The Role of Multiparametric MRI and MRI-targeted Biopsy in Detecting Clinically Significant Prostate Cancer in the Community Setting: A Retrospective Study.

Multiparametric MRI and the Prostate Imaging-Reporting and Data System (PI-RADS) have emerged as tools to reveal suspicious prostate lesions and MRI-targeted biopsy has shown potential to avoid repeat prostate biopsies and miss fewer significant cancers. This retrospective study sought to assess the differences in diagnostic yield and sampling efficiency between MRI-targeted and standard biopsies in a community urology practice. We concluded that MRI-targeted biopsy was more efficient than a standard biopsy, although neither technique achieved a superior diagnostic yield of clinically significant cancer in our community setting. We recommend that a standard biopsy be performed alongside targeted biopsy.

Lower extremity neuropathies after robot-assisted laparoscopic prostatectomy on a split-leg table.

BACKGROUND AND PURPOSE: Lower extremity neuropathies from prolonged lithotomy positioning have been well documented. When we initiated our robot-assisted laparoscopic prostatectomy (RALP) program in December 2002, we chose to use the split-leg table that allows patient support in a more anatomic position, hypothesizing that this would reduce risk of neurologic compression injuries. We report our incidence of lower extremity neuropathies associated with RALP using split-leg positioning and review patient and surgical variables associated with this complication. PATIENTS AND METHODS: We retrospectively reviewed records of 377 patients who underwent RALP using a split-leg table. Patient data including height, weight, body mass index, age, and smoking status; surgical variables such as surgeon operative experience and intraoperative times were also assessed. Intraoperative time was defined as anesthesia induction to anesthesia emergence to more accurately measure total time patients spent in the split-leg position. RESULTS: Of 377 patients, lower extremity neuropathies developed in 5 (1.3%) in the immediate postoperative period. Of all variables examined, only increased intraoperative time was identified as a potential risk factor for the development of this complication (496.2 ± 34.8 min vs 366.3 ± 96.1 min, P<0.001). Overall mean operative time for all patients was 368.0 ± 96.6 minutes. Three of the five patients had symptoms suggestive of a femoral mononeuropathy. CONCLUSIONS: Intraoperative time as defined in our study is a significant risk factor for development of postoperative neuropathy. We also found that split-leg positioning appears to put the femoral nerve at risk for injury, instead of the common peroneal nerve as has been previously reported from prolonged lithotomy positioning.

Utility of the RENAL nephrometry scoring system in the real world: predicting surgeon operative preference and complication risk.

OBJECTIVE: • To evaluate the utility of the RENAL scoring system in predicting operative approach and risk of complications. The RENAL nephrometry scoring system is designed to allow comparison of renal masses based on the radiological features of (R)adius, (E)xophytic/endophytic, (N)earness to collecting system, (A)nterior/posterior and (L)ocation relative to polar lines. METHODS: • A retrospective review of all patients at a single institution undergoing radical nephrectomy (RN) or partial nephrectomy (PN) for a renal mass between July 2007 and May 2010 was carried out. • Preoperative RENAL score was calculated for each patient. Surgical approach and operative outcomes were then compared with the RENAL score. RESULTS: • In all, 249 patients underwent either RN (158) or PN (91) with average RENAL scores of 8.9 and 6.3, respectively (P < 0.001). • Patients who underwent RN were more likely to have hilar tumours (64% vs 10%, P < 0.001) than patients who underwent PN, but were no more likely to have posteriorly located tumours (50% each). • There were more complications among patients with RN (58%) vs patients with PN (42%, P= 0.02). • RENAL scores were higher in patients with PN who developed complications than in patients with PN who did not develop complications (6.9 vs 6.0, P= 0.02), with no difference noted among patients with RN developing complications (8.9 vs 8.9, P= 0.99). CONCLUSION: • The RENAL system accurately predicted surgeon operative preference and risk of complications for patients undergoing PN.

Combined renal sinus fat and perinephric fat renal cell carcinoma invasion has a worse prognosis than either alone.

