Dr. Thong is a urologist specializing in urologic oncology and general urology. He has experience in all aspects of adult urology care, including endoscopic, robotic, and open surgery, and has a special interest in the treatment of prostate, kidney and bladder cancer. He has won numerous awards including the NIH Ruth L. Kirschstein National Research Service Award, and has authored and co-authored publications on the treatment of urologic cancers.
- Urologic oncology
Clinical Assistant Professor, Urology
Boards, Advisory Committees, Professional Organizations
Associate member, Society of Urologic Oncology (2015 - Present)
Member, American Society of Clinical Oncology (2015 - Present)
Associate member, American Urological Association (2010 - Present)
Associate fellow, American College of Surgeons (2008 - Present)
Member, American Medical Association (2008 - Present)
Residency:Stanford Medicine Dept of Urology (2014) CA
AB, Princeton University (2004)
MD, University of Chicago, Pritzker School of Medicine (2008)
Residency, Stanford University (2014)
Fellowship, Memorial Sloan Kettering Cancer Center (2016)
MPH, Harvard University (2016)
Concordance between patient-reported and physician-reported sexual function after radical prostatectomy.
Accurately tracking health-related quality-of-life after radical prostatectomy is critical to counseling patients and improving technique. Physicians consistently overestimate functional recovery. We measured concordance between surgeon-assessed and patient-reported outcomes and evaluated a novel method to provide feedback to surgeons.Men treated with radical prostatectomy self-completed the International Index of Erectile Function-6 questionnaire at each postoperative visit. Separately, physicians graded sexual function on a 5-point scale. International Index of Erectile Function -6 score<22 and grade ≥3 defined patient-reported and physician-assessed erectile dysfunction (ED), respectively. Feedback on concordance was given to physicians starting in May 2013 with the implementation of the Amplio feedback system. Chi-square tests were used to assess agreement proportions and linear regression to evaluate changes in agreement after implementation.From 2009 to 2015, 3,053 men completed at least 1 postprostatectomy questionnaire and had a concurrent independent physician-reported outcome. Prior to implementation of feedback in 2013, patients and physicians were consistent as to ED 83% of the time; in 10% of cases, physicians overestimated function; in 7% of cases, physicians, but not patients reported ED. Agreement increased after implementation of feedback but this was not statistically significant, likely owing to a ceiling effect. Supporting this hypothesis, increase in agreement postfeedback was greater during late follow-up (≥12mo), where baseline agreement was lower compared to earlier follow-up.Agreement was higher than expected at baseline; implementation of feedback regarding discrepancies between patient-reported and physician-assessed outcomes did not further improve agreement significantly. Our observed high rate of agreement may be partly attributed to our institutional practice of systematically capturing patient-reported outcomes as part of normal clinical care.
View details for DOI 10.1016/j.urolonc.2017.09.017
View details for PubMedID 29031420
Comparative Effectiveness of Targeted Prostate Biopsy Using Magnetic Resonance Imaging Ultrasound Fusion Software and Visual Targeting: a Prospective Study.
journal of urology
2016; 196 (3): 697-702
We compared the diagnostic outcomes of magnetic resonance-ultrasound fusion and visually targeted biopsy for targeting regions of interest on prostate multiparametric magnetic resonance imaging.Patients presenting for prostate biopsy with regions of interest on multiparametric magnetic resonance imaging underwent magnetic resonance imaging targeted biopsy. For each region of interest 2 visually targeted cores were obtained, followed by 2 cores using a magnetic resonance-ultrasound fusion device. Our primary end point was the difference in the detection of high grade (Gleason 7 or greater) and any grade cancer between visually targeted and magnetic resonance-ultrasound fusion, investigated using McNemar's method. Secondary end points were the difference in detection rate by biopsy location using a logistic regression model and the difference in median cancer length using the Wilcoxon signed rank test.We identified 396 regions of interest in 286 men. The difference in the detection of high grade cancer between magnetic resonance-ultrasound fusion biopsy and visually targeted biopsy was -1.4% (95% CI -6.4 to 3.6, p=0.6) and for any grade cancer the difference was 3.5% (95% CI -1.9 to 8.9, p=0.2). Median cancer length detected by magnetic resonance-ultrasound fusion and visually targeted biopsy was 5.5 vs 5.8 mm, respectively (p=0.8). Magnetic resonance-ultrasound fusion biopsy detected 15% more cancers in the transition zone (p=0.046) and visually targeted biopsy detected 11% more high grade cancer at the prostate base (p=0.005). Only 52% of all high grade cancers were detected by both techniques.We found no evidence of a significant difference in the detection of high grade or any grade cancer between visually targeted and magnetic resonance-ultrasound fusion biopsy. However, the performance of each technique varied in specific biopsy locations and the outcomes of both techniques were complementary. Combining visually targeted biopsy and magnetic resonance-ultrasound fusion biopsy may optimize the detection of prostate cancer.
View details for DOI 10.1016/j.juro.2016.03.149
View details for PubMedID 27038768
View details for PubMedCentralID PMC5014662
Accuracy of Self-reported Smoking Exposure Among Bladder Cancer Patients Undergoing Surveillance at a Tertiary Referral Center.
