Cheryl Guttman Krader, BS, Pharm

-Results from a prospective, randomized controlled clinical trial suggest that bipolar plasma vaporization of the prostate (BPVP) is a promising advance in the surgical treatment of BPH in men with average-size prostates. 

Bogdan Geavlete, MD, PhD, the study's first author, reported that BPVP offered an improved surgical efficiency when compared with bipolar transurethral resection in saline (TURis) and monopolar transurethral resection of the prostate (TURP) and was associated with a faster postoperative recovery and better long-term outcomes. He attributed the superiority of BPVP to the large vaporization surface and excellent coagulation properties of the "button" vapo-resection electrode (PlasmaButton, Olympus, Center Valley, PA). In a separate study, he reported that those attributes provided a premise for using the device during bipolar enucleation of the prostate (BPEP), which showed promise as a safe, efficient BPH endoscopic treatment modality for large prostates. 

Both studies were presented at the AUA annual meeting in Atlanta. 

The perioperative safety data showed the BPVP study group benefited from significantly lower mean hemoglobin level decrease compared with TURis and TURP (0.5 g/dL vs. 1.2 g/dL and 1.6 g/dL), as well as lower rates of intraoperative bleeding (1.8% vs. 8.2% and 13.5%) and capsular perforation (1.2% vs. 7.1% and 9.4%). Rates of postoperative hematuria and blood transfusion were also reduced in the BPVP group (2.9% and 1.2%) and significantly lower than after TURP (15.3% and 6.5%). Mean duration of catheterization was 23.5 hours for BPVP and twofold and threefold longer after TURis and TURP, respectively. Mean hospital stay for the three groups was 1.9, 3.1, and 4.2 days. 

"Some of these differences between groups may be explained by the excellent cauterization properties of the bipolar technique, which reduced bleeding and subsequently improved visualization," said Dr. Geavlete, assistant professor of urology at the St. John Emergency Clinical Hospital, Bucharest, Romania. 

There were no significant differences among the BPVP, TURis, and TURP groups concerning rates of irritative symptoms after surgery (12.4%, 11.2%, and 10.6%). IPSS scores were significantly reduced in all groups and rose slightly over time. However, at all follow-ups, IPSS scores in the BPVP series were significantly lower than in the comparator arms, and Qmax values were also consistently superior after BPVP. 

Articles

Results from a prospective, randomized controlled clinical trial suggest that bipolar plasma vaporization of the prostate is a promising advance in the surgical treatment of BPH in men with average-size prostates.

Bipolar techniques show advantages in treating benign prostatic hyperplasia

-Hospital adoption of robotic technology leads to an increase in overall volume of radical prostatectomy cases and has a positive impact on patient morbidity, according to research undertaken by urologists at Johns Hopkins University's James Brady Buchanan Urological Institute, Baltimore. 

First author Jeffrey K. Mullins, MD, a urologic surgery resident at Johns Hopkins, reported the findings at the AUA annual meeting in Atlanta. The data used were derived from the Maryland Health Services Cost Review Commission (HSCRC), a state agency that prospectively collects data for 30 days after index admission for all inpatient discharges from nonfederal hospitals. The study included men who underwent radical prostatectomy between 2000 and 2011 at 28 hospitals, of which 14 acquired robotic technology during the study period and 14 did not. Excluded were data from one extremely high-volume hospital (Johns Hopkins, >100 RPs per year), 16 extremely low-volume hospitals (<1 RP per year), and others where no RP was performed. 

For the 14 hospitals that acquired robotic technology during the study period, comparisons were made between the eight calendar quarters before acquisition and the most recent eight calendar quarters. The results showed a statistically significant increase in median quarterly RP volume (four to eight) and statistically significant decreases in the proportion of cases being performed by high-volume surgeons (32.8% to 14.3%) and at high-volume hospitals (64.9% to 60.0%). 

 The impact on patient outcomes was investigated by analyzing in-hospital mortality, intensive care unit admissions, length of stay, and 30-day readmissions, and the results showed statistically significant decreases from the pre- to post-robotic technology acquisition periods in both mean length of stay (2 to 1 day) and 30-day readmission rate (1.2% to 0.3%). 