PURPOSE: Recently groups reached differing conclusions when examining the prognostic significance of renal cell carcinoma perinephric and sinus fat invasion. We evaluated the impact of these pathological features on renal cell carcinoma survival and recurrence. MATERIALS AND METHODS: We identified the pathological and clinical records of 110 patients treated surgically for renal cell carcinoma with extrarenal extension at our institution between 1997 and 2007. Patients with von Hippel-Lindau disease were excluded from study. We used Kaplan-Meier survival curves with the log rank statistic to evaluate differences between groups. Cox logistic regression analysis was used to control for metastatic disease, tumor size and renal vein involvement to determine differences among the groups. RESULTS: Patients with perinephric plus sinus fat invasion had worse cancer specific survival than those with perinephric or sinus fat invasion alone (p <0.005). There was no difference in cancer specific survival between those with sinus vs perinephric fat invasion (p = 0.248). On multivariate analysis perinephric plus sinus fat invasion was a significant prognostic factor for death from renal cell carcinoma compared to sinus fat invasion alone (p = 0.038). CONCLUSIONS: Patients with combined renal sinus and perinephric fat invasion had a worse prognosis than those with either alone. Considerations should be made to stage these cases accordingly.

Gleason score and laterality concordance between prostate biopsy and prostatectomy specimens.

OBJECTIVES: Prostate biopsy involvement and Gleason score guide treatment decisions in prostate cancer. We evaluated concordance in Gleason score and laterality between biopsy and radical retropubic prostatectomy (RRP) specimens and factors that influenced this relationship. MATERIALS AND METHODS: We reviewed 538 prostate cancer diagnoses at a Veterans Affairs medical center (2000-2005) to identify men with prostate biopsy and RRP specimens. During this time there was a move from limited (6 core) to extended (12 core) biopsy schemes. Discordance in Gleason score was defined as any change in Gleason score. RESULTS: 152 men underwent RRP with biopsy showing Gleason < 7 in 56%, 7 in 36%, and > 7 in 8%. Biopsy involvement was unilateral in 59% and bilateral in 41%. Compared to the biopsy, RRP Gleason score was concordant in 76 (50%), higher in 51 (34%), and lower in 25 (16%). Bilateral involvement was concordant in 97%, while unilateral involvement was concordant in only 20%. Both Gleason score and laterality were concordant in only 26%. Gleason concordance was higher in those with 8 or more cores compared to < 8 cores taken (54% vs. 34%, p = 0.046), but concordance was not affected by age, PSA, prostate volume, or length of time from biopsy to RRP. During later years, concordance did not improve despite taking more cores. CONCLUSIONS: Prostate biopsy underestimated prostatectomy Gleason score in 34% of men and bilateral involvement in 80% of those with unilateral disease on biopsy. Taking at least eight cores improves the accuracy of the prostate biopsy.

Gleason score and laterality concordance between prostate biopsy and prostatectomy specimens

Objectives: Prostate biopsy involvement and Gleason score guide treatment decisions in prostate cancer. We evaluated concordance in Gleason score and laterality between biopsy and radical retropubic prostatectomy (RRP) specimens and factors that influenced this relationship. Material and Methods: We reviewed 538 prostate cancer diagnoses at a Veterans Affairs medical center (2000-2005) to identify men with prostate biopsy and RRP specimens. During this time there was a move from limited (6 core) to extended (12 core) biopsy schemes. Discordance in Gleason score was defined as any change in Gleason score. Results: 152 men underwent RRP with biopsy showing Gleason < 7 in 56 percent, 7 in 36 percent, and > 7 in 8 percent. Biopsy involvement was unilateral in 59 percent and bilateral in 41 percent. Compared to the biopsy, RRP Gleason score was concordant in 76 (50 percent), higher in 51 (34 percent), and lower in 25 (16 percent). Bilateral involvement was concordant in 97 percent, while unilateral involvement was concordant in only 20 percent. Both Gleason score and laterality were concordant in only 26 percent. Gleason concordance was higher in those with 8 or more cores compared to < 8 cores taken (54 percent vs. 34 percent, p = 0.046), but concordance was not affected by age, PSA, prostate volume, or length of time from biopsy to RRP. During later years, concordance did not improve despite taking more cores. Conclusions: Prostate biopsy underestimated prostatectomy Gleason score in 34 percent of men and bilateral involvement in 80 percent of those with unilateral disease on biopsy. Taking at least eight cores improves the accuracy of the prostate biopsy.