European urology focus
2016; 2 (4): 441–44
Smoking is a risk factor for developing bladder cancer (BCa). Even though continued exposure after diagnosis may adversely affect prognosis, patients may be reluctant to disclose to their physicians that they are currently smoking, leading to inaccurate reporting of exposure and missed opportunities to deliver smoking-cessation advice and treatment in the context of cancer care.We examined the extent of misclassification of recent smoking exposure among patients undergoing BCa surveillance.A consecutive sample of 145 patients with a self-reported smoking history and prior initial diagnosis of BCa was recruited from a tertiary referral urology clinic.Patients were asked if they had smoked a cigarette or used nicotine replacement therapy (NRT) within the past week and whether they lived with a smoker. At the same visit, we collected urine under a biospecimen protocol. We used urinary cotinine, the primary metabolite of nicotine, as an objective biomarker of recent smoking exposure. Nine patients whose urine could not be interpreted for cotinine were excluded. We calculated the smoking status misreporting rate by comparing biochemically verified smoking status (≥31.5 ng/ml vs <31.5 ng/ml) against self-reported current smoking status (yes vs no) while considering recent NRT use.Overall, 11% (15 of 136) of patients had cotinine values consistent with current smoking. Of these 15 patients, 7 reported being former smokers, resulting in a 47% misclassification rate. However, three of the seven patients who denied smoking in the past week were currently using NRT. Excluding NRT users, the misclassification rate was 33%.Future studies investigating the impact of postdiagnosis nicotine exposure on BCa outcomes should use biochemical verification combined with self-reported smoking exposure to classify patients accurately.Bladder cancer patients may misreport smoking exposure, thereby missing opportunities for smoking cessation.
View details for DOI 10.1016/j.euf.2015.12.002
View details for PubMedID 28723477
Unexpected Long-term Improvements in Urinary and Erectile Function in a Large Cohort of Men with Self-reported Outcomes Following Radical Prostatectomy
2015; 68 (5): 899-905
It is generally assumed that if a man does not regain urinary continence or erectile function within 12 mo of radical prostatectomy (RP), then the chance of subsequent recovery is low.To determine the probability of achieving good urinary function (UF) or erectile function (EF) up to 48 mo postoperatively in men who reported poor UF or EF at 12 mo after RP.We identified 3187 patients who underwent RP from 2007 through 2013 at a tertiary institution and had extended multidisciplinary follow-up with patient-reported UF and EF scores at ≥12 mo.Open or minimally invasive RP.Primary outcome was good UF as defined by a urinary score ≥17 (range: 0-21) or good EF as defined by a modified International Index of Erectile Function-6 score ≥22 (range: 1-30). The probability of functional recovery beyond 12 mo was determined by Kaplan-Meier analyses.Among patients incontinent at 12 mo, the probability of achieving good UF at 24, 36, and 48 mo was 30%, 49%, and 59%. In patients experiencing erectile dysfunction at 12 mo, the probability of recovering EF at 24, 36, and 48 mo was 22%, 32%, and 40%. On multivariable analyses, 12-mo functional score and age were associated with recovery, but only score was consistently significant.Men with incontinence or erectile dysfunction at 12 mo have higher than anticipated rates of subsequent functional improvement. Probability of recovery is strongly influenced by score at 12 mo. Further research should address the impact of ongoing multidisciplinary follow-up care on our observed rates of recovery.Many prostate cancer patients continue to recover urinary and erectile function after 12 mo. The level of functional recovery by 12 mo is associated with long-term recovery and should be discussed by the physician and patient when deciding on rehabilitative interventions.
View details for DOI 10.1016/j.eururo.2015.07.074
View details for Web of Science ID 000363475800037
View details for PubMedID 26293181
View details for PubMedCentralID PMC4605865
Development of a realistic in vivo bone metastasis model of human renal cell carcinoma
CLINICAL & EXPERIMENTAL METASTASIS
2014; 31 (5): 573-584
About one-third of patients with advanced renal cell carcinoma (RCC) have bone metastases. The incidence of RCC is increasing and bone metastatic RCC merits greater focus. Realistic preclinical bone metastasis models of RCC are lacking, hampering the development of effective therapies. We developed a realistic in vivo bone metastasis model of human RCC by implanting precision-cut tissue slices under the renal capsule of immunodeficient mice. The presence of disseminated cells in bone marrow of tissue slice graft (TSG)-bearing mice was screened by human-specific polymerase chain reaction and confirmed by immunohistology using human-specific antibody. Disseminated tumor cells in bone marrow of TSG-bearing mice derived from three of seven RCC patients were detected as early as 1 month after tissue implantation at a high frequency with close resemblance to parent tumors (e.g., CAIX expression and high vascularity). The metastatic patterns of TSGs correlated with disease progression in patients. In addition, TSGs retained capacity to metastasize to bone at high frequency after serial passaging and cryopreservation. Moreover, bone metastases in mice responded to Temsirolimus treatment. Intratibial injections of single cells generated from TSGs showed 100 % engraftment and produced X-ray-visible tumors as early as 3 weeks after cancer cell inoculation. Micro-computed tomography (μCT) and histological analysis revealed osteolytic characteristics of these lesions. Our results demonstrated that orthotopic RCC TSGs have potential to develop bone metastases that respond to standard therapy. This first reported primary RCC bone metastasis model provides a realistic setting to test therapeutics to prevent or treat bone metastases in RCC.
