Vol. 171, No.4, Supplement, Tuesday, May 11, 2004 METHODS: SalvRP was performed for recurrent cancer after EBRT (62), transperineal brachytherapy (9), and a combination of open seed implant and EBRT (29). Bilateral and unilateral nerve-sparing salvRP (NS-salvRP) was performed in 9 and 11 cases respectively. Nine and 11 patients respectively received bilateral and unilateral nerve grafts. Continence was defined as no or infrequent pad use. Potency was defined as the recovery of erections satisfactory for intercourse with or without sildenafil. Disease progression after salvRP was defined as a prostate specific antigen >0.4 ng/mL. The median follow-up after salvRP was 58 months. RESULTS: The overall 5-year progression-free probability was 54%. The 5-year actuarial continence recovery was 62% and the median time to continence was 19 months. Anastomotic strictures occurred in 27 patients, and artificial sphincters were inserted in 20 patients. By multivariate analysis, EBRT (P=0.03) and negative surgical margins (P=0.01) were adverse features for continence recovery. The 5-year actuarial potency recovery was 19% overall and 49% for patients who were potent pre-salvRP. Fifteen patients had a prosthesis inserted for post-salvRP impotence. By univariate analysis, NS-salvRP (P=0.002), organ- confined disease (P=0.01), and small prostate size (P=0.04) were associated with recovery of erections. Nerve grafts had no association with the recovery of erections or continence. Major technical complications occurred in 14 patients with urinary fistula (2), rectal injury (7), ureteral injury (4), and obturator nerve injury (1). Both patients with urinary fistula underwent delayed salvage cystectomy. In the last 71 cases, there has been only rectal injury (1.4%). Since 1995, the postoperative complication rate was 19%, and only 4% of patients had a grade 2 or greater complication. CONCLUSIONS: SalvRP is a safe and effective therapy for selected patients with radio-recurrent prostate cancer. The majority of patients achieve social continence after salvRP. Approximately half of previously potent patients will recover erections after salvRP. With increasing experience, major technical complications are infrequently encountered. Source of Funding: American Foundation for Urologic Disease, NIH T32- 82088 1461 LOCAL CONTROL AND LONG TERM DISEASE FREE SURVIVAL FOLLOWING RADICAL PROSTATECTOMY FOR Dl PROSTATE CANCER IN THE PSA ERA Carl K Gjertson*, Kevin P Asher, Joshua D Sclar, Aaron E Katz, Erik T Goluboff, Carl A Olsson, Mitchell C Benson, James M McKiernan, New York, NY INTRODUCTION AND OBJECTIVE: With the advent of PSA screening and better imaging techniques, the number of lymph node metastases found after radical prostatectomy (RP) is decreasing. We examined a contemporary series of nodal metastases discovered at RP. We analyzed disease free survival rates, incidence of pelvic recurrence and morbidity, and also examined extent of lymph node dissection as a possible prognostic factor. METHODS: A search of our institutional comprehensive clinical database of surgical urologic oncology was performed. Patients with nodal metastases at the time of RP were included in this analysis. Recurrence was defined as any PSA above 0.1 ng/ml or initiation of androgen deprivation therapy (ADT). Predicted disease free survival rates were calculated with the Kattan nomogram. RESULTS: We identified 2121 patients with complete pathological data that had surgery between 1190 and 12100. 28 had lymph node metastases ( 1.3%), and 24 had adequate follow-up data for analysis. The median age, PSA, clinical stage, and biopsy Gleason score was 65 years, 10.5 ng/ml (range 2.4 to 94), T2a, and 7 respectively. The mean number of nodes dissected was 8 (range 1-30), and 80% of patients had only one positive node. Median pathological grade was Gleason 8, and 50% of patients had positive surgical margins. The median predicted 5-year DFS based on pathologic stage was 5.5% by the Kattan nomogram. With a median follow-up of 69 months, our Kaplan-Meier estimated 5-year DFS was 15.6%. Four patients ( 17%) are currently without evidence of disease (NED), with follow-up ranging from 26-92 months. Stratifying patients by number of nodes dissected revealed an estimated 27% 5-year DFS for those with more than 7 nodes dissected, and 7% for patients with 7 nodes or less. This difference was not statistically significant, however, with p= 0.35 by log rank test. There were no perioperative or long-term complications such as pelvic recurrence, gross hematuria, urinary retention, hydronephrosis, or urosepsis. CONCLUSIONS: The incidence of lymph node metastasis discovered at RP in a contemporary series during the PSA era is quite low (1.3% ). Kaplan-Meier 5-year DFS correlated well with mean predicted DFS as calculated by the Kattan nomogram. Despite overall poor 5-year DFS, it