OBJECTIVE •  To define selection criteria for pelvic lymph node dissection (PLND) based on a contemporary Australian cohort of men with clinically localised prostate cancer undergoing radical prostatectomy (RP) with PLND, as stage migration of prostate cancer has led to re-evaluation of the role of PLND at the time of RP. PATIENTS AND METHODS •  In all, 200 consecutive men treated by one surgeon between 2000 and 2005 with open RP and PLND. •  The clinical and pathological data were extracted by retrospective chart review. •  Associations between clinical predictors and LN positivity were assessed by logistic regression analysis. RESULTS •  Overall, there were LN metastases were in 10 (5%) men. •  The LN positivity rate was significantly associated with biopsy Gleason score, preoperative prostate-specific antigen (PSA) concentration and percentage of positive cores (PPC), with respective odds ratios (OR)(95% confidence interval [CI]) of 3.70 (1.98-6.92), 1.11 (1.04-1.19) and 1.04 (1.01-1.06) •  Trend toward significant association with clinical stage (OR 1.75, 95% CI 0.97-3.13) •  On multivariate analysis, PSA concentraion and biopsy Gleason score were significant predictors of LN disease. •  All 10 men with LN metastases came from a high-risk group of 96, identifiable by having at least one of the following: stage ≥cT2b, biopsy Gleason score ≥4+3, PSA concentration of ≥10 ng/mL or PPC of ≥38%. CONCLUSIONS •  The risk of LN metastases depends upon well-defined clinical risk factors of stage, biopsy Gleason score, PSA concentration and PPC •  The present data suggests a simple risk-stratification method, using these risk factors, of identifying men to have PLND at the time of RP.

OBJECTIVE •  To validate the relationship of the R.E.N.A.L nephrometry score to histological features of renal lesions treated by surgical excision by radical nephrectomy (RN) or nephron-sparing surgery (NSS) at an Australian tertiary referral centre. PATIENTS AND METHODS •  Patients undergoing surgery between 2005 and 2009 with imaging studies available were included. •  The R.E.N.A.L. nephrometry score is an objective measure of factors important in determining suitability for NSS, e.g. size, exophytic nature, proximity to collecting system and polar location, and R.E.N.A.L scoring was done using the online template at http://www.nephrometry.com. •  Pathological details were collected by retrospective chart review. •  Comparisons were made using chi-squared or Fisher's exact tests and trends analysed by linear regression. RESULTS •  The rate of benign pathology decreased from 12/58 (20.7%) low-complexity lesions to 1/16 (6.2%) high-complexity lesions (P= 0.09), renal cell carcinomas (RCCs) were stable between 45/58 (77.6%) and 13/16 (81.2%), but other malignancies increased (P= 0.058) from 1/58 (1.7%) to 2/16 (12.5%). •  Among the RCCs, high vs low R.E.N.A.L score was associated with an increasing risk of clear cell histology (84.6% vs 64.4%, P < 0.05), stage ≥pT3 (76.9% vs 8.9%, P < 0.001) and grade 4 tumours (15.4% vs 2.2%, P < 0.05), and conversely with a lower risk of papillary histology (0% vs 24.4%, P < 0.02) and stage T1a (0% vs 84.4%, P < 0.001). CONCLUSIONS •  Increasing R.E.N.A.L score is associated with histological features of tumour aggressiveness, thus reinforcing the need for RN for lesions with a high score, and conversely the safety of NSS or observation for lesions with a low score.

