Urology News

Abstract: Purpose: To determine the incidence, identify risk factors and determine the prognosis for incidental (clinically significant) prostate adenocarcinoma ((cs)PCA), prostatic urothelial carcinoma (PUC) and high-grade intra-epithelial neoplasia (HGPIN) in patients undergoing radical cystoprostatectomy for urothelial carcinoma of the bladder. Materials and Methods: 1476 patients without a history of PCA were analyzed. Incidences of (cs)PCA, PUC and HGPIN were determined in the total cohort and selected subgroups of patients. PUC was stratified in prostatic stroma (PUC-s) and prostatic urethra/duct (PUC-d) involvement. Univariate and multivariate analyses with multiple variables was performed. Recurrence-free survival (RFS) and overall survival (OS) rates were calculated. Median follow-up time was 13.2 years. Results: 753 (51.0%) of the 1476 patients had cancer involving the prostate. PCA, csPCA, PUC and HGPIN were present in 37.9%, 8.3%, 21.1% and 51.2% of the patients, respectively. Of the 312 (21.1%) patients with PUC, 163 (11.0%) patients had PUC-d only and 149 (10.1%) patients PUC-s. Risk factors for csPCA, PUC and HGPIN were identified, however, absence of these risk factors did not rule out their presence. Ten-year OS in patients with no-PUC, PUC-d and PUC-s was 47.1%, 43.3% and 21.7%, respectively (p < 0.001). None of the patients with csPCA died of prostate cancer. Conclusions: Over half of the patients undergoing radical cystoprostatectomy had cancer involving the prostate. Presence of PUC, in particular PUC-s, was associated with a worse prognosis, while csPCA did not alter survival. Pre-operative clinical and histopathologic risk factors are not reliable enough to accurately predict csPCA and/or PUC.

Abstract: Purpose: To evaluate the long-term outcome of bladder auto-augmentation in children with neurogenic bladder dysfunction (NBD). Materials And Methods: Data were compiled from the records of 25 children, median age 9.3 (0.9 - 14.2) years, who underwent detrusor myotomy between 1992 and 2008. All patients were diagnosed with small bladder capacity, low compliance and high end-filling pressures and unresponsive to CIC and anticholinergics. Results: Median follow-up was 6.8 (0.1 to 15.6) years. Median postoperative bladder capacity was unchanged or decreased to 95 (25 to 274) mL during the first 3 months compared to preoperative capacity of 103 (14 to 250) mL. Five months postoperatively, the bladder capacity increased significantly to 176 (70 to 420) mL (p <0.01). This increment remained significant during the rest of follow-up. Bladder compliance doubled after one year to 10 (1 to 31) mL/cm H2O (p < 0.05) compared to the preoperative level, and further increase was seen after 5 years to 17 (5 to 55) mL/cm H2O (p<0.05). Median maximal detrusor pressure (Pdet) was 43 (8 to 140) cmH2O preoperatively. It decreased significantly (p <0.01) and at the final follow-up it was 26 (6 to 97) cmH2O. Kidney function developed normally in all cases except in one patient with persistent uremia. Reflux was alleviated in 7 of 9 cases. Eighteen of the patients became continent on CIC. Conclusions: Bladder auto-augmentation in children with NBD offers after a transient drop in bladder capacity a long lasting increase in capacity and compliance, while the end filling-pressure decreases.

Abstract: Purpose: Urolithiasis is associated with pain and other health-related quality of life decrements. Lack of access to multidisciplinary care is a barrier to prevention. We developed a shared medical appointment (SMA) to improve access as well as patient education and exposure to multidisciplinary care. Materials and Methods: 112 patients (51 ± 14 y, range 19-87) were seen in 27 SMAs over 14 months. Patients were seen using existing clinic space, staff, and providers. We targeted new patients for the SMAs. We incorporated presentations as well as multidisciplinary rounding in a group setting to provide care for the participants. Patients were surveyed to measure satisfaction as well as knowledge of key prevention concepts. Results: Appointment wait time decreased steadily from 180 ± 77 days prior to SMAs to 84 ± 39 days. The number of patients seen per month increased by 43%. The number of new clinic patients, which includes those seen both in SMAs and in individual appointments, who received nutrition education and intervention increased from approximately 50% prior to SMAs to nearly 75%. Patients who attended a SMA overwhelmingly (87%) rated their satisfaction as “excellent” or “very good;” 90% of patients said they would recommend this kind of visit to others. Post-tests revealed that patients in SMAs had superior knowledge ( P < 0.02) than controls. Conclusions: SMAs can be an efficient way to evaluate and manage new patients for urolithiasis prevention. Patient satisfaction was high; knowledge about prevention was higher than that of patients seen in individual appointments.

