical prostatectomy (RARP) series have reviewed the impact o... more Background: Several robot-assisted radical prostatectomy (RARP) series have reviewed the impact of the initial learning curve on perioperative outcomes. However, little is known about the impact of experience on urinary and sexual outcomes. Herein, we review the perioperative, pathological and functional outcomes of our initial 700 consecutive procedures with at least 1 year follow up. Methods: From 2003-2006, 700 consecutive men underwent RARP at a single, academic institution. Perioperative data and pathologic outcomes were prospectively collected. Validated, UCLA-PCI-SF36v2 quality-of-life questionnaires were also obtained at 1, 3, 6 and 12 months following surgery. Outcomes between groups (cases 1-300, 301-500, and 501-700) were compared. Results: Mean operative time (OT) and blood loss significantly decreased during the experience (286, 198, 190 min; p <or= 0.001; 266, 190, 169 ml; p <or=0.001). Positive surgical margin (PSM) rate decreased in pT2 patients (15% versus 10% versus 7%; p = 0.03) despite operating on men with higher grade disease (biopsy GS>or=7 in 24%, 40%, 44%; p <or= 0.001). At 12 months postRARP, pad free continence rate was 81% when self reported and 62% when assessed by the UCLA-PCI-SF36v2 questionnaire in the initial group. Continence rates improved to 93% and 75%, respectively, for cases 501-700 (p <or= 0.05). Furthermore, significant improvement in continence rates between consecutive case groups was observed at all postoperative time points. Potency rate was 83% (bilateral nerve preservation) and 56% (unilateral nerve preservation) at 12 months when self reported and 63% and 37% respectively by the UCLA-PCI-SF36v2. No significant differences in sexual function were noted with increased experience. Conclusions: A prolonged learning curve is observed for EBL, OT and pT2-PSM. In addition, to the best of our knowledge, this is first series demonstrating a continued improvement in urinary continence with increased RARP experience.
The Journal of Urology, Apr 1, 2008
INTRODUCTION AND OBJECTIVE: With increasing experience, surgeons have tackled more complex roboti... more INTRODUCTION AND OBJECTIVE: With increasing experience, surgeons have tackled more complex robotic assisted laparoscopic prostatectomies (RALP), including those with prior transurethral procedures for symptomatic BPH (TURP). Concern has been raised over outcomes in these patients, particularly with respect to of patients with respect to their perioperative data, oncologic outcomes, sexual function and urinary control pre-and postoperatively. METHODS: Data was collected from prospective RALP databases at 2 institutions. All patients who indicated a history of a prior TURP were included. Preoperative information, operative statistics and pathologic data were prospectively collected and retrospectively data were reviewed. RESULTS: 48 patients underwent RALP after TURP. There were no conversions or transfusions required. PSMs were seen in 15/48 (31.3%) patients. PSMs were seen in 3/26 (11.5%) and 12/22 (54.5%) patients with pT2 and pT3 tumors, respectively. Overall, 22/47 (46.8%)
Urology, Nov 1, 2008
We evaluated trifecta outcomes (continence, potency and undetectable PSA) for preoperatively cont... more We evaluated trifecta outcomes (continence, potency and undetectable PSA) for preoperatively continent and potent men following robotic laparoscopic radical prostatectomy (RLRP) with bilateral nerve sparing technique. Materials and Methods: The prospective RLRP database was analyzed for patients with Ն1 year follow up. Continence and potency were evaluated using both UCLA-PCI questionnaire (no pads, erections sufficient for intercourse) and as reported at patient-surgeon encounter. Trifecta rates were calculated for both definitions. PSAϾ0.05 ng/ml was defined as biochemical recurrence. Results: Out of 1348 RLRP patients operated between February 2003 and January 2008, 380 were continent and potent preoperatively (per UCLA-PCI) and had at least 1 year follow up. The subjective (per patient-surgeon encounter) and objective (per UCLA-PCI) trifecta rates were 34% vs. 16%, 52% vs. 31%, 71% vs. 44% and 76% vs. 44% at 3,6,12 and 24 months, respectively. The differences between the values are statistically significant (pϽ0.0001). Conclusions: Trifecta rates following RLRP are similar to previously reported but vary significantly depending upon definitions applied for postoperative continence and potency.
