Age and sex have no impact on expression levels of markers of immune cell infiltration and immune checkpoint pathways in patients with muscle-invasive urothelial carcinoma of the bladder treated with radical cystectomy.

OBJECTIVES: Advanced age and female sex have been associated with worse outcomes in patients undergoing radical cystectomy for muscle-invasive bladder cancer. A reduced immune response has been implicated as a mechanism. The objective of our study was to analyze the expression patterns of various cellular proteins active in bladder cancer immune pathways, and assess the correlation between age, sex, and the expression of these immune markers. METHODS: We obtained surgical tissue samples from equally distributed male/female patients with/without lymph node metastasis who had undergone radical cystectomy for urothelial carcinoma (UC) of the bladder (n = 50). Immunohistochemistry (IHC) for CD3 (cluster of differentiation), CD4, CD8, CD56, LAG-3 (lymphocyte-activation gene), TIM-3 (T-cell immunoglobulin and mucin-domain), PD-1 (programmed death) and PD-L1 molecules was performed and scored by a single pathologist (high versus low). Spearman's correlation and Chi square tests investigated the association between age, sex, and IHC results. RESULTS: Mean age at surgery was 67 years (range 50-78 years); all patients were Caucasians. The following percent of patients scored high for a stain: 18% CD3, 10% CD4, 0% CD8, 0% CD56, 20% LAG-3, 4% TIM-3, 0% PD-1 and 0% PD-L1. There was no association between patients' age, sex, and the expression of any of the immune markers (p > 0.05 for all). CONCLUSIONS: The association between advanced age, female sex, and worse outcomes in bladder cancer may be independent of the immune pathways active in the disease that we examined in this study.

A1 Adenosine Receptor-Mediated Inhibition of Parasympathetic Neuromuscular Transmission in Human and Murine Urinary Bladder.

The potential role of A1 adenosine receptors in modulating neuromuscular transmission in the detrusor muscle of the urinary bladder has been tested in human and murine preparations with the intent to determine the viability of using adenosine receptor agonists as adjuncts to treat overactive bladder. In human detrusor muscle preparations, contractile responses to electrical field stimulation were inhibited by the selective A1 adenosine receptor agonists 2-chloro-N(6)-cyclopentyladenosine, N(6)-cyclopentyladenosine (CPA), and adenosine (rank order of potency: 2-chloro-N(6)-cyclopentyladenosine > CPA > adenosine). Pretreatment with 8-cyclopentyl-3-[3-[[4(fluorosulphonyl)benzoyl]oxy]propyl]-1-propylxanthine, an irreversible A1 antagonist, blocked the effects of CPA, thus confirming the role of A1 receptors in human detrusor preparations. In murine detrusor muscle preparations, contractions evoked by electrical field stimulation were reduced by CPA or adenosine. Amplitudes of the P2X purinoceptor-mediated excitatory junctional potentials (EJPs) recorded with intracellular microelectrodes were reduced in amplitude by CPA and adenosine with no effect on the spontaneous EJP amplitudes, confirming the prejunctional action of these agents. 8-Cyclopentyltheophylline, a selective A1 receptor antagonist, reversed the effects of CPA on EJP amplitudes with no effect of spontaneous EJPs, confirming the role of A1 receptors in mediating these effects.

Impact of county rurality and urologist density on urological cancer mortality in illinois.

PURPOSE: The urology work force is contracting at a time when service demand is increasing due to demographic changes, especially in rural areas. We investigated the impact of rural status and urologist density on kidney and renal pelvis, bladder and prostate cancer mortality at the county level in Illinois. MATERIALS AND METHODS: We stratified the 102 Illinois counties by 2003 RUCCs as urban (36, RUCCs 1 to 3) and rural (66, RUCCs 4 to 9). Area Health Resource Files were used for county demographic data and urologist density. County level age adjusted mortality rates from 1990 to 2010 were derived from National Center for Health Statistics data using SEER*Stat. We examined the associations of urological cancer mortality rates with rural status and urologist density. RESULTS: Average urologist density significantly differed between rural and urban counties (1.9 vs 3.4/100,000 population, p < 0.01). The kidney and renal pelvis cancer mortality rate in rural counties was higher than in urban counties while that of prostate cancer was lower (4.9 vs 4.3 and 28.7 vs 32.2/100,000 population, respectively, each p < 0.01). Urologist density correlated with the mortality rate of kidney and renal pelvis cancer (Pearson coefficient -0.33, p < 0.01) but not with the bladder or prostate cancer mortality rate. Multiple regression analysis revealed that rurality and lower urologist density (p = 0.01 and < 0.05) were significantly associated with higher kidney and renal pelvis cancer mortality. CONCLUSIONS: Rural residence and low urologist density were associated with increased kidney and renal pelvis cancer mortality on the county level in Illinois. Further expansion and testing of evidence-based telemedicine is warranted because remote technical consultation is now technologically feasible, effective, inexpensive and satisfactory to patients.

Low enhancing papillary renal cell carcinoma diagnosed by using dual energy computerized tomography: a case report and review of literature.