Chyluria after partial nephrectomy: case report and review of the literature.

We report a case of 61-year-old male who presented with chyluria after partial nephrectomy. During workup for appendicitis, an incidental exophytic renal mass was revealed on CT scan. The patient ultimately underwent uncomplicated open partial nephrectomy. Postoperatively, his JP drain output turned milky white with urine remaining clear. JP fluid analysis was consistent with lymph. At 3 weeks postsurgery, his drain output decreased, but his urine turned milky white. Urinalysis confirmed fat in the urine. CT imaging revealed chyloma/urinoma with extravasation. The patient was initially treated conservatively, with a medium-chain fatty acid diet and then ureteral stenting. His stent was eventually removed and his chlyuria resolved 14 weeks later. In nonendemic countries, nonparasitic chyluria is exceedingly rare and postsurgical chyluria even more so. We review the sequelae of untreated disease and surgical options for intractable chyluria not responsive to conservative management. In non-endemic countries, non-parasitic chyluria is exceedingly rare, and post surgical chyluria even more so. We review the sequelae of untreated disease and surgical options for intractable chyluria not responsive to conservative management.

Surgically discovered xanthogranulomatous pyelonephritis invading inferior vena cava with coexisting renal cell carcinoma.

Xanthogranulomatous pyelonephritis (XGP) is a chronic inflammatory process that results in replacement of renal and/or perirenal tissue with a diffuse infiltrate of inflammatory cells referred to as xanthoma cells. We present a case of a 49-year-old man with an incidentally discovered renal mass with inferior vena cava (IVC) thrombus, who was found intraoperatively to have a significant inflammatory process involving the posterior wall of his IVC and right renal vein consistent with XGP surrounding a focus of clear cell renal cell carcinoma in the midportion of his right kidney.

The significance of lymphovascular invasion in transurethral resection of bladder tumour and cystectomy specimens on the survival of patients with urothelial bladder cancer.

OBJECTIVE: To test the hypothesis that patients with bladder cancer who had evidence of lymphovascular invasion (LVI) in their transurethral resection of bladder tumour (TURBT) and radical cystectomy (RC) specimens would have a worse prognosis and higher likelihood of clinical understaging, and to assess the effect of LVI discovered at RC on subsequent disease-related mortality, as the prognostic significance of LVI in TURBT or RC specimens of patients treated for urothelial carcinoma of the bladder is not completely established. PATIENTS AND METHODS: We retrospectively reviewed the records of 163 patients with urothelial carcinoma of the bladder seen at our institution, and who had TURBT (69) or RC (94) between 1995 and 2005. We compared patients with LVI on TURBT and/or RC specimens to a group of controls who did not have LVI on TURBT (34) or RC (32). RESULTS: Patients with LVI present in their TURBT specimen had a shorter disease-specific survival than those without LVI, with a 5-year survival of 33.6% vs 62.9% (log-rank test P = 0.027; hazard ratio 2.21). LVI at TURBT varied with clinical stage (P = 0.049). Patients with LVI and who were clinical stage I or II had lower survival than those without LVI (P = 0.049; hazard ratio 2.68). LVI did not affect survival among those with clinical stage III or IV (P = 0.29). There was a trend for patients with LVI at TURBT to be clinically understaged compared to those without LVI (75% vs 46%) but the difference was not significant (P = 0.086). Patients with LVI detected in their RC specimen were significantly more likely to have cancer recurrence than were those with no evidence of LVI (48% vs 19%, P = 0.006). For the RC group there was also a significant difference in survival distribution between patients with evidence of LVI vs those without (5-year survival 45.5% vs 78.4%, P = 0.017). Those with LVI were significantly more likely to die from the disease than those without LVI (P = 0.017; hazard ratio 2.92). CONCLUSIONS: Our findings suggest that LVI is a histological feature that might be associated with a poorer prognosis in patients with urothelial carcinoma of the bladder. The presence of LVI in TURBT specimens predicts shorter survival for patients with stage I or II disease. The presence of LVI in RC specimens predicts recurrence of disease and shorter survival. Further studies are needed to determine whether this group of patients would benefit from early RC and/or perioperative chemotherapy to improve clinical outcomes.

