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those not having a nerve-sparing procedure, neoadjuvant or adjuvant therapy within 6 months of RRP and a follow-up of < 6 months were excluded from the analyses. Erectile function was evaluated by the surgeon when possible or by an annual questionnaire. Potency was defined as erectile function sufficient for intercourse with or without a phosphodiesterase-5 inhibitor. RESULTSOf 619 men who had a bilateral and of 178 who had a unilateral nerve-sparing RRP, 72% and 53%, respectively, were potent. When stratifying by age groups ( ≤ 49, 50-59, 60-69 and ≥ 70 years) potency rates were 86%, 76%, 58% and 37%, respectively. Potency was more common after bilateral than unilateral nervesparing RRP in all age groups ( P < 0.001). Age, bilateral nerve-sparing (odds ratio 2.9) and surgeon experience were associated with potency in a multivariate analysis. CONCLUSIONCareful patient selection and meticulous surgical technique are essential to achieve the right balance between cancer control and morbidity. The patient's age, nerve-sparing RRP and the surgeon's experience were the significant predictors of return of potency after RRP. KEYWORDSradical prostatectomy, potency, nerve-sparing surgery Study Type -Therapy (case series) Level of Evidence 4 OBJECTIVETo report the return of erectile function in 1620 consecutive men after radical retropubic prostatectomy (RRP), chosen by half of men diagnosed with clinically localized prostate cancer, and the goal of which is to completely excise the tumour while preserving continence and erectile function.

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E 4 4 9What ' s known on the subject? and What does the study add? The surgical implications of renal cell carcinoma with coexisting bland and tumour thrombi of the inferior vena cava is not well described. In this study we review our experience managing these tumours. On multivariate analysis, we found that the presence of bland thrombus was associated with an increased need for surgical interruption of the inferior vena cava. OBJECTIVE• To study the role of interruption of the inferior vena cava (IVC) in patients with renal cell carcinoma (RCC) and associated bland and tumour thrombi. METHODS• We reviewed 129 consecutive patients with the preoperative diagnosis of RCC with tumour thrombus who underwent radical nephrectomy and tumour thrombectomy in one academic institution between May 1997 and February 2011. RESULTS• Percentages of patients with levels I, II, III and IV tumour thrombus were 29%, 13%, 48% and 9%, respectively.• The perioperative mortality rate was 2.3%. There were 29 (22%) perioperative complications recorded.• In all, 19 patients underwent surgical interruption of the IVC by ligation or segmental resection, including one level II, 14 level III and four level IV thrombi.• A total of 15 patients (12%) had bland thrombus associated with the tumour thrombus; four of these underwent intraoperative IVC fi lter placement and eight underwent surgical IVC interruption.• Advanced level of tumour thrombus was the only signifi cant factor predicting association of bland thrombus (odds ratio [ OR ] = 2.09, 95% confi dence interval [ CI ] : 1.082 -4.037, P = 0.028).• On multivariate analysis, level of thrombus (OR = 3.1, 95% CI: 1.30 -7.74, P = 0.011) and association of bland thrombus (OR = 9.07, 95% CI: 2.42 -34.01, P = 0.001) were signifi cant factors for IVC interruption. CONCLUSIONS• Surgical interruption of the IVC is a feasible option in selected patients with chronic IVC obstruction. Association of bland thrombus with tumour thrombus should alert the surgical team to the potential for a challenging surgery.• Precise preoperative imaging to assess the degree of venous obstruction and to help with differentiation between bland and tumour thrombus is key to achieving a surgical outcome with minimal morbidity. KEYWORDSrenal tumour , tumour thrombus , inferior vena cava fi lter , pulmonary emboli , tumour thrombus emboli , bland thrombus emboli Study Type -Therapy (case series) Level of Evidence 4

Gleason grade on needle biopsy is an inexact predictor of the final grade following radical prostatectomy. Patients with biopsy Gleason score 6 who are under graded are at significantly higher risk for adverse pathological features and biochemical recurrence than patients who remain with Gleason score 6 or less on final pathology findings.

OBJECTIVETo determine the outcome and predictors of recurrence in patients with a pretreatment prostate biopsy Gleason score (GS) of ≥ 8 and treated with radical prostatectomy (RP). PATIENTS AND METHODSWe retrospectively reviewed 1048 consecutive patients who underwent RP by one surgeon (M.S.S.); patients who had a pretreatment biopsy GS of ≥ 8 were identified. Information was recorded on patient age, initial prostate specific antigen (PSA) level, clinical stage, biopsy GS, pathology GS, extraprostatic extension (EPE), tumour volume, surgical margin status, seminal vesicle invasion (SVI), and lymph node involvement. The results were assessed statistically using the KaplanMeier method, univariate log-rank tests and multivariate analysis using Cox's proportional hazards regression. RESULTSIn all, 123 patients met the initial selection criteria; 44 were excluded from further analyses (five salvage RP, 23 <1 year followup and 16 adjuvant treatment). Thus 79 patients were included in the uni-and multivariate analyses; 25 (31%) patients had a GS of £ 7 in the RP specimen and 54 (69%) remained at GS ≥ 8. The mean follow-up was 55 months, the age of the patients 63 years and the mean ( SD ) initial PSA level 13 (12) ng/mL. The overall biochemical failure rate was 38% (41% if the final GS was ≥ 8 and 32% if it was £ 7). For those with a GS of ≥ 8 in the RP specimen, 20% (11/54) were organconfined; two patients (2.5%) in this group developed local recurrence. If the final GS was £ 7, 52% (13/25) were organ-confined. In the univariate analysis, significant risk factors for recurrence were PSA ≥ 20 ng/mL, EPE, SVI, a positive surgical margin and tumour volume. Cox's proportional regression indicated that a PSA of ≥ 20 ng/mL (hazard ratio 7.9, 95% confidence interval 2.6-24.2, P < 0.001), the presence of EPE (4.2, 1.6-10.9, P = 0.004) and a positive surgical margin (3.8, 1.5-9.7, P = 0.005) were significant independent predictors in a multivariate analysis. CONCLUSIONRP is a reasonable treatment option for patients with a prostate biopsy GS of ≥ 8 and clinical stage T1-2. These patients have a high chance of remaining disease-free if their PSA level is £ 20 ng/mL. Patients with a pretreatment biopsy GS of ≥ 8 should be counselled about the potential differences between the biopsy and the RP specimen GS.

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