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Nephron-sparing surgery (NSS) is increasingly recognised as a preferred form of management for the incidentally detected small renal mass (SRM). Within the context of equivalent oncological outcomes, patients treated by NSS may have a survival advantage over those treated by radical nephrectomy (RN) through a reduced risk of chronic kidney disease and its associated cardiac morbidity. Despite this, according to Medicare data from the USA, a disproportionate number of patients with SRMs continue to be treated with RN instead of NSS. Similar data from Australia are not yet available. The present study explores the evolving management of SRMs at an Australian tertiary centre over a 5-year period. It utilises the R.E.N.A.L. Nephrometry Score to assess how lesion complexity has influenced surgical decision-making and charts the increasing use of NSS in the management of low-complexity renal masses at our centre. OBJECTIVE: •  To examine recent trends in the use of nephron-sparing surgery (NSS) at our centre. Specifically, we sought to examine the process of surgical decision-making by applying the R.E.N.A.L. nephrometry scoring system to assess the complexity of lesions for which surgery was undertaken. PATIENTS AND METHODS: •  We performed a retrospective review of renal masses treated by surgery from January 2005 to December 2009, including 79 RN and 70 NSS. •  CT images were available for analysis in 50 patients within each group. •  Lesions were scored on the basis of their complexity using the R.E.N.A.L. nephrometry scoring system developed by Kutikov and Uzzo. RESULTS: •  There was no difference in age between patients undergoing RN and NSS (median age 61 vs 60 years). •  RN was performed for significantly larger lesions (mean [sd] 68 [9] vs 29 [2] mm, P < 0.05) of predominantly moderate and high complexity (12% low, 56% moderate, 32% high). •  NSS was primarily used for low-complexity lesions, but included four (8%) moderate-complexity lesions in the final 2 years of the study. •  The use of NSS increased from 28.6% of cases in 2005 to 60.0% of cases in 2009, which mirrored the increase in the proportion of operations performed for low-complexity lesions (22.2% low-complexity in 2005 to 70.6% in 2009, P < 0.01 for trend). CONCLUSIONS: •  The increasing use of NSS at our institution mirrored the increasing treatment of low-complexity renal lesions. •  This may reflect an increased detection and referral of such lesions, or a shift towards treatment of lesions that in the past would have been under surveillance. •  Practice at our centre reflects a shifting paradigm towards preferential use of NSS for the treatment of suitable renal masses.

PURPOSE: We designed and fully evaluated the performance of a nomogram to identify patients with prostate cancer who may be suitable for active surveillance. MATERIALS AND METHODS: We developed a nomogram to predict the probability of minimal prostate cancer (total tumor volume less than 0.5 cc, organ confined disease and no Gleason pattern 4 or 5) using preoperative data on 2,525 Australian patients who underwent radical prostatectomy. Accuracy and error rates at multiple probability cutoffs were compared with those of contemporary Epstein criteria and the Prostate Cancer Research International: Active Surveillance trial inclusion criteria when applied to these patients. High risk disease was defined as 1 or more adverse characteristics (including positive surgical margins, seminal vesicle invasion, extracapsular extension, 50% or greater Gleason pattern 4/5 and/or tumor volume 4.0 cc or greater) at radical prostatectomy. RESULTS: Minimal cancer was confirmed in 152 men (6.0%) at prostatectomy. The bootstrap corrected predictive accuracy of our nomogram was 93.3% vs 89.1% and 91.0% for Prostate Cancer Research International: Active Surveillance and Epstein criteria, respectively. For men with a nomogram derived minimal cancer probability of 0% to 4.9%, 5.0% to 19.9%, 20.0% to 34.9%, 35.0% to 49.9% and 50.0% to 71.0% the rate of high risk disease was 70.8%, 37.8%, 22.4%, 9.0% and 3.8%, respectively. In contrast, the rate of high risk disease for men who met Prostate Cancer Research International: Active Surveillance and Epstein criteria were 17.1% and 13.9%, respectively. CONCLUSIONS: A detailed breakdown of the expected rates of false-positive results and high risk disease associated with the nomogram derived probability of minimal cancer would provide more complete information to clinicians and patients on which to base therapeutic clinical decisions for presumed early stage prostate cancer.