Review of topical treatment of upper tract urothelial carcinoma.

A select group of patients with upper tract urothelial carcinoma may be appropriate candidates for minimally invasive management. Organ-preserving endoscopic procedures may be appropriate for patients with an inability to tolerate major surgery, solitary kidney, bilateral disease, poor renal function, small tumor burden, low-grade disease, or carcinoma in situ. We review the published literature on the use of topical treatment for upper tract urothelial carcinoma and provide our approach to treatment in the office setting.

Prevalence of delayed clinician response to elevated prostate-specific antigen values.

OBJECTIVE: To assess the frequency of delayed response to an abnormal prostate-specific antigen (PSA) value. PATIENTS AND METHODS: Retrospective review of prostate cancer cases diagnosed between January 1, 2000, and December 31, 2005, in a rural Department of Veterans Affairs health care system serving 44,000 veterans across 2 states. Clinician response was defined as a reference to the elevated PSA result in clinical notes, orders for further evaluation, treatment of presumed prostatitis, or a urology visit or referral. Delay was measured as days between an abnormal PSA result and clinician response. RESULTS: We identified 327 men who met inclusion criteria with an abnormal PSA value before prostate cancer diagnosis. At first PSA elevation, median age was 64 years; 94% were younger than 75 years. Of the 327 men, 253 (77.4%) had a timely (< or =30 days) response to an abnormal PSA value; 23 (7.0%) had between 31 and 180 days; 24 (7.3%), between 181 and 360 days; and 27 (8.3%), more than 360 days between an abnormal PSA measurement and clinician response. The delayed group had nearly an additional year's (309 days) lapse before completed urologic consultation and prostate gland biopsy (313 days) as compared with the timely group. The presence of urologic symptoms, abnormal results from rectal examination, higher PSA values, and higher PSA velocity (P<.05) were associated with timely clinician response to an abnormal PSA measurement. CONCLUSION: In a cohort of men with prostate cancer and an antecedent abnormal PSA value, 15.6% had more than 180 days between an abnormal PSA measurement and clinician response. These findings add to the growing literature demonstrating that missed results occur more frequently than is generally appreciated. Improved systems for clinical data management are needed.

Impact of previous bacille Calmette-Guérin failure pattern on subsequent response to bacille Calmette-Guérin plus interferon intravesical therapy.

OBJECTIVES: To evaluate the effect of the bacille Calmette-Guérin (BCG) failure pattern in patients with non-muscle-invasive bladder cancer on the subsequent response to intravesical immunotherapy. METHODS: Data from the national Phase II multicenter trial for BCG plus interferon-alpha intravesical therapy for non-muscle-invasive bladder cancer were analyzed. The cancer-free rates for BCG-naive (BCG-N) and BCG-failure (BCG-F) patients with different failure patterns were compared using Kaplan-Meier analysis. RESULTS: At a median follow-up of 24 months, the BCG-N and BCG-F patients had a cancer-free rate of 59% and 45%, respectively. The BCG-F patients with immediate recurrence (refractory disease), within 6, 6 to 12, 12 to 24, and longer than 24 months had a cancer-free rate of 34%, 41%, 43%, 53%, and 66%, respectively (P = 0.005 for trend). No statistically significant difference was found in the cancer-free rates between patients with failure after 12 months and those with failure after 24 months or between BCG-N patients and those with failure after 12 and 24 months. A multivariate analysis of patients with failure after 12 months revealed that the number of previous courses of BCG did not significantly affect the treatment response. CONCLUSIONS: Patients with non-muscle-invasive bladder cancer with disease recurrence more than 1 year after BCG treatment and who were treated with low-dose BCG plus interferon-alpha had response rates similar to those of BCG-N patients treated with regular-dose BCG plus interferon. Although cystectomy should still be strongly considered, these patients might benefit from another trial with intravesical immunotherapy. In contrast, recurrence within 1 year of BCG treatment should lead to consideration of either cystectomy or alternative intravesical therapies.