View details for DOI 10.1007/s10585-014-9651-8
View details for Web of Science ID 000337082400008
View details for PubMedID 24715498
Preclinical trial of a new dual mTOR inhibitor, MLN0128, using renal cell carcinoma tumorgrafts
INTERNATIONAL JOURNAL OF CANCER
2014; 134 (10): 2322-2329
mTOR is a rational target in renal cell carcinoma (RCC) because of its role in disease progression. However, the effects of temsirolimus, the only first-generation mTOR inhibitor approved by the FDA for first-line treatment of metastatic RCC, on tumor reduction and progression-free survival are minimal. Second-generation mTOR inhibitors have not been evaluated on RCC. We compared the effects of temsirolimus and MLN0128, a potent second-generation mTOR inhibitor, on RCC growth and metastasis using a realistic patient-derived tissue slice graft (TSG) model. TSGs were derived from three fresh primary RCC specimens by subrenal implantation of precision-cut tissue slices into immunodeficient mice that were randomized and treated with MLN0128, temsirolimus, or placebo. MLN0128 consistently suppressed primary RCC growth, monitored by magnetic resonance imaging (MRI), in three TSG cohorts for up to 2 months. Temsirolimus, in contrast, only transiently inhibited the growth of TSGs in one of two cohorts before resistance developed. In addition, MLN0128 reduced liver metastases, determined by human-specific quantitative polymerase chain reaction, in two TSG cohorts, whereas temsirolimus failed to have any significant impact. Moreover, MLN0128 decreased levels of key components of the two mTOR subpathways including TORC1 targets 4EBP1, p-S6K1, HIF1α and MTA1 and the TORC2 target c-Myc, consistent with dual inhibition. Our results demonstrated that MLN0128 is superior to temsirolimus in inhibiting primary RCC growth as well as metastases, lending strong support for further clinical development of dual mTOR inhibitors for RCC treatment.
View details for DOI 10.1002/ijc.28579
View details for Web of Science ID 000332309700007
View details for PubMedID 24243565
Relating prognosis in chromophobe renal cell carcinoma to the chromophobe tumor grading system.
Korean journal of urology
2014; 55 (4): 239-244
The chromophobe subtype of renal cell carcinoma (chRCC) has generally been associated with a better prognosis than the clear cell type; however, debate continues as to absolute prognosis as well as the significance of certain prognostic variables. We investigated the significance of pathologic stage and a recently proposed chromophobe tumor grading (CTG) scheme in predicting chRCC outcomes.All available chRCCs were identified from our surgical pathology archives from 1987-2010. Original slides were reviewed to verify diagnoses and stage, and each case was graded following a novel chromophobe tumor grade system criteria. Disease status was obtained from a clinical outcome database, and cancer specific deaths and recurrences were recorded.Eighty-one cases of chRCC were identified, and 73 had adequate follow-up information available. There were only 3 instances of cancer related recurrence or mortality, which included 1 disease specific mortality and 2 disease recurrences. Pathologic stage and CTG 3 were found to be significantly associated with the recurrences or death from chRCC, but there was no association with CTG 1 and CTG 2.chRCC is associated with a very low rate of cancer specific events (4.1%) even at a tertiary referral center. In our study, pathologic stage and CTG 3, but not CTG 1 or 2, were significantly associated with the development of these events.
View details for DOI 10.4111/kju.2014.55.4.239
View details for PubMedID 24741411
- Tissue slice grafts of human renal cell carcinoma: An authentic preclinical model with high engraftment rate and metastatic potential UROLOGIC ONCOLOGY-SEMINARS AND ORIGINAL INVESTIGATIONS 2014; 32 (1)
Estimating the risk of chronic kidney disease after nephrectomy
CANADIAN JOURNAL OF UROLOGY
2013; 20 (6): 7035-7041
To identify factors associated with the development of chronic kidney disease (CKD) after nephrectomy and to create a clinical model to predict CKD after nephrectomy for kidney cancer for clinical use.We identified 144 patients who had normal renal function (eGFR > 60) prior to undergoing nephrectomy for kidney cancer. Selected cases occurred between 2007 and 2010 and had at least 30 days follow up. Sixty-six percent (n = 95) underwent radical nephrectomy and 62.5% (n = 90) developed CKD (stage 3 or higher) postoperatively. We used univariable analysis to screen for predictors of CKD and multivariable logistic regression to identify independent predictors of CKD and their corresponding odds ratios. Interaction terms were introduced to test for effect modification. To protect against over-fitting, we used 10-fold cross-validation technique to evaluate model performance in multiple training and testing datasets. Validation against an independent external cohort was also performed.Of the variables associated with CKD in univariable analysis, the only independent predictors in multivariable logistic regression were patient age (OR = 1.27 per 5 years, 95% CI: 1.07-1.51), preoperative glomerular filtration rate (GFR), (OR = 0.70 per 10 mL/min, 95% CI: 0.56-0.89), and receipt of radical nephrectomy (OR = 4.78, 95% CI: 2.08-10.99). There were no significant interaction terms. The resulting model had an area under the curve (AUC) of 0.798. A 10-fold cross-validation slightly attenuated the AUC to 0.774 and external validation yielded an AUC of 0.930, confirming excellent model discrimination.Patient age, preoperative GFR, and receipt of a radical nephrectomy independently predicted the development of CKD in patients undergoing nephrectomy for kidney cancer in a validated predictive model.