OBJECTIVE • To quantify the effect of hypertension and diabetes - which have been identified as both initiating and progressing factors in chronic kidney disease (CKD), as well as predictors of long-term renal impairment in patients undergoing nephrectomy - on renal function after unilateral nephrectomy for malignancy. PATIENTS AND METHODS • A retrospective analysis was carried out of 80 unilateral nephrectomies performed at the Wagga Wagga Base Hospital, Calvary Private Hospital and Austin Hospital from January 2007 to December 2009. • Prognostic variables were patient age, sex and the presence of hypertension or diabetes. • The percentage reduction in glomerular filtration rate (GFR) after nephrectomy was measured and compared between variables using a two-sample Student's t-test. RESULTS • All patients who had diabetes also had hypertension. • Of the 80 patients, 22 (27.5%) fulfilled the criteria for CKD with a preoperative GFR < 60 mL/min. • Patients with hypertension and diabetes had a significantly greater percentage reduction in postoperative GFR (36 ± 2%) than those who had neither risk factor (23 ± 2%, P < 0.003). A similar finding was observed for patients with hypertension alone (32 ± 1%, P < 0.009). • The difference in postoperative GFR reduction between diabetics and those with hypertension alone was not statistically significant (P= 0.205). • The differential reduction in GFR in patients with CKD risk factors persisted at 3-12 months follow-up. CONCLUSIONS • An increased percentage reduction in GFR is seen in patients with hypertension and diabetes undergoing unilateral nephrectomy for malignancy. • These data could be used to identify those patients who would benefit from early referral and subsequent intervention to delay the progression of CKD, as well as those for whom nephron-sparing surgery might be a more appropriate surgical option.

BACKGROUND The epidemiology of patients with acute scrotal pain presenting to the emergency department (ED) is largely unknown. Urgent surgical referral is recommended for patients presenting with suspected testicular torsion. However, we have noted an increasing use of Doppler ultrasound (US) as an adjunctive tool in the evaluation of patients with acute scrotal pain. This study aimed to retrospectively review the presentation of patients with acute scrotal pain to a tertiary ED and the use of ultrasound in the assessment of acute scrotal pain. METHODS An explicit chart review was performed including all patients presenting to an adult tertiary ED between 2003 and 2008 with acute scrotal pain. The timing of presentation, initial assessment, review by the Urology team and the use of US were recorded. The diagnosis recorded at hospital discharge was the primary end point, while follow-up at outpatient clinic or private urologist rooms was used as a secondary end point. RESULTS There were 329 patients with acute scrotal pain during the study period, with 294 patients included in the study. Of these, 173 (58.8%) had a US scan performed in the ED. There were 44 (15.0%) patients who underwent scrotal exploration, with 19 having a prior US. There was a significant increase in the use of US over the study period. CONCLUSIONS Colour-flow duplex Doppler ultrasonography appeared to play an increasing role in the assessment for patients presenting with acute testicular pain. Rapid and more reliable assessments of these patients may be possible through greater education of emergency personnel in ultrasonography techniques.

OBJECTIVES: To determine whether preoperative laboratory values are independently associated with death from clinically confined clear cell renal cell carcinoma (RCC) after radical nephrectomy. METHODS: We identified 1707 patients with clinically confined (pNx/pN0, pM0), unilateral, sporadic clear cell RCC treated with radical nephrectomy between 1970 and 2002. Associations of abnormal preoperative laboratory values including hypercalcemia, anemia, elevated erythrocyte sedimentation rate (ESR), and elevated alkaline phosphatase with death from RCC were evaluated using Cox proportional hazards regression models, both univariately and multivariately by adjusting for known prognostic features of the 2002 primary tumor classification, tumor size, nuclear grade, and coagulative tumor necrosis. RESULTS: At last follow-up, 1009 patients had died, including 425 who died from RCC at a median of 3.0 years after surgery (range, 0 to 26 years). Even after adjusting for known prognostic features, 9% of patients with preoperative hypercalcemia exhibited significantly increased likelihood of dying from RCC compared with patients with normal or lower levels of serum calcium (relative ration [RR] 1.64; P = 0.002). Similarly, preoperative anemia (35% of patients; RR 1.27; P = 0.026) and elevated ESR (44% of patients; RR 1.66; P = 0.003) portended an increased risk of death from RCC even after multivariate adjustment. CONCLUSIONS: Abnormal preoperative laboratory values including hypercalcemia, anemia, and elevated ESR are independently associated with increased risk of cancer-specific death from clinically confined clear cell RCC. Consideration of these variables in future models may improve prognostic accuracy. We believe these factors should be routinely assessed and included in prospective studies of outcome in RCC patients.