"We know that the introduction of robotic technology has been associated with nationwide increases in post-RP hospital discharges, and in this study, we have observed a similar trend in Maryland hospitals," said Dr. Mullins, who worked on the study with Brian Matlaga, MD, MPH, and colleagues. 

"The impact of acquiring robotic technology on postsurgical morbidity has not been fully defined, and although the Maryland HSCRC lacks granular data on postoperative morbidity, our study shows reductions in length of stay and 30-day readmissions in men operated on at hospitals with robotic technology. 

"These are important observations because men who get out of the hospital faster and stay out of the hospital are more likely to have a smooth and accelerated recovery after surgery. Furthermore, these endpoints have significant health care cost implications that may begin to justify the increased cost associated with performing a robotic prostatectomy," Dr. Mullins said. 

A second analysis compared patient demographics and outcomes at robotic adopter and non-adopter hospitals, but only including data from procedures performed beginning in the last quarter of 2008, which is when the ICD-9 modifier for robotic surgery was first introduced. The results showed that compared to non-adopter hospitals, hospitals with robotic technology were more likely to be high-volume centers (63.8% vs. 0%) and had a higher proportion of high-volume surgeons (>40 cases per year, 25.3% vs. 0%). 

Compared with the non-adopting hospitals, patients undergoing RP at hospitals with robotic technology were again found to have a significantly shorter length of stay (1 vs. 2 days) and significantly lower 30-day readmission rate (0.2 vs. 6%). 

Analyses of quarterly case volumes throughout the study period also showed an increase at hospitals adopting robotic technology, from 8.9 to 10.7 cases (+20.5%), whereas there was a 52.8% decrease from three to 1.4 cases at hospitals that did not acquire a robot. 

Hospital adoption of robotic technology leads to an increase in overall volume of radical prostatectomy cases and has a positive impact on patient morbidity.

Robotic radical prostatectomy raises surgical volume, lowers morbidity

-A final analysis of data after 11 years of follow-up in the European Randomised Study of Screening for Prostate Cancer (ERSPC) shows a highly statistically significant benefit of PSA screening for reducing prostate cancer mortality. 

 2012; 15:366:981-90) confirm data from an interim analysis for 9 years of follow-up (

 2009; 360:1320-8). However, with longer follow-up, the benefits of screening increased, according to data presented at a late-breaking session at the AUA annual meeting in Atlanta. 

In the final analysis, there were 462 prostate cancer deaths in the control arm, representing 8.6% of detected cancers and 0.52% of all control men. In the screening arm, there were 299 prostate cancer deaths, translating to 4.3% of detected cancers and 0.4% of the men. 

The absolute risk reduction of prostate cancer mortality by screening was 1.07/1,000 men randomized, up 30% from the earlier analysis, and there were also reductions from the interim to the final analysis in both the number of men needed to invite to screen to avoid one man dying from prostate cancer (1,410 to 936) and the number needed to diagnose (48 to 33). 

All of these numbers are likely to change with additional follow-up. Nevertheless, longer follow-up is needed to assess the effect of PSA-based screening, said Dr. Roobol. 

'Screening needs to be individualized'							

 "It is obvious from the ERSPC data that some men will benefit from PSA-based screening, but some men will not and might be harmed due to unnecessary testing, overdiagnosis, and overtreatment of potentially indolent disease. It is also obvious that screening on the basis of the PSA test needs to be individualized. In other words, there is no indication for a population-based program," she commented. 

"Currently, the situation for men who consider having a PSA test remains unchanged. The outcome needs to be balanced against the number of screens, biopsies, and potential risks of overdiagnosis. Men who decide to be PSA tested should make this decision on the basis of balanced information." 

The ERSPC is a multicenter trial including eight centers and randomizing men ages 50 to 75 years to screening or a control arm. The final analyses excluded data from one center where there was short follow-up. 

There were 182,160 men randomized, including 162,388 within a predefined core age group of 55 to 69 years; 72,891 men were in the screening group and 89,352 were randomized to control (145 patients died during the randomization process). PSA screening was conducted every 2 years at one center and otherwise every 4 years. In the final analysis, the average number of screening tests per patient was 2.3. 

According to the protocol, lateralized sextant biopsy would be performed in men in the screening group whose PSA was ≥3.0 ng/mL. Biopsy had a positive predictive value of 24%. 