View details for Web of Science ID 000328717300007
View details for PubMedID 24331345
Stage I Testicular Seminoma: A SEER Analysis of Contemporary Adjuvant Radiotherapy Trends.
journal of urology
2013; 190 (4): 1240-1244
PURPOSE: Patients with clinical stage I testicular seminoma have historically been treated with adjuvant radiotherapy (RT) in the United States. However, nearly 80% of patients on surveillance will not relapse and even with relapse, salvage rates approach 100%. It remains unclear how practice patterns have changed with recently accumulating evidence and changes in guidelines. We evaluated, in a population-based setting, contemporary trends and factors that may affect utilization of adjuvant RT. MATERIALS AND METHODS: A total of 8,151 men from 2000 to 2009 diagnosed with stage I testicular seminoma were identified in the national Surveillance, Epidemiology, and End Results (SEER) registry. A multivariate regression model was constructed to analyze the association of year, age, race, socioeconomic status, SEER region, pathologic stage, and tumor size with administration of adjuvant RT. RESULTS: Utilization of adjuvant RT significantly decreased from 2000 to 2009. In 2000, 74.7% of patients received radiation, compared with only 37.7% of patients in 2009 (p<0.0001). Later year of diagnosis was significantly associated with decreased odds of receiving adjuvant RT (p<0.0001, 2000-2005 vs. 2006-2009, Odds ratio (OR) 0.40, 95% CI 0.36-0.44). Men older than 35 years (p<0.0002, OR 1.20, 95% CI 1.09-1.32) and men in the highest socioeconomic index quartile (p<0.0001, OR 1.34, 95% CI 1.16-1.54) were more likely to receive adjuvant RT. CONCLUSIONS: Utilization of adjuvant RT for clinical stage I testicular seminoma has decreased significantly in the last decade. Older age and higher socioeconomic status were associated with higher rates of adjuvant RT.
View details for DOI 10.1016/j.juro.2013.03.114
View details for PubMedID 23567749
Patient-derived tissue slice grafts accurately depict response of high-risk primary prostate cancer to androgen deprivation therapy
JOURNAL OF TRANSLATIONAL MEDICINE
Effective eradication of high-risk primary prostate cancer (HRPCa) could significantly decrease mortality from prostate cancer. However, the discovery of curative therapies for HRPCa is hampered by the lack of authentic preclinical models.We improved upon tumorgraft models that have been shown to predict drug response in other cancer types by implanting thin, precision-cut slices of HRPCa under the renal capsule of immunodeficient mice. Tissue slice grafts (TSGs) from 6 cases of HRPCa were established in mice. Following androgen deprivation by castration, TSGs were recovered and the presence and phenotype of cancer cells were evaluated.High-grade cancer in TSGs generated from HRPCa displayed characteristic Gleason patterns and biomarker expression. Response to androgen deprivation therapy (ADT) was as in humans, with some cases exhibiting complete pathologic regression and others showing resistance to castration. As in humans, ADT decreased cell proliferation and prostate-specific antigen expression in TSGs. Adverse pathological features of parent HRPCa were associated with lack of regression of cancer in corresponding TSGs after ADT. Castration-resistant cancer cells remaining in TSGs showed upregulated expression of androgen receptor target genes, as occurs in castration-resistant prostate cancer (CRPC) in humans. Finally, a rare subset of castration-resistant cancer cells in TSGs underwent epithelial-mesenchymal transition, a process also observed in CRPC in humans.Our study demonstrates the feasibility of generating TSGs from multiple patients and of generating a relatively large number of TSGs from the same HRPCa specimen with similar cell composition and histology among control and experimental samples in an in vivo setting. The authentic response of TSGs to ADT, which has been extensively characterized in humans, suggests that TSGs can serve as a surrogate model for clinical trials to achieve rapid and less expensive screening of therapeutics for HRPCa and primary CRPC.