Abstract: Purpose: Congenital hydronephrosis and isolated pyelectasis are frequently diagnosed by prenatal ultrasound (US). About 80% have a spontaneously resolution in early childhood. Currently, there is no agreed-upon protocol for antenatal follow-up: most clinicians use a renal pelvis anterior-posterior diameter (APPD) >4mm as threshold for identifying isolated pyelectasis and hydronephrosis at 33 weeks of gestational age (GA) or APD > 7mm at 40 weeks of GA. The aim of this study was to define a fetal renal pelvis diameter cut-off at 20 and 30 weeks GA able to predict significant nephron-uropathies that will require surgical procedure. Materials and Methods: Our protocol included two prenatal US at 20 and 30 week GA and 3 postnatal US at the 1st, 6th, 12th month of life. Between January 2009 and December 2011 we collected 149 prenatal isolated pyelectasis and 41 hydronephrosis, with a renal pelvis anterior-posterior diameter >4 mm at 20 weeks GA. Results: We identified the cut off of 6mm at 20 weeks of GA for isolated pyelectasis (100% sensitivity; 84,3% specificity) and that of 10 mm at 30 weeks GA (100% sensitivity; 91,9% specificity). For hydronephrosis we recognized the cut off of 10 mm at 20 weeks GA (100% sensitivity; 86,1% specificity) and 12 mm at 30 weeks GA (100% sensitivity, 66,7% specificity). Conclusions: using these thresholds we could save a relevant number of US controls in both antenatal and postnatal period and also invasive postnatal tests (i.e. micturating cystourethrography and MAG3 scintigraphy) without missing even a single case ofobstructive nephropathy requiring surgery.

Y. Madani and B. Mann Department of Respiratory Medicine, West Middlesex University Hospital, London, United Kingdom

Journal of Endourology , Vol. 0, No. 0.

Journal of Endourology , Vol. 0, No. 0.

Purpose: The purpose of this guideline is to provide a clinical framework for the use of radiotherapy after radical prostatectomy as adjuvant or salvage therapy. Materials and Methods: A systematic literature review using the PubMed®, Embase, and Cochrane databases was conducted to identify peer-reviewed publications relevant to the use of radiotherapy after prostatectomy. The review yielded 294 articles; these publications were used to create the evidence-based guideline statements. Additional guidance is provided as Clinical Principles when insufficient evidence existed. Results: Guideline statements are provided for patient counseling, the use of radiotherapy in the adjuvant and salvage contexts, defining biochemical recurrence, and conducting a re-staging evaluation. Conclusions: Physicians should offer adjuvant radiotherapy to patients with adverse pathologic findings at prostatectomy (i.e., seminal vesicle invastion, positive surgical margins, extraprostatic extension) and should offer salvage radiotherapy to patients with prostatic specific antigen or local recurrence after prostatectomy in whom there is no evidence of distant metastatic disease. The offer of radiotherapy should be made in the context of a thoughtful discussion of possible short- and long-term side effects of radiotherapy as well as the potential benefits of preventing recurrence. The decision to administer radiotherapy should be made by the patient and the multi-disciplinary treatment team with full consideration of the patient's history, values, preferences, quality of life, and functional status. Please visit the ASTRO and AUA websites (http://www.redjournal.org/webfiles/images/journals/rob/RAP%20Guideline.pdf and http://www.auanet.org/education/guidelines/radiation-after-prostatectomy.cfm) to view this guideline in its entirety, including the full literature review.

Objective: To determine the extent to which the year of diagnosis, year of birth, and age at diagnosis influence the incidence trends of kidney cancer in the United States.Methods: Cancer registry data from the National Cancer Institute's Surveillance, Epidemiology, and End-Results (SEER) program were obtained for 64,041 patients with kidney cancer diagnosed between 1973 and 2008. Overall and age-specific incidence rates were calculated and adjustments were made for birth cohort and period effects. Results were stratified by race and sex. Age-period-cohort analysis was used to examine the effects of age, year of diagnosis (period), and year of birth (cohort) on incidence trends.Results: The overall age-standardized annual incidence per 100,000 increased during the study period (1973 to 2008) by race, from 6.75 (95% confidence interval, 6.18-7.36) to 19.56 (18.85-20.20) among whites, from 5.31 (3.50-7.71) to 25.38 (23.00-27.92) among blacks, and from 5.61 (3.50-8.50) to 13.98 (12.41-15.71) among other races; and by sex, from 9.44 (8.49-10.47) to 26.48 (25.39-27.60) among men and from 4.21 (3.65-4.84) to 13.38 (12.64-14.11) among women. Age-period-cohort analysis revealed a strong influence from period and cohort effects. The 1983 birth cohort, for example, had a 2-fold increase in kidney cancer (incidence rate ratio, 1.93 [1.63-2.25]) compared with the referent 1948 cohort.Conclusion: From 1973 to 2008, the incidence rate of kidney cancer increased for each sex and race across all age groups. Age-period-cohort models revealed that period-related factors, although significant, cannot alone account for these unfavorable temporal trends.

