Bioactivity and prostate tissue distribution of metformin in a preprostatectomy prostate cancer cohort.

Metformin has recently been shown to have potential to reduce prostate cancer risk. We conducted a randomized, double-blind, placebo-controlled trial to determine the modulating effects of metformin on tissue and systemic biomarkers of drug activity and its distribution into the prostate tissue. Twenty patients with prostate cancer scheduled to undergo prostatectomy were randomly assigned to receive either extended-release metformin or placebo for a median of 34 days before surgery. Prostatectomy and serum samples were analyzed for metformin concentrations, serum biomarkers of drug activity (prostate-specific antigen, insulin, insulin-like growth factor-1, insulin-like growth factor binding protein 3, sex hormone-binding globulin, and testosterone) and tissue biomarkers of proliferation, apoptosis, cell cycle regulation, and mTOR inhibition. For participants in the metformin arm, the prostate tissue and serum metformin concentrations ranged from 0.88 to 51.2 µg/g tissue and from not detectable to 3.6 µg/ml, respectively. There were no differences between the two groups in either the postintervention tissue biomarker expression in the prostatectomy tissue or pre to postintervention changes in serum biomarkers. We conclude that metformin distributes to human prostate tissue, suggesting that metformin could exert its effects directly on tissue targets. However, there was no difference in tissue and systemic drug effect biomarkers between the two treatment arms. Future studies with longer intervention duration and larger sample size should be considered in order to evaluate the potential of metformin for prostate cancer prevention.

Predictors of Reporting Success With Increased Fluid Intake Among Kidney Stone Patients.

OBJECTIVE: To determine how kidney stone patients' knowledge, behaviors, and preferences toward fluid intake differed from those reporting being successful or unsuccessful at increasing fluid intake for prevention. MATERIALS AND METHODS: Three hundred two kidney stone patients filled out a survey on stone history, fluid intake success, and knowledge, behaviors, and preferences toward fluid intake. Responses were compared between those reporting being very successful at fluid intake and those reporting being not successful or only somewhat successful. Self-reported fluid intake success was correlated in a subset of 41 subjects using 24-hour urine volumes. RESULTS: Self-reported fluid intake success correlated significantly with 24-hour urine volumes. Unsuccessful fluid drinkers were less likely to be aware of their future stone risk and were less likely to be counseled on prevention by a urologist. Successful fluid drinkers reported the fewest barriers per person, were more likely to prefer water for fluid intake, and were more likely to like the "taste" of water. Strategies used for remembering to drink varied significantly with those unsuccessful most often reporting "just tried to remember" and those successful at fluid intake most likely to carry a water bottle. All groups reported similar perceived severity from stones, perceived benefits of drinking fluids, and preference for using urine color to monitor hydration. CONCLUSION: Awareness of future stone risk, preference for water, counseling on stone prevention by a urologist, and specific strategies used for increasing fluid intake varied between patients who were successful or unsuccessful with fluid intake. Addressing these differences may help improve fluid intake success.

Radical Prostatectomy or External Beam Radiation Therapy vs No Local Therapy for Survival Benefit in Metastatic Prostate Cancer: A SEER-Medicare Analysis.

PURPOSE: We assessed survival after radical prostatectomy, intensity modulated radiation therapy or conformal radiation therapy vs no local therapy for metastatic prostate cancer adjusting for patient comorbidity, androgen deprivation therapy and other factors. MATERIALS AND METHODS: We identified men 66 years old or older with metastatic prostate cancer treated with radical prostatectomy, intensity modulated radiation therapy, conformal radiation therapy or no local therapy in the SEER-Medicare linked database from 2004 to 2009. Multivariable Cox proportional hazards models before and after inverse propensity score weighting were used to assess all cause and prostate cancer specific mortality. Competing risk regression analysis was done to assess prostate cancer specific mortality. RESULTS: Of 4,069 men with metastatic prostate cancer radical prostatectomy in 47, intensity modulated radiation therapy in 88 and conformal radiation therapy in 107 were selected as local therapy vs no local therapy in 3,827. Radical prostatectomy was associated with a 52% decrease (HR 0.48, 95% CI 0.27-0.85) in the risk of prostate cancer specific mortality after adjusting for sociodemographics, primary tumor characteristics, comorbidity, androgen deprivation therapy and bone radiation within 6 months of diagnosis. Intensity modulated radiation therapy was associated with a 62% decrease (HR 0.38, 95% CI 0.24-0.61) in the risk of prostate specific cancer specific mortality. Conformal radiation therapy was not associated with improved survival compared to no local therapy. Propensity score weighting yielded comparable results. Competing risk analysis revealed a 42% and 57% decrease (SHR 0.58, 95% CI 0.35-0.95 and SHR 0.43, 95% CI 0.27-0.68, respectively) in the risk of prostate cancer specific mortality for radical prostatectomy and intensity modulated radiation therapy. CONCLUSIONS: Local therapy with radical prostatectomy and intensity modulated radiation therapy but not with conformal radiation therapy was associated with a survival benefit in men with metastatic prostate cancer. This finding warrants prospective evaluation in clinical trials.