View details for DOI 10.1186/1479-5876-11-199
View details for Web of Science ID 000323850900001
View details for PubMedID 23985008
Comparison of Three Different Tools for Prediction of Seminal Vesicle Invasion at Radical Prostatectomy
2012; 62 (4): 590-596
Statistical prediction tools are increasingly common, but there is considerable disagreement about how they should be evaluated. Three tools--Partin tables, the European Society for Urological Oncology (ESUO) criteria, and the Gallina nomogram--have been proposed for the prediction of seminal vesicle invasion (SVI) in patients with clinically localized prostate cancer who are candidates for a radical prostatectomy.Using different statistical methods, we aimed to determine which of these tools should be used to predict SVI.The independent validation cohort consisted of 2584 patients treated surgically for clinically localized prostate cancer at four North American tertiary care centers between 2002 and 2007.Robot-assisted laparoscopic radical prostatectomy.Primary outcome was the presence of SVI. Traditional (area under the receiver operating characteristic [ROC] curve, calibration plots, the Brier score, sensitivity and specificity, positive and negative predictive value) and novel (decision curve analysis and predictiveness curves) statistical methods quantified the predictive abilities of the three models.Traditional statistical methods (ie, ROC plots and Brier scores) could not clearly determine which one of the three SVI prediction tools should be preferred. For example, ROC plots and Brier scores seemed biased against the binary decision tool (ESUO criteria) and gave discordant results for the continuous predictions of the Partin tables and the Gallina nomogram. The results of the calibration plots were discordant with those of the ROC plots. Conversely, the decision curve indicated that the Partin tables represent the best strategy for stratifying the risk of SVI, resulting in the highest net benefit within the whole range of threshold probabilities.When predicting SVI, surgeons should prefer the Partin tables over the ESUO criteria and the Gallina nomogram because this tool provided the highest net benefit. In contrast to traditional statistical methods, decision curve analysis gave an unambiguous result applicable to both continuous and binary models, providing an insight into clinical utility.
View details for DOI 10.1016/j.eururo.2012.04.022
View details for Web of Science ID 000308563100010
View details for PubMedID 22561078
View details for PubMedCentralID PMC3674492
- Learning From Our Patients: Complications and the Future of Radical Cystectomy for Bladder Cancer JOURNAL OF UROLOGY 2012; 187 (6): 2018-2018
Evolution of Open Radical Retropubic Prostatectomy-How Have Open Surgeons Responded to the Challenge of Minimally Invasive Surgery?
JOURNAL OF ENDOUROLOGY
2009; 23 (11): 1893-1897
With the advent of minimally invasive surgery (MIS) for treating urologic malignancies, emphasis has been placed on reducing patient morbidity and resuming normal activity. We sought to clarify whether open surgeons (OS) have modified their techniques, surgical equipment, and perioperative management in response to this trend.A survey sent to all members of the Society of Urologic Oncology assessed changes that OS performing radical retropubic prostatectomy have made in analgesia, operative technique, perioperative management, and follow-up patterns. We also assessed OS sense of competition from MIS. Surgeon perception of the influence MIS had on these changes was scored from 0 to 4 (0 = not at all, 1 = slightly, 2 = moderately, 3 = greatly, 4 =completely). Overall and major influence by MIS included scores 1-4 and 3-4, respectively.Reduced radical retropubic prostatectomy (RRP) case volume because of MIS competition was reported by 20 OS (24%), with 27 OS (32%) starting to perform MIS, and 20 (24%) doing mostly/exclusively MIS. MIS has influenced OS to reduce incision length (overall influence 56%/major influence 33%), operative time (40%/12%), blood loss (31%/17%), and transfusion rate (33%/14%). MIS has influenced OS to use new instruments (48%/44%) or loupes (20%/9%), modify dissection (45%/31%) or anastomotic technique (14%/12%), and increase the use of hemostatic agents (48%/19%). MIS has reduced convalescence in OS patients by reducing length of stay (52%/28%), time to a regular diet (40%/18%), duration of drain (21%/16%) and Foley (32%/15%), time to return to work (49%/25%), and exercise (44%/21%). MIS has changed follow-up of OS patients by increasing the use of clinical pathways (14%/9%) and validated questionnaires (22%/13%).To date, the influence of MIS on the OS has not been comprehensively assessed. This survey finds that OS report that MIS serves as major competition to the open technique and that it has influenced them to modify their surgical technique, reduce convalescence, and alter follow-up recommendations.
View details for DOI 10.1089/end.2008.0509
View details for Web of Science ID 000271505300019
View details for PubMedID 19630483
Continued improvement of perioperative, pathological and continence outcomes during 700 robot-assisted radical prostatectomies
CANADIAN JOURNAL OF UROLOGY
2009; 16 (4): 4742-4749
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.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.Mean operative time (OT) and blood loss significantly decreased during the experience (286, 198, 190 min; p
or=7 in 24%, 40%, 44%; p
View details for Web of Science ID 000268985000008
View details for PubMedID 19671227
MULTI-INSTITUTIONAL EXTERNAL VALIDATION OF SEMINAL VESICLE INVASION NOMOGRAMS: HEAD-TO-HEAD COMPARISON OF GALLINA NOMOGRAM VERSUS 2007 PARTIN TABLES
INTERNATIONAL JOURNAL OF RADIATION ONCOLOGY BIOLOGY PHYSICS
2009; 73 (5): 1461-1467
The Partin tables represent one of the most widely used prostate cancer staging tools for seminal vesicle invasion (SVI) prediction. Recently, Gallina et al. reported a novel staging tool for the prediction of SVI that further incorporated the use of the percentage of positive biopsy cores. We performed an external validation of the Gallina et al. nomogram and the 2007 Partin tables in a large, multi-institutional North American cohort of men treated with robotic-assisted radical prostatectomy.Clinical and pathologic data were prospectively gathered from 2,606 patients treated with robotic-assisted radical prostatectomy at one of four North American robotic referral centers between 2002 and 2007. Discrimination was quantified with the area under the receiver operating characteristics curve. The calibration compared the predicted and observed SVI rates throughout the entire range of predictions.At robotic-assisted radical prostatectomy, SVI was recorded in 4.2% of patients. The discriminant properties of the Gallina et al. nomogram resulted in 81% accuracy compared with 78% for the 2007 Partin tables. The Gallina et al. nomogram overestimated the true rate of SVI. Conversely, the Partin tables underestimated the true rate of SVI.The Gallina et al. nomogram offers greater accuracy (81%) than the 2007 Partin tables (78%). However, both tools are associated with calibration limitations that need to be acknowledged and considered before their implementation into clinical practice.