Functional Outcomes in African-Americans After Robot-Assisted Radical Prostatectomy
Journal of Endourology, Aug 1, 2012
World Journal of Urology, Feb 21, 2015
4, p = 0.02) were predictors of BCR on multivariate analysis. Conclusion Among men with positive ... more 4, p = 0.02) were predictors of BCR on multivariate analysis. Conclusion Among men with positive lymph nodes at time of robotic prostatectomy, those with two or fewer positive nodes and Gleason <8 exhibited favorable biochemical-free survival without adjuvant therapy.
Journal of Robotic Surgery, Jan 24, 2007
We sought to evaluate post-operative return of urinary and sexual function in men undergoing robo... more We sought to evaluate post-operative return of urinary and sexual function in men undergoing robotic-assisted laparoscopic radical prostatectomy (RLRP). Prospective assessment of urinary continence and sexual function was performed in patients undergoing RLRP. Subjective assessment involved the use of the validated RAND-36 Item Health Survey/ UCLA Prostate Cancer Index questionnaire. Questionnaires were completed pre-operatively and at 1, 3, 6 and 12 months post-operatively. Subset analyses were performed to assess the effect of age on functional outcomes. A total of 338 consecutive patients underwent RLRP between February 2003 and August 2005. Included patients for evaluation comprised of 21, 129, and 150 patients, aged <50, 50-59, and ‡60 years old, respectively. Kaplan-Meier curve analysis demonstrated that younger men (<60 years) achieved subjective continence significantly earlier than older age group ( ‡60 years) (P = 0.02). Continence rates, however, equalized among all age groups at 1 year follow-up. Younger men (<50 years) also demonstrated a quicker and greater return of sexual function (P = 0.01), which persisted through assessment at 1 year post-operatively. Our results suggest that younger men may have an earlier return of continence and potency when compared to men > 60 years. Despite this finding, continence outcomes appear to be equal among age groups after 1 year of follow-up. Moreover, men < 60 years continue to report superior potency outcomes compared to men > 60 years at 1 year post-operatively. Such findings are valuable in counseling patients undergoing RLRP.
Early Removal of Urethral Catheter with Suprapubic Tube Drainage Versus Urethral Catheter Drainage Alone after Robot-Assisted Laparoscopic Radical Prostatectomy
The Journal of Urology, Jul 1, 2014
Retrospective single institution data suggest that postoperative pain after robot-assisted laparo... more Retrospective single institution data suggest that postoperative pain after robot-assisted laparoscopic radical prostatectomy is decreased by early removal of the urethral catheter with suprapubic tube drainage. In a randomized patient population we determined whether suprapubic tube drainage with early urethral catheter removal would improve postoperative pain compared with urethral catheter drainage alone. Men with a body mass index of less than 40 kg/m(2) who had newly diagnosed prostate cancer and elected robot-assisted laparoscopic radical prostatectomy were included in analysis. Block randomization by surgeon was used and randomization assignment was done after completing the urethrovesical anastomosis. In patients assigned to suprapubic tube drainage the urethral catheter was removed on postoperative day 1 and all catheters were removed on postoperative day 7. Visual analog pain scale and satisfaction questionnaires were administered on postoperative days 0, 1 and 7. A total of 29 patients were randomized to the urethral catheter vs 29 to the suprapubic tube plus early urethral catheter removal at the time of interim futility analysis. Mean visual analog pain scale scores did not differ between the groups at any time point and a similar percent of patients cited the catheter as the greatest bother with nonsignificant differences in treatment related satisfaction. Complications during postoperative week 1 did not vary between the groups. Based on interim results the trial was terminated due to lack of effect. Patients randomized to suprapubic tube vs urethral catheter drainage for the week after prostatectomy had similar pain, catheter related bother and treatment related satisfaction in the perioperative period. We no longer routinely offer suprapubic tube drainage with early urethral catheter removal at our institution.