In the final analysis, the incidence of prostate cancer in the screening and control arms was 9.6% and 6.0%, respectively, both up from the previous analysis (8.2% and 4.8%, respectively). The excess incidence of prostate cancer in the screening versus control arm was 35 per 1,000 men, nearly the same as previously reported, and due mainly to detection of low-risk cancers (T1-T2 with Gleason 6), which represented 60% of screening group prostate cancers and 42% of those in the control arm. 

Incidence of cancers that were high risk (any stage with Gleason 8-10 or T4) or advanced at diagnosis was lower in the screening group than in the control arm (10% vs. 20.4%, respectively). 

"Now, we are continuing to work on the basis of the unique ERSPC dataset. For the study group, the question is not if to screen, but how and who should be screened," Dr. Roobol said. 

A final analysis of data after 11 years of follow-up in the European Randomised Study of Screening for Prostate Cancer (ERSPC) shows a highly statistically significant benefit of PSA screening for reducing prostate cancer mortality.

PSA screening reduces deaths by 29% in large trial

Both the clinical presentation and management of incident kidney stone disease appear to vary by age such that older individuals are more likely than their younger counterparts to present with a concurrent urinary tract infection (UTI), have no or atypical pain, and require surgical intervention, reported researchers from Mayo Clinic, Rochester, MN. 

Data from their study were derived from a National Institutes of Health-funded chart review of Olmsted County, MN, residents participating in the Rochester Epidemiology Project. A random sample of nearly 3,500 charts with a first-time ICD-9 code for nephrolithiasis between the years 1984 and 2003 was selected and subjected to manual review to validate incident cases of symptomatic stone disease, defined by having no prior stone diagnosis, symptoms (hematuria, UTI, and/or pain), and stone confirmation by imaging, passage, or surgery. 

Only 1,590 validated first-time, symptomatic adult stone formers were identified with an age range from 18 to 96 years. The patients were divided into five age groups with the youngest including persons 18 to 29 years and the oldest representing those ages 70 years and above. Comparisons were made between age groups for differences in rates of various presenting symptoms, laboratory results, interventions, and outcomes. 

"It was my impression that older patients with stone disease seemed less likely to report pain than younger individuals. This led me to hypothesize there are age-related differences in stone disease presentation, and a colleague suggested investigating it using the available database," said Dr. Krambeck, who reported the findings at the AUA annual meeting in Atlanta. 

"Previously published literature reports age-related differences in stone composition, but our findings on presentation and outcomes are novel. We believe that because stone disease in older patients seems less likely to present with specific symptoms, it may be important to have a higher index of suspicion to ensure a timely diagnosis of urolithiasis in the elderly. Perhaps clinicians should also have a lower threshold for intervention for stone disease in older persons who also appear to have more morbidity associated with their stone disease." 

The study results showed increasing age significantly increased the likelihood of patients presenting with atypical or no pain, fever, diarrhea, pyuria, and bacteremia, while renal colic and voiding symptoms were more common among younger individuals. The risk of having UTI increased 1.26-fold per decade of life. 

Increasing age was also associated with an increased likelihood of having a computed tomography scan, urologic consult, and hospitalization related to stone disease. Overall, surgical intervention was required in about one-third of the cohort, and the likelihood of having surgery increased significantly with rising age, by 1.24-fold for each decade of life. Type of surgery performed also varied by age, with younger individuals more likely to have ureteroscopy and older persons more likely to have shock wave lithotripsy, temporizing stent placement, and percutaneous nephrolithotomy. 

Consistent with previous reports, there were also age-related differences in stone composition. Calcium phosphate stones were more common in younger patients and uric acid and atypical stones more likely in those aged 70 years and above. Stone size and location did not vary by age. 

Both the clinical presentation and management of incident kidney stone disease appear to vary by age such that older individuals are more likely than their younger counterparts to present with a concurrent urinary tract infection (UTI), have no or atypical pain, and require surgical intervention.

Cheryl Guttman Krader, BS, Pharm

Articles

Bipolar techniques show advantages in treating benign prostatic hyperplasia

Robotic radical prostatectomy raises surgical volume, lowers morbidity

PSA screening reduces deaths by 29% in large trial

Older kidney stone patients more likely to have concurrent urinary tract infection