View details for DOI 10.1016/j.ijrobp.2008.06.1913
View details for Web of Science ID 000264728000024
View details for PubMedID 18938046
Robotic Radical Prostatectomy in Overweight and Obese Patients: Oncological and Validated-Functional Outcomes
2009; 73 (2): 316-322
To determine the impact of body mass index (BMI) on perioperative functional and oncological outcomes in patients undergoing robotic laparoscopic radical prostatectomy (RLRP) when stratified by BMI.Data were collected prospectively for 945 consecutive patients undergoing RLRP. Patients were evaluated with the UCLA-PCI-SF36v2 validated-quality-of-life questionnaire preoperatively and postoperatively to 24 months. Patients were stratified by BMI as normal weight (BMI < 25 kg/m(2)), overweight (BMI = 25 to < 30 kg/m(2)) and obese (BMI > or = 30 kg/m(2)) for outcomes analysis.Preoperatively, obese men had a significantly greater percentage of medical comorbidities (P < .01) as well as a baseline erectile dysfunction (lower mean baseline Sexual Health Inventory for Men score [P = .01] and UCLA-PCI-SF36v2 sexual function domain scores [P = .01]). Mean operative time was significantly longer in obese patients when compared with normal and overweight men (234 minutes vs 217 minutes vs 214 minutes; P = .0003). Although overall complication rates were comparable between groups, a greater incidence of case abortion caused by pneumoperitoneal pressure with excessive airway pressures was noted in obese men. Urinary continence and potency outcomes were significantly lower for obese men at both 12 and 24 months (all P < .05).In this series, obese men experienced a longer operative time, particularly during the initial robotic experience. As such, surgeons early in their RLRP learning curve should proceed cautiously with surgery in these technically more difficult patients or reserve such cases until the learning curve has been surmounted. These details, including inferior urinary and sexual outcomes, should be discussed with obese patients during preoperative counseling.
View details for DOI 10.1016/j.urology.2008.08.493
View details for Web of Science ID 000264038100027
View details for PubMedID 18952266
A Single Microfocus (5% or Less) of Gleason 6 Prostate Cancer at Biopsy-Can We Predict Adverse Pathological Outcomes?
JOURNAL OF UROLOGY
2008; 180 (6): 2436-2440
Patients with Gleason score 6 microfocal prostate cancer, defined as 5% or less in 1 biopsy core, are often considered to have favorable disease. Few studies have addressed clinical parameters that predict pathological upgrading or up staging at radical prostatectomy.From a prospective database of 1,271 consecutive robot assisted laparoscopic prostatectomies performed from 2003 to 2008 patients with Gleason score 6 microfocal prostate cancer were identified. Adverse pathological outcome was defined as any upgrading and/or up staging on prostatectomy pathological findings. Multivariate logistic regression was used to evaluate the ability of patient age, clinical stage, the total number of biopsy cores, preoperative prostate specific antigen, prostate volume and pathological prostate specific antigen density to predict adverse pathological outcomes.A total of 192 patients with a median age of 59 years (range 42 to 73) were identified with Gleason score 6 prostate cancer involving 5% or less of 1 biopsy core, including 177 (92%) with clinical T1c disease. Mean +/- SD preoperative prostate specific antigen was 6.0 +/- 3.9 ng/ml (range 0.8 to 35). Overall 42 patients (22%) had adverse pathological outcomes, including upgrading in 35 (18%) and up staging in 16 (8%). Multivariate logistic regression revealed that age more than 65 years and pathological prostate specific antigen density greater than 0.20 ng/ml/gm were predictive of an increased risk of adverse pathological results (p = 0.0081 and 0.0169, respectively).While a microfocus of Gleason score 6 prostate cancer on biopsy is commonly considered low risk disease, there was a greater than 1/5 risk of pathological upgrading and/or up staging. Patients with Gleason score 6 microfocal prostate cancer should be counseled that they may harbor more aggressive disease, especially when pretreatment clinical risk factors are present, such as advanced age or high clinical prostate specific antigen density.