Patient experiences and preferences with ureteral stent removal.

PURPOSE: Ureteral stent removal is a source of patient morbidity. We surveyed 599 patients to evaluate their experiences and identify the preferred method of stent removal. MATERIALS AND METHODS: Visitors to a kidney stone website were invited to participate. Respondents were asked how their ureteral stent was removed? Pain during and after the procedure, patient experiences, and preferences regarding stent removal were queried. Chi-square and ANOVA tests were used to identify significant differences among removal methods. RESULTS: Five hundred seventy-one respondents were included in the study. The majority of stents (44%) were removed by office cystoscopy while 39% had their stents removed by string. Mean pain during stent removal was 4.8 out of 10 with 57% reporting moderate-to-severe pain levels of 4 or more. Removal by office cystoscopy resulted in the highest experienced pain (5.3). Thirty-two percent reported delayed severe pain after stent removal, including 9% who returned for emergency care. Removal by string resulted in more emergency room visits when compared to cystoscopy. Willingness to undergo the same removal technique was lowest for those who underwent office cystoscopy and highest for operating room cystoscopy. Being informed of why a stent was placed and the removal process was of high priority for respondents. CONCLUSIONS: The majority of patients report moderate-to-severe pain with stent removal and a third report delayed significant pain after stent removal. Variations exist in the patient experience with stent removal based on the method used. More research is needed to identify effective ways to prevent or manage stent-removal-related adverse events.

Prostate cancer detection by using digital rectal examination: contemporary practice patterns in the United States.

BACKGROUND: Digital rectal examination (DRE) may play an important role as a secondary method of prostate cancer detection if prostate-specific antigen (PSA) screening decreases. Current practice patterns in the use of DRE are not well defined, and potential variations in its use among different subgroups of men are unclear. MATERIALS AND METHODS: The Behavioral Risk Factor Surveillance System was examined for the year 2010. All men aged 40 years old or older were asked if they ever had a rectal examination to check their prostate and the date of their last examination. Men who reported having had a DRE within the past 12 months were considered up to date. The proportion of men who reported having had a DRE and independent demographic and socioeconomic predictors for having had a DRE were determined. RESULTS: A total of 110,661 respondents were included: 72.2% of respondents reported ever having had a DRE; 36.8% had had a DRE within the past year, and 49.7% within the past 2 years. On multivariate analysis for reporting having an up-to-date DRE, older men, those with higher body mass index, and those of black race were more likely to have an up-to-date DRE. Asian or Hispanic race, divorced or widowed marital status, lower education, lower income, and lack of health insurance were independently associated with being less likely to have an up-to-date DRE. CONCLUSIONS: Of American men, 36.8% reported having an up-to-date DRE within the past year and 49.7% of men within the past 2 years. Demographic and socioeconomic characteristics were strongly associated with the likelihood of having an up-to-date DRE.

Sequential compression devices in postoperative urologic patients: an observational trial and survey study on the influence of patient and hospital factors on compliance.

BACKGROUND: Sequential compression devices (SCDs) are commonly used for thromboprophylaxis in postoperative patients but compliance is often poor. We investigated causes for noncompliance, examining both hospital and patient related factors. METHODS: 100 patients undergoing inpatient urologic surgery were enrolled. All patient had SCD sleeves placed preoperatively. Postoperative observations determined SCD compliance and reasons for non-compliance. Patient demographics, length of stay, inpatient unit type, and surgery type were recorded. At discharge, a patient survey gauged knowledge and attitudes regarding SCDs and bother with SCDs. Statistical analysis was performed to correlate SCD compliance with patient demographics; patient knowledge and attitudes regarding SCDs; and patient self-reported bother with SCDs. RESULTS: Observed overall compliance was 78.6%. The most commonly observed reasons for non-compliance were SCD machines not being initially available on the ward (71% of non-compliant observations on post-operative day 1) and SCD use not being restarted promptly after return to bed (50% of non-compliant observations for entire hospital stay). Mean self-reported bother scores related to SCDs were low, ranging from 1-3 out of 10 for all 12 categories of bother assessed. Patient demographics, knowledge, attitudes and bother with SCD devices were not significantly associated with non-compliance. CONCLUSIONS: Patient self-reported bother with SCD devices was low. Hospital factors, including SCD machine availability and timely restarting of devices by nursing staff when a patient returns to bed, played a greater role in SCD non-compliance than patient factors. Identifying and addressing hospital related causes for poor SCD compliance may improve postoperative urologic patient safety.