Extrafascial Versus Interfascial Nerve-sparing Technique for Robotic-assisted Laparoscopic Prostatectomy: Comparison of Functional Outcomes and Positive Surgical Margins Characteristics
Urology, Sep 1, 2009
To evaluate the pathologic and functional outcomes of patients with bilateral interfascial (IF) o... more To evaluate the pathologic and functional outcomes of patients with bilateral interfascial (IF) or extrafascial nerve-sparing (EF-NSP) techniques. It is believed that the IF-NSP technique used during robotic-assisted radical prostatectomy (RARP) spares more nerve fibers, while EF dissection may lower the risk for positive surgical margins (PSM). A prospective database was analyzed for RARP patients with bilateral IF- or EF-NSP technique. Collected parameters included age, body mass index, prostate-specific antigen, clinical and pathologic Gleason score and stage, estimated blood loss, operative time, and PSM characteristics. Functional outcomes were evaluated with the use of the University of California Los Angeles Prostate Cancer Index questionnaire. Men receiving postoperative hormonal or radiation therapy were excluded from sexual function analysis. A total of 110 and 703 cases with bilateral EF- and IF-NSP, respectively, were analyzed. EF-NSP patients had higher prostate-specific antigen, clinical, pathologic stage, and pathologic Gleason score. PSM rate did not achieve statistically significant difference between groups. There was a trend toward lower pT3-PSM in the EF group (51% vs 28%; P = .08). Mid- and posterolateral PSM location were lower in the EF-NSP group, 11% vs 37% and 11% vs 29%, respectively (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). The IF-NSP group patients achieved statistically significant better sexual function (P = .02) and potency rates (P = .03) at 12 months after RARP. In lower risk patients, bilateral IF-NSP technique does not result in significantly higher PSM rates. EF-NSP appears to reduce posterolateral and mid-prostate PSM. Men with bilateral IF-NSP demonstrate significantly better sexual function outcomes.
The Journal of Urology, Apr 1, 2005
INTRODUCTION AND OBJECTIVE: TGF-13 is a multifunctional growth factor that is a potent inhibitor ... more INTRODUCTION AND OBJECTIVE: TGF-13 is a multifunctional growth factor that is a potent inhibitor of the immune response. Previously, it has been demonstrated that renal cell carcinoma cells express increased levels of expression of TGF-13 and a decreased level of expression ofTGF-13 receptors. In macrophages, TGF-13 is a potent inducer of cell death in a dose-dependent manner. In the present study, we test the hypothesis that macrophages that are rendered insensitive to TGF-13 will lead to an increased cytotoxic activity of macrophages on renal cell carcinoma cells. METHODS: Murine macrophage cell line, Raw 264.7, and murine renal cell carcinoma cell line, Renca, were routinely maintained in Dulbecco's Modified Eagle Medium (DMEM) supplemented with 10% fetal bovine serum (FBS). To generate TGF-13 resistant cells, Raw 264.7 was transfected with either control vector (GFP) or TGF-13 receptor type II dominant negative (TI3RIIDN) using lipofectamine. Subsequently transfected cells (Raw-TI3RIIDN) were co-cultured with Renca and percentage of apoptotic cells were determined by fluorescence assisted cell sorter (FACS) using Annexin V-PE assay kit. Anti-murine macrophage antibody was used to set the gate against Raw 264.7. Finally, Western blot and Elisa assays were used to measure inducible Nitric Oxide Synthetase (i-NOS), TNF-a, and Fas-Ligand. RESULTS: When co-cultured for 24 hours with Raw 264.7 parental cells, Raw-GFP, and Raw-TI3RIIDN cells, the percentage of apoptotic Renca cells was 6. 7%, 3.5%, and 65%, respectively. To determine whether the increased cytotoxic effect of Raw-TI3RIIDN is due to soluble factors , the two cell types were co-cultured but physically separated by a microporous membrane that allows soluble factors but not cells to cross the membrane. Again, the fraction of apoptotic Renca cells in the presence of Raw-TI3RIIDN cells was 47% (as compared to 11% in control). As an initial attempt to identify the soluble factor(s) secreted by Raw-TI3RIIDN cells that leads to apoptosis of Renca, Western blot analysis for iNOS and Elisa for TNF-a and Fas-Ligand were carried out. The results demonstrated a significant increase in the levels of iNOS and TNF-a in Raw-TI3RIIDN cells. CONCLUSIONS: Overexpression of TI3RIIDN in Raw 264.7 cells results in an enhanced cytotoxic effect on the murine renal cell carcinoma cell line, Renca. The mechanism may be, in part, due to soluble factors such as oxygen radicals and TNF-a.