View details for DOI 10.1016/j.juro.2008.08.027
View details for Web of Science ID 000260982200050
View details for PubMedID 18930486
Robotic laparoscopic radical prostatectomy for biopsy gleason 8 to 10: Prediction of favorable pathologic outcome with preoperative parameters
JOURNAL OF ENDOUROLOGY
2008; 22 (7): 1477-1481
We sought to evaluate the pathologic results and postoperative outcomes for men undergoing robot-assisted laparoscopic radical prostatectomy (RLRP) for biopsy Gleason score (GS) 8 to 10 disease. Stratification of these patients according to preoperative variables was also performed in an attempt to predict organ-confined cancer.A prospective RLRP database identified all patients with preoperative biopsy GS 8 to 10. Variables, including prostate-specific antigen (PSA), percent positive biopsy cores (%PBC), maximal percentage of cancer in biopsy core (%MCB), clinical stage, pathologic stage, pathologic GS, surgical margins status, lymph node status, time to biochemical recurrence, and recurrence rate, were evaluated. Preoperative variables were treated as continuous and categorical using PSA, %PBC and %MCB cutoffs of 10 ng/mL, 50%, and 30%, respectively.Between February 2003 and September 2007, a total of 1225 RLRPs were performed at the University of Chicago Medical Center. Seventy-two (5.9%) patients had preoperative biopsy GS 8 to 10. Two patients received neoadjuvant hormonal therapy and were excluded. Among 70 patients evaluated, 33 (47%) had organconfined (pT(2)N0) disease. Forty (60.6%) patients had pathologic downgrading to GS
View details for DOI 10.1089/end.2008.0091
View details for Web of Science ID 000258385000014
View details for PubMedID 18613786
The cemented all-polyethylene acetabular cup: Factors affecting survival with emphasis on the integrated polyethylene spacer - An analysis of the effect of cement spacers, cement mantle thickness, and acetabular angle on the survival of total hip arthroplasty
JOURNAL OF ARTHROPLASTY
2006; 21 (2): 191-198
Four hundred seven primary total hip arthroplasties were performed using a cemented, direct compression molded all-polyethylene acetabular component. Based on a double-blinded randomization schedule, one group received acetabular cups with cement spacers made from polyethylene integrated into the cup, whereas the other group received the same acetabular cups with the polyethylene spacers removed. Patients were followed up for an average of 6.5 years. During this follow-up period, there were 3 revisions for acetabular cup loosening and 40 acetabular cups that had a global radiolucent line at least 1 mm wide. Acetabular cups with polyethylene spacers were found to have a significantly higher initial rate of failure (P < .0380) when compared with cups without cement spacers. Yet, polyethylene spacers resulted in a significantly thicker and more uniform cement mantle in zones 1, 2, and 3 (P < .0001). Cups initially placed at an angle of 45.0 degrees to 50.5 degrees had the highest survival rate compared with all possible angle ranges (P < .0158).
View details for Web of Science ID 000236480100008
View details for PubMedID 16520206
The effect of femoral notching during total knee arthroplasty on the prevalence of postoperative femoral fractures and on clinical outcome.
journal of bone and joint surgery. American volume
2005; 87 (11): 2411-2414
The treatment of a supracondylar femoral fracture following total knee arthroplasty is complicated by the presence of the prosthetic components. Anterior femoral notching during arthroplasty has been implicated as a contributing risk factor for femoral fracture. We retrospectively reviewed the effect of anterior femoral notching on the subsequent occurrence of a periprosthetic supracondylar fracture of the distal aspect of the femur and the outcomes of primary total knee arthroplasty in such patients.The prevalence and depth of femoral notching were determined on a review of the lateral radiographs by observers blinded to the clinical results of 1089 consecutive total knee replacements performed in 1997 and 1998. Linear and logistic regression modeling was used to analyze the relationship between femoral notching and the prevalence of supracondylar femoral fracture, postoperative range of motion, the Knee Society score, and the Knee Society functional and pain scores.Femoral notching was performed in 325 (29.8%) of the 1089 knees in our series. During an average follow-up period of 5.1 years, only two supracondylar femoral fractures occurred, both in femora treated without notching. Femoral notching was not associated with an increased rate of fracture (p = 1.000) or with significant differences in the measures of outcome (range of motion [p = 0.117], knee score [p = 0.967], functional score [p = 0.861], need for a lateral release [p = 0.234], or postoperative pain [p = 0.948]).This study demonstrated no difference in knees managed with or without notching of the anterior distal aspect of the femur with respect to the occurrence of a supracondylar fracture, range of motion, Knee Society score, Knee Society function, or pain.
View details for PubMedID 16264115
Simultaneous bilateral versus unilateral total hip arthroplasty - An outcomes analysis
JOURNAL OF ARTHROPLASTY
2005; 20 (4): 421-426
This study compared the morbidity, mortality, and outcomes of 900 simultaneous bilateral total hip arthroplasties in 450 patients and 450 unilateral total hip arthroplasties. Pulmonary complications were significantly higher in the simultaneous bilateral group (1.6% vs 0.7%; P < .0312). Fourteen (3.1%) patients in the simultaneous bilateral group and 18 (4%) patients in the unilateral group died within the first postoperative year. Patients with mortality in the first postoperative year were significantly older (69.8 vs 62.3 years; P < .0012). Long-term patient survival, the prosthetic survival, and functional outcomes were not significantly different between groups. Simultaneous bilateral total hip arthroplasty has advantages where both hips are symptomatic and has less risk in younger patients with understanding of the increased risk of pulmonary complications.
View details for DOI 10.1016/j.arth.2004.09.062
View details for Web of Science ID 000230039300003
View details for PubMedID 16124956
The role of cemented sockets in 2004 - Is there one?