BACKGROUND: Papillary renal cell carcinoma (pRCC) is a mixed group of tumors that constitutes about 15-20% of all renal cortical cancers. Strong enhancement on computerized tomography (CT) is a feature of clear cell, but not of pRCC making the differentiation of papillary tumors from benign cysts a diagnostic problem in some cases. CASE PRESENTATION: We report here a case of a female patient with pRCC that was initially diagnosed as a benign renal cyst. The patient is a 66 year old Caucasian female who initially presented with an ultrasound showing a 2.6 cm hypo-echoic lesion within the inferior pole of her left kidney. This was followed by a contrast enhanced computerized tomography that suggested the hypo-echoic lesion to be a hyper-attenuating benign renal cyst. Follow-up CT scan 4 months later demonstrated an increase in the size of the lesion to 3.2 cm with equivocal enhancement. A dual energy computerized tomography (DECT) showed the lesion to be a solid mass suspicious for renal cell carcinoma. A robotic partial nephrectomy revealed a papillary renal cell carcinoma with negative margins. CONCLUSION: In this case report, we reviewed the literature on variations in enhancement of renal tumors and the possible role of dual energy contract enhanced CT in differentiating papillary tumors with low enhancement from benign kidney cystic lesions.

Body composition analysis in bariatric surgery: use of air displacement plethysmograph.

Body weight, body mass index (BMI), and percent excess weight loss are used to assess patient outcomes after bariatric surgery; however, they provide little insight into the true nature of the patient's weight loss. Body composition measurements monitor fat versus lean mass losses to permit interventions to reduce or avoid lean body mass loss after bariatric surgery. A retrospective review of patients who underwent bariatric surgery between 2002 and 2008 was performed. Patients underwent body composition testing via air displacement plethysmography before and after surgery (6 and 12 months). Body composition changes were assessed and compared with the BMI. Results include 330 patients (54 male, 276 female). Average preoperative weight was 139 kg, BMI was 50 kg/m(2), fat percentage was 55 per cent, and lean mass percent was 45 per cent. Twelve months after surgery average weight was 90 kg, mean BMI was 32 kg/m(2), fat percentage was 38 per cent, and lean mass percent was 62 per cent. Body composition measurements help monitor fat losses versus lean mass gains after bariatric surgery. This may give a better assessment of the patient's health and metabolic state than either BMI or excess weight loss and permits intervention if weight loss results in lean mass losses.

One hundred and two consecutive robotic-assisted minimally invasive colectomies--an outcome and technical update.

BACKGROUND: The objective of this study was to review 102 consecutive robotic colectomies at our institution. We evaluated the 8-year experience of one surgeon (DLC) in Peoria, IL using the da Vinci system. METHODS: An IRB-approved retrospective review was performed. Results were compared with the literature. Changes in technique over the years were evaluated. RESULTS: One hundred and two robotic colectomies, right (59) and sigmoid (43), were performed. Mean age is 63.5 years and mean BMI 27.4 kg/m². Preoperative indications are polyps (53), diverticular disease (27), cancer (19), and carcinoid (3). Mean total case time (TCT) for all cases is 219.6 ± 45.1 (50-380) min, and mean robot operating time (ROT) is 126.6 ± 41.6 (12-306) min. Operative times for Right: Port setup time (PST) 32.4 ± 10.5 (20-64) min, ROT 145.2 ± 39.6 (53-306) min, TCT 212.3 ± 46.4 (50-380) min; times for sigmoid: PST 31.2 ± 9.6 (10-57) min, ROT 101.2 ± 29.2 (12-165) min, TCT 229.7 ± 41.6 (147-323) min. Median length of stay for all patients is 3 (2-27) days. The overall complication rate is 18.6%, the overall conversion rate 8.8%, and the anastomotic leak rate is 0.98%. Residents PGY 1-5 participated in 61 cases (59.8%). CONCLUSION: We report our updated procedural sequence and technical alterations. Experience has allowed residents to evolve to be primary surgeons. We add our results to the current robotic literature.

Project PROMIS: Peoria Regional Outpatient Medical Imaging Study.

BACKGROUND: Abdominal aortic aneurysm (AAA) accounts for > 15,000 reported deaths annually. Early screening in high-risk populations is important to decrease morbidity and mortality from rupture. METHODS: A prospective, population-based study of free ultrasound-based AAA screening was conducted from July 2004 to December 2006. Before examination, subjects completed surveys asking their medical history, including known AAA risk factors. Incidence rates and comparison analyses were performed. RESULTS: The final analysis included 979 patients, of whom AAA was discovered in 27 (2.8%). AAA was found in only male patients > 60 years old (4% of the male population). AAA size ranged from 3 to 10 cm. Of patients diagnosed with AAA, 85% were current or past smokers, and 70% had hypercholesterolemia. There was a 6% incidence of AAA in male smokers > or = 60 years old who had hypercholesterolemia. CONCLUSIONS: Four factors were predominant in our population of patients with AAA: patient age, male sex, smoking history, and hypercholesterolemia.

Stricture dilation after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: In surgical treatment of morbid obesity, maintaining a restrictive anastomosis is key to long-range success. However, laparoscopic Roux-en-Y gastric bypass (LRYGB) may result in gastrojejunal (GJ) stricture, requiring treatment in up to 27% of patients. METHODS: This is a retrospective review of the outcome of 223 consecutive LRYGB patients. Patients developing stricture received standard endoscopic balloon dilation by the same surgeon. Stricture and nonstricture groups were compared for excess body weight loss (EBWL) at 1, 3, 6, and 12 months. RESULTS: GJ stricture requiring dilation occurred in 38 patients (17%). After dilation all patients were relieved of stricture symptoms and none required revision. By 12 months, patients with stricture had an EBWL of 86% compared with nonstrictured patients at 75%. CONCLUSION: Endoscopic balloon dilation is a safe and effective treatment option for GJ stricture. Improved weight loss occurred for patients with stricture requiring dilation.