PURPOSE: We review the usefulness of prostate specific antigen kinetics (ie prostate specific antigen velocity and doubling time) in the treatment of patients with prostate cancer. MATERIALS AND METHODS: The MEDLINE database was searched to identify studies investigating prostate specific antigen kinetics in patients with prostate cancer. RESULTS: Various techniques are available for estimating prostate specific antigen kinetics, but to minimize the impact of prostate specific antigen variability on such calculations at least a 90-day period and preferably more than 2 measurements should be used. There is little to suggest which measure of prostate specific antigen kinetics may be superior since both appear to provide useful prognostic information. Prostate specific antigen velocity is easier to calculate but prostate specific antigen doubling time may have greater biological justification. Retrospective studies show that before treatment prostate specific antigen kinetics provide prognostic information regarding the risk of treatment failure and subsequent death from cancer. Additionally, in patients treated surgically preoperative prostate specific antigen kinetics predict the risk of adverse pathology, while in those undergoing conservative treatment prostate specific antigen kinetics are associated with the risk of progression and need for intervention. In patients with biochemical failure after therapy prostate specific antigen kinetics predict the risk and potential site of clinical recurrence, the likely response to salvage therapy, and the risk of death from cancer. Preliminary assessments also suggest that prostate specific antigen kinetics may serve as a surrogate end point to replace cancer specific mortality. CONCLUSIONS: Although prospective studies are lacking, the current literature suggests that prostate specific antigen kinetics provide valuable prognostic information, and should be further evaluated in clinical decision making and as a surrogate end point for future trials.

OBJECTIVE: To assess progression and survival among patients with small-volume, well-differentiated, organ-confined prostate cancer found at radical retropubic prostatectomy (RRP), often defined as being 'insignificant', thus testing whether they are indeed 'insignificant'. PATIENTS AND METHODS: We identified 6496 men treated for prostate cancer by RRP between 1990 and 1999, and defined 'insignificant' tumours as those in men having a prostate-specific antigen (PSA) level of < 10 ng/mL before RRP, a cancer volume of < or = 0.5 mL, a specimen Gleason of score < or = 6 and stage < or = pT2. Survival was assessed using the Kaplan-Meier method and compared using the two-sided log-rank test. RESULTS:'Insignificant' tumours were found in 354 (5.5%) men, of whom only one had metastatic progression and none died from prostate cancer, with a median (range) follow-up of 9.2 (0.8-15.6) years. Biochemical progression-free survival (87% vs 85%, respectively, at 10 years, P = 0.5), systemic progression-free survival (100% vs 99%, P = 0.3), overall survival (91% vs 88%, P = 0.16) and cancer-specific survival (100% in each group, P = 0.32) were each similar among men with 'insignificant' prostate cancer and men with low-risk (defined by Gleason score, preoperative PSA level, seminal vesicle and surgical margin status)'significant' cancer. Clinical stage, biopsy Gleason score and preoperative PSA doubling time were multivariably predictive of 'insignificant' tumours at RRP. CONCLUSIONS:'Insignificant' prostate cancer at RRP is associated with a comparable risk of biochemical progression as low-risk 'significant' cancer. Although clinical predictors for 'insignificant' pathology can be identified, it remains to be established whether such patients can be safely managed conservatively.

PURPOSE: Extraprostatic extension (EPE) of tumor conveys an adverse prognosis in early-stage prostate cancer. Previous studies reported on the linear and radial distance of EPE (EPEr) as measured from the prostate edge. In this study, the correlation of the EPEr from a large whole mount prostatectomy series was determined with respect to the needle biopsy and prostatectomy specimen findings. METHODS AND MATERIALS: In a 24-month period, 404 patients underwent radical prostatectomy and the specimens were whole mounted. The preoperative records, biopsy findings, and EPEr from these specimens were evaluated. RESULTS: The range of the EPEr distance was 0.0-5.7 mm. A three-category model was used that included 283 patients (70%) with no EPE, 59 (15%) with "near EPE"(range, 0.01-0.59 mm), and 62 (15%) with "far EPE"(>/=0.6 mm). Univariate analysis revealed that patient age and prostate volume did not correlate with EPEr, in contrast to all other factors evaluated. Multivariate analysis identified the preoperative serum prostate-specific antigen, the percentage of cancer in the biopsy cores, and clinical tumor stage as significant. However, the Gleason score was not associated with the EPEr. Greater discrimination was possible in estimating the probability of extension in the "near" category than in the "far" category. CONCLUSION: EPEr is associated with the preoperative prostate-specific antigen level, percentage of cancer in the biopsy cores, and clinical tumor stage. These data might be useful in planning local therapies for prostate cancer, but additional studies identifying factors associated with EPEr beyond 3-5 mm could have relevance regarding the appropriate radiotherapeutic management strategies.