JOURNAL OF ARTHROPLASTY
2004; 19 (4): 92-94
Cement fixation of the acetabular cup in total hip arthroplasty (THA) has evolved through multiple generations of cement technology. Whereas cement technology has produced improvements in cemented femoral fixation, the cemented socket still produces inconsistent results. Even with our current knowledge that cemented cups require exposure of cancellous bone, a clean and dry socket, and adequate bony coverage of the cup, surgeons such as myself are unable to control radiolucency at the bone-cement interface. The technical difficulty of cementing the acetabular cup has led to the increasing prevalence of cementless acetabular cups. Although cementless fixation has resulted in increased incidence of osteolysis, the surgical procedure is less technically demanding, and the long-term mechanical fixation results have been more consistent. Given the experiential learning curve that most orthopedic surgeons face with cemented fixation of the acetabular cup component, the role of the cemented socket in THA today is limited.
View details for DOI 10.1016/j.arth.2004.02.006
View details for Web of Science ID 000222353400021
View details for PubMedID 15190559
Long-term deterioration of joint evaluation scores.
journal of bone and joint surgery. British volume
2004; 86 (3): 438-442
We investigated the long-term changes in the Harris Hip and Knee Society scores (HSS and KSS) to determine whether they result from overall functional decline rather than actual changes in the condition of the prosthesis. The HHS for 106 total hip arthroplasties with a minimum follow-up of ten years, no medical complications after operation and no evidence of radiological loosening, and the KSS for 264 total knee arthroplasties with a minimum follow-up of 12 years and no medical complications after operation or signs of radiographical loosening were evaluated. There were statistically significant drops in the functional scoring components of the joint evaluation systems despite no loosening of the prostheses or other significant medical complications. The HHS declined at an average of 0.67 points per year from between three and ten years after operation (p < 0.0001). Contributing to this were deterioration in gait and limp (p < 0.0004), the use of support aids (p < 0.0001), the distance walked (p < 0.0001) and the ability to climb stairs (p < 0.0455). The functional component of the KSS declined significantly at an average 0.88 points per year betwen the third and 12th years (p < 0.0001). There were significant declines in every component of the functional score including the distance walked (p < 0.0001), the ability to climb stairs (p < 0.0001) and the use of support aids (p < 0.0001). The knee score component of the KSS did not decline significantly (p < 0.9750). The combination of functional and pain scores within the HHS system leads to an inaccurate decline in the entire score. The decline of HHS and Knee Society functional scores in total joint arthroplasties, in the absence of implant-related problems, suggests that deterioration in the functional capacity of ageing patients is an important factor in longitudinal studies using these scoring systems.
View details for PubMedID 15125135
Intra-operative findings in varus osteoarthritis of the knee. An analysis of pre-operative alignment in potential candidates for unicompartmental arthroplasty.
journal of bone and joint surgery. British volume
2004; 86 (1): 43-47
Interest in unicompartmental knee arthroplasty (UKA) for the treatment of medial compartment osteoarthritis has increased in recent years with apparent improvement in the long-term results. This is a result of improved surgical technique, patient selection, and implant design. In an effort further to improve patient selection we analysed the relationship between the pre-operative alignment of the knee and the anatomical findings at the time of surgery. We compared these findings with the indications for UKA. From 4021 total knee arthroplasties we compared intra-operative observations with the pre-operative clinical data in order to identify knees with isolated, medial, compartment changes, which would have been ideal candidates for UKA. We found that only 247 of the knees (6.1%) met anatomical qualifications for isolated, medial, unicompartmental osteoarthritis, and of these, only 168 (4.3%) met clinical standards ideal for UKA. Preoperative alignment showed a significant relationship with patterns of disease. Logistic regression revealed a relationship between pre-operative alignment and intraoperative findings resembling a Gaussian distribution. Patients with a pre-operative varus alignment of 7 degrees were slightly more likely to be selected for UKA. But the further the anatomical alignment in either direction varies from 7 degrees of varus, the more unlikely it is for the knee to exhibit a disease pattern of isolated, medial, unicompartmental osteoarthritis.
View details for PubMedID 14765864
Total joint arthroplasty in the extremely elderly - Hip and knee arthroplasty after entering the 89th year of life
JOURNAL OF ARTHROPLASTY
2003; 18 (7): 817-821
The goal of this study was to evaluate the complications and efficacy of total joint arthroplasty in the extremely elderly and compare the survival with the normal age-matched population. One hundred one joint arthroplasties (45 total knee arthroplasties [TKAs], 56 total hip arthroplasties [THAs]) were performed in 83 patients 89 years old and older. Over an average follow-up period of 2.5 years, 26 (31%) of the patients died. Three patients (3.6%) died within the first 2 months' postoperatively. The perioperative medical complication rate (excluding deaths) was 14%. Significant improvements were noted in pain scores, Harris Hip Scores, and Knee Society Scores. The survival of patients in their nineties who undergo total joint arthroplasty is at least equal to the survival of an age-matched population for 2.5 years following surgery. With careful patient selection and patient care to minimize medical complications, total joint arthroplasty can be an excellent option for patients who are age 89 and older.
View details for DOI 10.1054/S0883-5403(03)00338-3
View details for Web of Science ID 000185968000001
View details for PubMedID 14566733