Renal cell carcinoma (RCC) has a steadily increasing incidence in the United States. The change in incidence and natural history of RCC is often attributed to the widespread use of abdominal imaging and the incidental detection of small renal masses. However, the etiology of sporadic RCC remains poorly understood.

We appreciate the kind and thoughtful editorial remarks. As previously stated, the incidence of renal cell carcinoma (RCC) has been rising steadily in the United States for several decades, and many have attributed this in part to the increased detection of small, incidental renal masses found on cross-sectional imaging. However, several observations have challenged the assertion that these incidence trends are solely due to the incidental detection of localized renal tumors by routine imaging. For example, Chow et al demonstrated not only an increased incidence of advanced stage tumors but also a steady parallel rise in the RCC mortality rate (a trend that was upheld even after adjusting for stage). Therefore, the question of whether these adverse temporal trends in RCC incidence rates are mostly driven by factors related to the year of diagnosis (period-related factors such as increased abdominal imaging) or to factors related to the year of birth (cohort-related factors such as rates of obesity, hypertension, new genetic mutations, etc), or a combination thereof, has become increasingly germane. Indeed, a more thorough understanding of the factors that mediate RCC risk would help guide investigators and public health officials to design and implement thoughtful screening and detection programs in high-risk populations.

Objective: To elucidate the probability that Gleason 6 tumors diagnosed in the prostate-specific antigen (PSA) era treated with radical prostatectomy (RP) develop metastasis.Methods: Between October 2000 and June 2012, 1781 men underwent open RP by a single surgeon. Biochemical recurrence (BCR) was defined as a serum PSA value ≥0.2 ng/mL, or 2 progressively rising PSA values >0.14 ng/mL. Significant BCR (sBCR) was defined as a BCR with a PSA doubling time (PSADT) <36 months. Insignificant BCR (iBCR) was defined as BCR with a PSADT ≥36 months.Results: Eight hundred fifty-seven of men (48.1%) undergoing open RP had a pathologic diagnosis of Gleason 6. Twenty-three of 857 of these men (2.7%) developed BCR, 7 were designated as iBCR (mean PSADT 81 months, range 36 to 100), 16 were sBCR (mean PSADT 8 months, range 1.5-20 months). There was a 10-fold difference in PSADT between the sBCR and iBCR groups (P <.001). All men with sBCR underwent salvage radiation therapy (SRT) and all demonstrated a subsequent PSA decline to ≤0.1 ng/mL, suggesting all men had local recurrence. Two men (0.23%) developed a BCR after salvage radiation therapy, both of whom were found to have Gleason 7 disease after pathologic re-review.Conclusion: In our large cohort of men with pathological Gleason 6 disease undergoing open RP, sBCR were attributable exclusively to local disease recurrences. Our findings support the conclusion that Gleason 6 disease exhibits a very low capacity for metastatic spread.

The current study looks at biochemical recurrence as a surrogate for the ability to metastasize compared to the study done at Hopkins by Ross et al, which directly demonstrated that Gleason score 6 cancer is never associated with lymph node metastases. The current authors incorrectly state that the study by Ross et al analyzed only Gleason score 6 cancers with organ-confined disease. In our multi-institutional study of 14,123 patients with entirely submitted Gleason score 6 tumors without lymph node metastases we evaluated all Gleason score 6 cancers without exclusion. In a separate study that we performed on men with Gleason 6 organ-confined cancer, we specifically wanted to determine if men with these findings could be told that they were virtually cured from both local and distant failure.

The primary and unique observation of our article is that pathological Gleason 6 cancers rarely, if ever, metastasize at the time of radical prostatectomy (RP). The editorial comment raises minor methodological issues that are typically raised by reviewers and not in an editorial comment. Nevertheless, we feel compelled to respond.

Nearly 20 percent of kidneys that are recovered from deceased donors in the U.S. are refused for transplant due to factors ranging from scarring in small blood vessels of the kidney's filtering units to the organ going too long without blood or oxygen...

