Although historically underutilized in patients with poorly differentiated disease, radical prostatectomy provides excellent long-term survival and should be offered to healthy patients.

Compared to other treatment modalities, surgery, either radical cystectomy or partial cystectomy, offers the best OS and CSS for men aged 80 years or older with T2 bladder cancer.

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INTRODUCTION AND OBJECTIVES: Robotic surgery has a variable learning curve with multiple factors potentially affecting operative times. We sought to measure the effect of patient, provider, and system-related variables on operative time.METHODS: Retrospective data was collected over a 3.5 year period on 1,099 patients undergoing 11 robotic surgeries by 23 urologists and gynecologists at Cedars-Sinai Medical Center in Los Angeles. Data included patient age, BMI, comorbidities, operative time, surgeon volume, and type of robot (da Vinci Standard vs da Vinci S System). Analyses were performed by linear regression modeling.RESULTS: Average procedure time was 4.87 þ/-1.33 hours. Surgeons performed an average of 49 þ/-83 surgeries (range 1 to 362, median ¼ 8). The upper 25th percentile of surgeons by volume performed 60 or more procedures, and the lower 25th percentile performed four or less. Patients with 25 30) was 0.35 þ/-0.08 hours longer vs BMI < 25 (p < 0.001). Diabetes was also associated with increased procedure time, but age and heart disease were not. After performing a subset analysis of surgeons who performed 20 or more surgeries (n ¼ 10), the average procedure time for the first 10 surgeries was 4.82 þ/-2.83 hours and for the last 10 was 5.03 þ/-2.90 hours. The upper (n¼5) and lower (n¼6) 25th percentile of surgeons had an average procedure time of 5.31 þ/-0.74 hours and 4.36 þ/-0.77 hours, respectively (p ¼ 0.067). After accounting for covariates such as robot type and BMI, high volume surgeons took 0.90 þ/-0.44 hours longer than low volume surgeons (p¼0.042). The average time for the da Vinci Standard was 4.70 þ/-1.12 hours (n¼639 procedures) and for the da Vinci S was 5.10 þ/-1.55 hours (n¼493 procedures) (p < 0.001). After accounting for surgeon volume, BMI, department and procedure type, the first generation da Vinci Standard had procedure times 0.35 þ/-0.08 hours shorter than the second generation da Vinci S (p < 0.001).CONCLUSIONS: Unexpectedly, surgeon operative times did not tend to improve over time, and operative times were not significantly different between high and low volume surgeons. Also surprisingly operative times were not faster with the newer generation da Vinci model. After overcoming learning curves, surgeons may have an inherent "pace" that dictates their operative time.

172 Background: Extremely high prostate specific antigen (PSA) at diagnosis has traditionally precluded a surgical approach for prostate cancer. This database study evaluates the national trends in management of patients with high PSA at prostate cancer diagnosis. Methods: Men age 75 or less with a diagnosis of prostatic adenocarcinoma and a PSA of 20ngm/ml and over were identified from the SEER 18 Database (2004 to 2009). Exclusion criteria included patients with metastatic disease at diagnosis, more than one primary cancer, unknown stage, unknown Gleason score, unknown treatment, or diagnosis at autopsy. Patients were analyzed for demographics, stage at presentation, treatment patterns, and survival using appropriate statistics. Results: A total of 15,485 patients with PSA between 20 and 98.8ngm/ml were identified. Mean age at diagnosis was 64±7.3 years. A total of 4,510 (29.1%) patients did not receive any definitive treatment (NDT group), 6,503 (52%) received Radiation, and 4,472 (28.9%) underwent surgery. A total of 531 patients underwent adjuvant radiation after surgery. The mean PSA of patients who underwent surgery (47.3ngm.ml) or RT (44.3 ngm/ml) was lower than the patients who did not have any definitive treatment (50.9 ngm/ml). Increasing age and increasing T and N stage were associated with a trend towards a surgical approach while Gleason score and PSA levels were not associated a trend towards surgery. Increasing age and Gleason score were associated with an increasing trend towards radiation while increasing PSA, T stage, and N stage were associated with a decreasing trend towards radiation. Increasing age and PSA was associated with an increasing trend towards NDT, while an increasing stage was associated with a reduced trend towards NDT. The N stage and Gleason score did not predict a trend for the NDT. Conclusions: The PSA level, even when very high, is not the sole factor that determines whether or not patients with prostate cancer receive surgery. Nationwide trends suggest that while radiation is the most common treatment modality undertaken by patients with PSA over 20 ngm/ml, patients younger than age 50 are more likely to undergo surgery irrespective of the PSA level.