Analysis of complications following partial and total nephrectomy for renal cancer in a population based sample.

PURPOSE: We determined the frequency and predictors of complications of partial and total nephrectomy in a population based sample. MATERIALS AND METHODS: There were 3,019 partial and 18,575 total nephrectomies identified from the Nationwide Inpatient Sample data set of the Healthcare Cost and Utilization Project (2000 to 2003). The prevalence of International Classification of Diseases, 9th Revision coded complications following nephrectomy was determined. Hospital and patient related factors associated with the occurrence of a complication were determined by logistic regression analysis. We evaluated the impact of complications on in-hospital mortality, length of stay and hospital charges. RESULTS: Respiratory, digestive and bleeding complications were the most common, with similar patterns for partial nephrectomy and total nephrectomy. Significant predictors of complications after total nephrectomy included age, male sex, comorbidity severity index and hospital location (rural vs urban), while comorbidity was the only significant predictor for partial nephrectomy complications. Any complication had a significant impact on in-hospital mortality, total charges and length of stay. Digestive and urinary complications, hemorrhage, and postoperative infections had a significant impact on in-hospital mortality after partial nephrectomy, while these same complications, in addition to respiratory and cardiac complications, had a significant impact on total charges and length of stay. All except digestive complications had a significant impact on mortality, hospital charges and length of stay for patients undergoing total nephrectomy. CONCLUSIONS: In a population based cohort partial nephrectomy and total nephrectomy are associated with low morbidity and mortality profiles, and all complications affect mortality, length of hospital stay and charges.

Complete response of bony metastatic bladder urothelial cancer to neoadjuvant chemotherapy and cystectomy.

We report on a 38-year-old male diagnosed with biopsy-proven bladder urothelial carcinoma metastatic to the bone, who had a complete response to neoadjuvant chemotherapy consisting of carboplatin and gemcitabine. The final pathology of his radical cystoprostatectomy revealed no residual cancer. The patient continues to be without evidence of disease 2 years postoperatively. This case shows that neoadjuvant chemotherapy with nonstandard regimens can yield responses in patients with bone metastases.

Final results from a national multicenter phase II trial of combination bacillus Calmette-Guérin plus interferon alpha-2B for reducing recurrence of superficial bladder cancer.

BACKGROUND: Both bacillus Calmette-Guérin (BCG) and interferon-alpha (IFN-alpha) express activity against superficial bladder cancer. The results of a national multicenter phase II trial of a combination of these 2 agents used in a wide range of patients are reported. MATERIALS AND METHODS: Patients previously having BCG failure received IFN-alpha (50 million units) plus reduced dose BCG, while patients naïve to BCG received the same IFN-alpha dose with standard dose BCG. All patients who were relapse free received an additional 3 series of 3-week reduced dose BCG plus IFN-alpha treatments at 3, 9, and 15 months after completing induction. Any relapse during the 3-month evaluation was counted as a failure of therapy for Kaplan-Meier analysis. Multivariate analysis was performed to identify factors associated with recurrence. RESULTS: Of 1,007 valuable patients, 59% and 45% of patients naïve to BCG and those having BCG failure, respectively, remained disease free at 24-month median follow-up. Stage T1, tumor size>5 cm, prior BCG failure more than once, and multifocality were all statistically significant risk factors for recurrence. CONCLUSIONS: Although BCG plus IFN-alpha can be effectively applied to both patients naïve to BCG and those having BCG failure, certain patient and tumor characteristics influence durable response.

Maximizing clinical information obtained by CT.

CT scanning is an integral part of the urologist's practice today. It is the most commonly used imaging modality and the one with which urologists are most familiar. CT urography, CT angiography, and 3D reconstruction enable the urologist to perform comprehensive evaluations of patients who have different urologic diseases, using a single imaging modality. It is thus prudent that urologists become familiar with CT applications, to maximize the clinical information available from them.