PURPOSE: Regulatory T cells (Tregs) have been implicated as inhibitors of antitumoral immunity, and evidence suggests that elimination of Tregs may augment natural and pharmacologic immunity. We tested for the presence of putative Tregs within renal cell carcinoma (RCC) tumors. EXPERIMENTAL DESIGN: We identified 170 patients who underwent radical or partial nephrectomy for clear cell RCC between 2000 and 2002. Specimens were stained with anti-CD4, anti-CD25, and anti-Foxp3 antibodies and examined using confocal microscopy. Associations of CD4(+)CD25(+)Foxp3(-) and CD4(+)CD25(+)Foxp3(+) T cells with death from RCC were evaluated using Cox proportional hazards regression models. RESULTS: At last follow-up, 46 of 170 patients had died; of these, 37 died from RCC at a median of 1.4 years following nephrectomy (range, 0-4.4). Among the 124 remaining patients, median follow-up was 3.7 years (range, 0-5.7). Forty-three (25.3%) tumors harbored CD4(+)CD25(+)Foxp3(+) T cells. The presence of Foxp3(+) T cells was not significantly associated with RCC death univariately. One hundred forty-three (84.1%) tumors harbored CD4(+)CD25(+)Foxp3(-) T cells. The indicator for >/=10% CD4(+)CD25(+)Foxp3(-) T cells was significantly associated with RCC death univariately [risk ratio (RR), 2.60; 95% confidence interval (95% CI), 1.35-4.98; P = 0.004], after adjusting for tumor B7-H1 expression (RR, 2.53; 95% CI, 1.32-4.85; P = 0.005) and lymphocytic infiltration (RR, 2.53; 95% CI, 1.32-4.87; P = 0.005). CONCLUSIONS: Increased presence of CD4(+)CD25(+)Foxp3(+) T cells was not significantly associated with RCC death. In contrast, CD4(+)CD25(+)Foxp3(-) T cells, which may represent a unique set of Tregs or activated helper T cells, was significantly associated with outcome.

OBJECTIVES To assess the early histological effects of pharmacological androgen deprivation (AD), which have been assessed only over longer periods, as surgical castration leads rapidly to diminished cell proliferation and enhanced cell death within the prostate. PATIENTS AND METHODS With Institutional Review Board approval, 35 patients were randomly assigned (seven in each group) to receive 0, 7, 14, 21 and 28 days of AD (flutamide, 250 mg orally three times/day, and one injection with leuprolide acetate 7.5 mg) before radical prostatectomy. The surgical specimens were assessed by conventional histology and immunohistochemistry, while macroarray analysis and quantitative real-time polymerase chain reaction (QRT-PCR) were used to examine gene expression. RESULTS There were morphological changes within the prostatic tissues as early as 7 days after initiating AD, similar to the response to castration. There was tumour cell vacuolization indicating cellular injury, glandular atrophy and mononuclear cell infiltration as prominent and progressive effects but, by contrast with castration studies, there were no changes in epithelial proliferation or apoptosis. Macroarray analysis, validated by QRT-PCR and immunohistochemistry, showed up-regulation of numerous and potentially counter-effective genes involved in the cell cycle and apoptosis. CONCLUSIONS Pharmacological AD induces significant involution within prostatic tissues over 7-28 days, but allows the persistence of some viable tumour cells capable of proliferation.