1339: Comparison of Validated Survey Evaluation Methods in the Determination of Post-Prostatectomy Sexual Function
The Journal of Urology, Apr 1, 2006
V343: Antegrade Nerve Preservation During Robotic Laparoscopic Radical Prostatectomy: The Video
The Journal of Urology, Apr 1, 2005
1068 Functional Outcomes in African-Americans After Robotic-Assisted Radical Prostatectomy
The Journal of Urology, Apr 1, 2010
Abstract Background and Purpose: Previous studies have demonstrated differences in surgical outco... more Abstract Background and Purpose: Previous studies have demonstrated differences in surgical outcomes after radical prostatectomy based on ethnicity. We compared sexual and urinary outcomes in African-American (AA) patients 6 and 12 months after robot-assisted radical prostatectomy (RARP) with those of non-AA patients. Patients and Methods: We reviewed our RARP database at our institution for patients with at least 12 months of follow-up. Erectile function was defined using the University of California, Los Angeles Prostate Cancer Index as erections “firm enough for masturbation and foreplay” or “firm enough for intercourse,” while urinary continence was defined as being “pad free.” Only patients who were potent and pad free preoperatively were included in the analysis. Multivariate logistic regression was used to compare postoperative potency and urinary pad-free status between AA and non-AA patients while controlling for pertinent demographic, clinical, and pathologic variables. Results: In the urinary c...
The Journal of Urology, Apr 1, 2008
respectively. 57% of Group1 and 88% of Group2 patients had bilateral (34%) had stage pT2c or grea... more respectively. 57% of Group1 and 88% of Group2 patients had bilateral (34%) had stage pT2c or greater disease. Tumor was limited to the posterior and mid prostate (MP) in 28.3% of Group1 cases. Anterior and posterior MP tumors were predominant in 86% of Group2 patients. The apex was involved in 37% and 58% of the Group1 and Group2 patients respectively and was the only site of tumor in 8% overall. MRI studies were positive in 43% of Group1 and 52% of Group2 cases (p=0.24). CONCLUSIONS: Current staging tools for predicting PCA behavior cannot distinguish patients with indolent cancer. Clinically based on preoperative data. Pathologically T2c or greater tumors were seen in 17% of cases overall. Patients considered for AS or FT would be inappropriately selected. These data support the development of a more accurate strategy for staging biopsy and imaging assessment of patients considered for AS or FT.
Journal of Pediatric Urology, Apr 1, 2009
Urology, Nov 1, 2008
Results: Demographic. Preoperative, operative and pathologic details are given in table 1. Mean h... more Results: Demographic. Preoperative, operative and pathologic details are given in table 1. Mean hospital stay was 1 day and mean catheter duration was 9.8 days (range 6-21 days). Only one patient required blood transfusion (0.01%). At a mean follow up of 78 weeks, 6 patients (4.8%) had biochemical recurrence compared to 14 (3.6%) in the non obese (Pϭ0.15). Three patients (2%) were using 2 pads per day compared to similar percentage among the non obese. Conclusions: Robotic surgery is feasible in the morbidly obese and can achieve good operative, post operative outcomes and oncologic control despite having larger prostates and a bad disease.
The Journal of Urology, Apr 1, 2007