The impact of age on the response of patients with superficial bladder cancer to intravesical immunotherapy.

PURPOSE: We determined the influence of age on response to intravesical immunotherapy in patients with superficial bladder cancer. MATERIALS AND METHODS: Data from a national phase II multicenter trial for BCG plus IFN-alpha intravesical therapy for superficial bladder cancer were analyzed. Recurrence-free survival 2 years after the initiation of therapy was examined in patients by incremental age decade. BCG-N patients received 81 mg BCG and 50 MU IFN-alpha, while patients who had previously been treated with BCG received a third of the BCG dose with 50 MU IFN-alpha and those who were BCG intolerant received a tenth of the BCG dose with 100 MU IFN-alpha. Kaplan-Meier survival curves were obtained. RESULTS: In all patients the largest difference in response was between the 289 who were 61 to 70 years old and the 123 who were older than 80 years with a 22% difference in cancer-free survival at a median followup of 24 months (61% vs 39%, p = 0.0002). When we assessed BCG-N and BCG treated patients separately in the 2 age groups, patients older than 80 years had a persistently lower response rate than younger patients 61 to 70 years old. Of BCG-N patients those older than 80 and younger than 50 years had the lowest cancer-free survival at a median followup of 24 months (47% and 45%, respectively). On multivariate analysis age was an independent risk factor for response. CONCLUSIONS: Aging appears to be associated with a decreased response to intravesical immunotherapy and is particularly apparent in patients older than 80 years. A potential explanation could be their depressed baseline immune status and consequent inability to mount an immune reaction to BCG or IFN-alpha.

Minimally invasive management of upper tract urothelial carcinoma.

Recently published studies that evaluated minimally invasive treatments for upper tract urothelial cancer (UTUC) were reviewed, including adjuvant topical therapy. Ureteroscopic management remains the initial diagnostic and possibly therapeutic procedure of choice. Percutaneous management is used to treat bulky tumors or tumors that cannot be accessed ureteroscopically. Low-grade UTUC in appropriately selected patients can be safely and effectively treated endoscopically. High-grade disease tends to fail, regardless of treatment modality, and warrants aggressive therapy. Adjuvant therapy seems to be safe, although its efficacy is debatable. Immunotherapy appears to be most effective in patients with upper tract carcinoma in situ.

The impact of provider volume on outcomes from urological cancer therapy.

PURPOSE: Growing evidence suggests an association between higher hospital and surgeon volumes, and better outcomes after high risk surgical procedures. We reviewed the literature on volume and outcomes, specifically in urological cancer therapy. MATERIALS AND METHODS: We searched the literature from 1966 to 2004 using MEDLINE with the keywords outcomes, urology, neoplasms, volume, hospital volume, surgeon volume, prostatectomy, cystectomy, nephrectomy, prostate cancer, bladder cancer, kidney cancer and testis cancer. Relevant articles were reviewed and results were compared for each urological cancer. RESULTS: Several studies demonstrated that higher hospital volume is associated with better outcomes for all urological cancer surgeries. We found that long-term morbidity associated with radical prostatectomy is significantly associated with individual surgeon volume. There were variations in outcome even among high volume surgeons, suggesting that surgical technique can independently impact outcome. Hospitals with a high volume of cystectomies and nephrectomies had decreased overall mortality rates compared with low volume hospitals. Patients undergoing retroperitoneal lymph node dissection for metastatic germ cell tumor had statistically significantly improved survival when treated at larger oncology centers. CONCLUSIONS: Evidence that high volume hospitals have better outcomes is increasing for urological cancer surgeries. Whether volume affects quality or better clinicians and services attract more patients can be debated. Centralizing health care will have major health policy implications, ie high volume hospitals may be overwhelmed and low volume hospitals may be at a disadvantage. An alternative would be to attempt to improve outcomes at low volume hospitals by identifying drivers of high quality care at high volume hospitals and transferring some of these characteristics.