OBJECTIVES: To assess the impact of clinical selection criteria on pathologic features among patients treated by radical retropubic prostatectomy and to evaluate the implications of broadening eligibility for permanent prostate brachytherapy monotherapy. METHODS: A consecutive series of 423 patients with prostate cancer, who underwent diagnostic biopsy and subsequent radical retropubic prostatectomy, were selected for this study. Four subgroups were defined using the American Brachytherapy Society selection criteria, including prostate size limits (group 1), no prostate size limits (group 2A), a modified set of criteria (group 2B), and clinical Stage T1-T2 (group 3). The rates of extraprostatic extension, seminal vesicle invasion, and lymph node involvement were compared. RESULTS: Adverse pathologic features at radical retropubic prostatectomy were noted in 8 (9.3%) of 86 patients in group 1, 11 (5.6%) of 195 patients in group 2A, 35 (12.0%) of 292 patients in group 2B, and 90 (21.8%) of 413 patients in group 3. The rates of extraprostatic extension, seminal vesicle invasion, and lymph node involvement appeared comparable among groups 1 (5.8%, 3.5%, and 0.0%, respectively), 2A (3.6%, 2.1%, and 0.0%, respectively), and 2B (6.9%, 3.8%, and 1.4%, respectively), but were greater in group 3 (9.7%, 7.8%, and 4.4%, respectively). CONCLUSIONS: Judicious broadening of the clinical selection criteria may allow a greater number of patients to be eligible for permanent prostate brachytherapy monotherapy by including patients whose risk of having adverse pathologic features is comparable to that of patients currently deemed suitable for permanent prostate brachytherapy monotherapy. Prospective assessment of oncologic outcomes of such an approach is required.

PURPOSE: Men with a family history of prostate cancer are at higher risk for prostate cancer. There are conflicting data regarding the impact of hereditary forms of prostate cancer on long-term outcomes after radical prostatectomy. We examined the impact of familial and hereditary prostate cancer treatment in the prostate specific antigen era. MATERIALS AND METHODS: Patients who underwent radical prostatectomy for prostate cancer from 1987 to 1997 were surveyed (3,560 responders) to determine the family history of prostate cancer. Patients were categorized as having familial prostate cancer if they had at least 1 first-degree relative with prostate cancer. Hereditary prostate cancer was defined as nuclear families with 3 cases of prostate cancer, families with prostate cancer in each of 3 generations and families with 2 men diagnosed before age 55 years. Sporadic prostate cancer was defined as patients with no family history. Clinical and pathological features, and long-term outcome measures, including biochemical recurrence-free, systemic progression-free and cancer specific survival, were compared among patients with familial, hereditary and sporadic prostate cancer. RESULTS: A total of 865 and 133 patients were categorized as having familial prostate cancer and hereditary prostate cancer, respectively. Preoperatively prostate specific antigen was higher in patients with hereditary prostate cancer than in the other 2 groups (p = 0.04). Ten-year biochemical progression-free, systemic progression-free and cancer specific survival were equivalent. CONCLUSIONS: Except for preoperative prostate specific antigen, clinicopathological features and long-term oncological outcomes are equivalent after radical prostatectomy in patients with familial, hereditary and sporadic prostate cancer.