Context:Because pelvic lymph node (LN)-positive prostate cancer (PCa) is generally considered a regionally metastatic disease, surgery needs to be better defined.Objective:To review the impact of radical prostatectomy (RP) and pelvic lymph node dissection (PLND), possibly in conjunction with a multimodal approach using local radiotherapy and/or androgen-deprivation therapy (ADT), in LN-positive PCa.Evidence acquisition:A systematic Medline search for studies reporting on treatment regimens and outcomes in patients with LN-positive PCa undergoing RP between 1993 and 2012 was performed.Evidence synthesis:RP can improve progression-free and overall survival in LN-positive PCa, although there is a lack of high-level evidence. Therefore, the former practice of aborting surgery in the presence of positive nodes might no longer be supported by current evidence, especially in those patients with a limited LN tumor burden. Current data demonstrate that the lymphatic spread takes an ascending pathway from the pelvis to the retroperitoneum, in which the internal and the common iliac nodes represent critical landmarks in the metastatic distribution. Sophisticated imaging technologies are still under investigation to improve the prediction of LN-positive PCa. Nonetheless, extended PLND including the common iliac arteries should be offered to intermediate- and high-risk patients to improve nodal staging with a possible benefit in prostate-specific antigen progression-free survival by removing significant metastatic load. Adjuvant ADT has the potential to improve overall survival after RP; the therapeutic role of a trimodal approach with adjuvant local radiotherapy awaits further elucidation. Age is a critical parameter for survival because cancer-specific mortality exceeds overall mortality in younger patients (Our understanding of radical prostatectomy in lymph node–positive prostate cancer needs a conceptual change from a palliative option to an effective instrument for significant improvement of long-term survival.

Abstract: Purpose: Organ-specific and effective doses (ED) from ionizing radiation during videourodynamics are unknown. The purpose of this study was to estimate radiation exposure in children undergoing videourodynamics, and to identify patient and exam factors that contribute to higher dose. Materials and Methods: Fluoroscopy data were collected from consecutive patients undergoing videourodynamics. Documented dose metrics were used to calculate entrance skin dose (ESD) after applying a series of correction factors. ED and organ dose (ovaries/testes) were estimated from ESD using Monte Carlo methods on a mathematical anthropomorphic phantom (ages 0/1/5/10/15 yrs). Regression analysis was performed to determine patient and procedural factors associated with higher dose. Results: There were 100 children (45% male, mean age 9.3 ± 5.7 yrs) with the diagnosis of neurogenic bladder (73%), anatomic abnormality (14%), or functional/non-neurogenic disorder (13%). Mean fluoroscopy time was 0.17±0.12 min. Mean age-adjusted ESD, ED, testes, and ovary doses were 2.18±2.00 mGy, 0.07±0.05 mSv, 0.09±0.10 mGy, and 0.20±0.13 mGy, respectively. On univariate analysis, age, height, weight, BMI, and bladder capacity, and fluoroscopy time were associated with ED. On multivariate adjusted analysis, BMI, bladder capacity, and fluoroscopy time were independently associated with ED. Conclusions: Organ-specific doses and ED from videourodynamics are determined in this study. ED from videourodynamics was on average less than that from a voiding cystourethrogram study in the literature.Higher fluoroscopy time, patient BMI, and bladder capacity are each independently associated with higher dose.

“It is a wise man who said that there is no greater inequality than the equal treatment of unequals.” —Felix Frankfurter In the 2001 publication of the sentinel randomized clinical trial Flanigan et al from the SWOG (Southwest Oncology Group) documented the survival advantage for cytoreductive nephrectomy in conjunction with systemic therapy for metastatic renal cell carcinoma. This landmark study in conjunction with the similar trial published by the EORTC (European Organization for Research and Treatment of Cancer) the same year ushered in an era of widespread debulking nephrectomy for patients with incurable cancer. It must be remembered that the systemic therapy used in these trials, subcutaneous interferon-α, had previously been associated with long-term survival rates similar to those of placebo in prior phase III trials. In addition the trial was limited to patients with good performance status (0-1) and the median survival advantage in the SWOG trial was 3 months.

As stated by Roghmann et al, all but 2 of the operations in the study were done by a single surgeon (DJP), who was experienced in open as well as robotic cystectomy. As stated repeatedly in the article, the overarching goal of our study was to demonstrate that patients undergoing radical cystectomy could be randomized to the open vs robotic approach. We successfully accomplished that goal. Having a single surgeon experienced and proficient in both approaches decreases the inherent variability that may be introduced when including multiple surgeons with varying degrees of experience in either approach in a pilot trial with limited patient sample size. We evaluated the patients in each arm of the trial undergoing continent urinary diversion in the form of orthotopic ileal neobladder. One patient in the robotic arm and 2 in the open arm underwent orthotopic ileal neobladder. There was no significant difference between the 2 groups in terms of type of urinary diversion that would limit the conclusions related to the perioperative outcomes in this study. However, the point raised by Roghmann et al is relevant, and the multi-institutional phase III national trial comparing the open and robotic approaches currently accruing patients does have type of urinary diversion as a stratification factor at randomization.