is still possible to render a small percentage of patients (17%) disease free with RP alone. Long-term pelvic morbidity did not occur after RP, and more extensive node dissections seemed to correspond with improved DFS. Source of Funding: None THE JOURNAL OF UROLOGY® 385 1462 PROSTATE CANCER ANDROGEN INDEPENDENCE DURING SALVAGE HORMONE THERAPY AFTER RADIATION FAILURE Andrew K Lee*, Lawrence B Levy, Rex Cheung, Mattew T Ballo, Houston, TX INTRODUCTION AND OBJECTIVE: To determine predictors for androgen independence (AI) following salvage hormone therapy (HT) in prostate cancer patients who have failed external beam radiation therapy (RT). METHODS: Of 1,461 men with non-metastatic prostate cancer treated with RT alone between 1987-2001, 272 men developed a PSA failure and received salvage HT. Patients with documented distant failure prior to or within 30 days of initiating salvage hormone therapy were excluded, leaving 169 patients for this analysis. Hormone therapy consisted of leuprolide or goserelin in 92 patients, total androgen blockade in 45 and orchiectomy in 32. Fifty-seven men developed AI defined as two consecutive rises in PSA with each rise 2: 0.2ng/mL or total rise of 2: 1.0 ng/ml while on hormone therapy. Patient age, pre-RT PSA, T-stage, Gleason score, time to PSA failure from end of RT, PSA doubling time, time to start of salvage hormones, and PSA level at the start of salvage HT were analyzed for associations with the rate of androgen independence. RESULTS: Median follow-up of living patients was 10.7 years (range, 4-15.5 years). The 10-year rates of AI and overall survival measured from the time of salvage hormone therapy were 44% and 49%, respectively. Median time to AI was 34 months for those patients who developed AI. Univariate analysis revealed a higher 5-year actuarial AI rate when the time to PSA failure from end of RT was s 12 months (45% vs. 27%, p< O.OOI), the PSA doubling time was s 10 months (44% vs. 23%, p=.002), and the PSA level at the start of salvage HT was > lOng/ml (45% vs. 28%, p=O.Ol). Multivariable analyses confirmed an independent association between AI and time to PSA failure from the end of RT (p=0.007) and rapid PSA doubling time (p=0.02). The 5-year rate of distant metastasis, measured from the time of salvage hormone therapy, for those patients who developed AI and those who did not was I% compared to 29% (p< O.OOOI), respectively. Despite this difference in distant metastases there was no significant difference in overall survival when measured from the date of salvage HT initiation. CONCLUSIONS: For patients with an isolated biochemical failure after RT, time to PSA failure from end of RT s 12 months and PSA doubling times 10 months were associated with subsequent androgen independent disease, and treatment beyond hormone therapy alone (e.g. chemotherapy protocols) should be considered for these patients. The data also suggest that salvage HT should be initiated before the PSA level reaches lOng/mi. Source of Funding: None Reconstruction and Pediatrics Video Session Tuesday, May 11, 2004 10:00 am· 12:00 pm Vl463 A NEW TECHNIQUE FOR PRIMMARY COMPLEX HYPOSPADIAS: ONLAY URETHROPLASTY AFTER SECTION OF THE URETHRAL PLATE ( THE THREE IN ONE TECHNIQUE) Antonio Macedo*, Mauricio Hachul, Gilmar Garrone, Riberto Liguori, Geovanne F Souza, Ricardo G Freitas, Yuri Nobre, Adriano Calado, Sergio Ottoni, Siio Paulo, Brazil; Valdemar Ortiz, Sao Paulo, Brazil; Miguel Srougi, Siio Paulo, Brazil INTRODUCTION AND OBJECTIVE: Surgical treatment of primary complex hypospadias, in which preservation of the urethral plate cannot be achieved, is usually performed in two ways: two staged procedure or with a tubularized island preputial flap technique. The objective of this video is to introduce an original treatment strategy that we call <<THREE-IN-ONE-TECHNIQUE>>. This technique combines three distinct tissues, the use of which is already well established in hypospadias surgery, in the form of two flaps and one graft allowing one stage on1ay urethroplasty in every case. METHODS: The penis is degloved after a sub coronal circular incision with delineation of the urethral plate. The penis is then rectificated and the urethral plate is tensionless fastened to the Buck's fascia of the corpora cavernosa. Then a defect in the ventral surface of the penis, between the urethral plate and the distal glans region, is observed. Such is the place the neourethra should reach. A free transplant of buccal mucosal from the inferior lip is retrieved. The urethral plate is rebuilded together with fastening of the buccal mucosa to Buck's fascia, therefore establishing continuity of the urethral plate with the neoplate of buccal mucosa. A transverse flap of the internal preputial region is anastomosed to the neourethral plate made. A flap of tunica vaginalis and tunica dartos covers the neourethra.