OBJECTIVES: The preoperative prediction of the likelihood of positive surgical margins (+SMs) at radical retropubic prostatectomy (RRP) may be useful for counseling and determining the surgical approach. The aim of this study was to assess the additional value of digital image analysis (DIA) of ploidy and proliferation on needle biopsies, in addition to the known preoperative predictors of +SMs at RRP. METHODS: We identified 454 patients treated by RRP at our institution from 1995 to 1998 for prostate cancer verified by transrectal ultrasound-guided biopsy, with a specimen adequate for DIA. Patients receiving preoperative hormonal therapy were excluded. The clinical features, transrectal ultrasound-guided biopsy findings, and DIA evaluation of MIB-I immunostaining and DNA ploidy were assessed in a multivariate logistic regression model to predict for +SMs at RRP. RESULTS: The mean +/- SD age at treatment was 64.5 +/- 6.5 years, the percentage of positive cores was 40.4%+/- 24.3%, the median prostate-specific antigen level was 6.3 ng/mL (range 0.6 to 112.0), median biopsy Gleason score was 6 (range 4 to 9), and median percentage of diploid nuclei was 67%(range 0% to 100%). Of the 454 patients, 185 (40.7%) had +SMs; this finding was time dependent (1995 to 1996, 45% and 1997 to 1998, 31%; P = 0.004). Univariately, preoperative prostate-specific antigen, biopsy Gleason score, extent of cancer on biopsy, MIB-1 expression, percentage of diploid or nondiploid nuclei, and year of surgery were predictive for +SMs. On multivariate analysis, the preoperative prostate-specific antigen level, biopsy Gleason score, percentage of positive cores, and year of surgery remained significant. CONCLUSIONS: The results of our study have shown that the likelihood of +SMs at RRP is best predicted on the basis of conventional prognostic factors. The DIA features of needle biopsies did not provide additional predictive power.

PURPOSE: Following radical retropubic prostatectomy for prostate cancer, if the serum prostate specific antigen fails to become undetectable, occult micrometastatic disease is suspected. We assessed the natural history of disease progression, and predictors of recurrence and survival in this group of patients. MATERIALS AND METHODS: We identified 303 men treated with radical retropubic prostatectomy for prostate cancer between 1990 and 1999, who had a detectable prostate specific antigen between 60 and 120 days postoperatively. Systemic recurrence-free and cancer specific survival were estimated using the Kaplan-Meier method, and analyzed using Cox proportional hazards models. RESULTS: Clinical and pathological features were more adverse among men whose postoperative prostate specific antigen was detectable. These men had poorer systemic recurrence-free survival and cancer specific survival compared to men with an undetectable postoperative prostate specific antigen, and even men whose prostate specific antigen subsequently became detectable. These differences persisted after multivariate adjustment for preoperative prostate specific antigen, specimen Gleason score, seminal vesicle and margin status. With a median followup of 8.5 years, 50 systemic recurrences and 26 deaths from cancer were observed. Gleason score and the prostate specific antigen doubling time were multivariate predictors of systemic recurrence, while Gleason score, margin status and seminal vesicle invasion were predictors of death from cancer. CONCLUSIONS: A detectable prostate specific antigen immediately following radical retropubic prostatectomy confers an increased risk of progression and death, but only in a subset of patients, who may be identified on the basis of pathological features and prostate specific antigen doubling time. In future such patients may be suitable for trials of systemic therapy.

BACKGROUND.: Obesity and prostate cancer are among the most common health problems affecting American men today. The authors' goal was to assess the impact of obesity on clinical and pathologic features of prostate cancer and long-term outcomes. METHODS.: The authors performed a prospective cohort study on 5313 men who underwent radical prostatectomy between 1990 and 1999. Patient height and weight were measured at the time of surgery to calculate the body mass index (BMI). The patients were separated into 3 BMI groups: BMI <25, 25-29.9, and >/=30 kg/m(2). The associations between BMI and age, prostate-specific antigen (PSA) level, and Gleason score were assessed with the Spearman rank correlation test. The associations between BMI and pathologic features were assessed with the Mantel-Haenszel chi(2) test. Fifteen-year biochemical progression-free survival, systemic progression-free survival, cancer-specific survival, and overall survival were estimated using the Kaplan-Meier method and evaluated using Cox models. RESULTS.: The median length of follow-up for the entire cohort was 10.1 years. Clinical and pathologic features appear worse in patients with a higher BMI. On univariate and multivariate analyses, it was found that BMI had no impact on biochemical progression, systemic progression, prostate cancer survival, or overall survival. CONCLUSIONS.: Obese patients appear to have worse pathologic features at the time of prostatectomy. Despite these features, long-term oncologic outcomes, including cancer-specific survival, remain the same regardless of BMI. BMI appears to influence prostate cancer outcomes at the time of prostatectomy, as evidenced by more aggressive pathologic features. However, after prostatectomy, BMI does not appear to be an independent predictor of recurrence or survival. Cancer 2006.(c) 2006 American Cancer Society.