Internet search trends analysis tools can provide real-time data on kidney stone disease in the United States.

OBJECTIVES: To evaluate the utility of using Internet search trends data to estimate kidney stone occurrence and understand the priorities of patients with kidney stones. Internet search trends data represent a unique resource for monitoring population self-reported illness and health information-seeking behavior. METHODS: The Google Insights for Search analysis tool was used to study searches related to kidney stones, with each search term returning a search volume index (SVI) according to the search frequency relative to the total search volume. SVIs for the term, "kidney stones," were compiled by location and time parameters and compared with the published weather and stone prevalence data. Linear regression analysis was performed to determine the association of the search interest score with known epidemiologic variations in kidney stone disease, including latitude, temperature, season, and state. The frequency of the related search terms was categorized by theme and qualitatively analyzed. RESULTS: The SVI correlated significantly with established kidney stone epidemiologic predictors. The SVI correlated with the state latitude (R-squared=0.25; P<.001), the state mean annual temperature (R-squared=0.24; P<.001), and state combined sex prevalence (R-squared=0.25; P<.001). Female prevalence correlated more strongly than did male prevalence (R-squared=0.37; P<.001, and R-squared=0.17; P=.003, respectively). The national SVI correlated strongly with the average U.S. temperature by month (R-squared=0.54; P=.007). The search term ranking suggested that Internet users are most interested in the diagnosis, followed by etiology, infections, and treatment. CONCLUSIONS: Geographic and temporal variability in kidney stone disease appear to be accurately reflected in Internet search trends data. Internet search trends data might have broader applications for epidemiologic and urologic research.

Factors influencing fluid intake behavior among kidney stone formers.

PURPOSE: We determined factors influencing the behavior of patients with kidney stones in the prevention of recurrent stones. MATERIALS AND METHODS: Patients with stones from an academic and a community practice were recruited for key informant interviews and focus groups. Groups were guided based on the framework of the health belief model. Content analysis was done on transcriptions using qualitative data analysis software. RESULTS: Key informant interviews were completed with 16 patients and with a total of 29 subjects in 5 focus groups. Content analysis revealed that patients were highly motivated to prevent stones. The minimum level of perceived benefit for adopting the behavior change varied among patients and the behaviors proposed. An important strategy to increase fluid intake was insuring availability with containers. Patients were more consistently confident in the ability to increase fluid, in contrast to ingesting medicine or changing the diet. While barriers to increasing fluid were multifactorial among individuals, the barriers aligned into 3 progressive stages that were associated with distinct patient characteristics. Stage 1 barriers included not knowing the benefits of fluid or not remembering to drink. Stage 2 barriers included disliking the taste of water, lack of thirst and lack of availability. Stage 3 barriers included the need to void frequently and related workplace disruptions. CONCLUSIONS: Patients with kidney stones are highly motivated to prevent recurrence and were more amenable to fluid intake change than to another dietary or pharmaceutical intervention. Barriers preventing fluid intake success aligned into 3 progressive stages. Tailoring fluid intake counseling based on patient stage may improve fluid intake behavior.

Randomized, double-blind, placebo-controlled trial of polyphenon E in prostate cancer patients before prostatectomy: evaluation of potential chemopreventive activities.

Compelling preclinical and pilot clinical data support the role of green tea polyphenols in prostate cancer prevention. We conducted a randomized, double-blind, placebo-controlled trial of polyphenon E (enriched green tea polyphenol extract) in men with prostate cancer scheduled to undergo radical prostatectomy. The study aimed to determine the bioavailability of green tea polyphenols in prostate tissue and to measure its effects on systemic and tissue biomarkers of prostate cancer carcinogenesis. Participants received either polyphenon E (containing 800 mg epigallocatechin gallate) or placebo daily for 3 to 6 weeks before surgery. Following the intervention, green tea polyphenol levels in the prostatectomy tissue were low to undetectable. Polyphenon E intervention resulted in favorable but not statistically significant changes in serum prostate-specific antigen, serum insulin-like growth factor axis, and oxidative DNA damage in blood leukocytes. Tissue biomarkers of cell proliferation, apoptosis, and angiogenesis in the prostatectomy tissue did not differ between the treatment arms. The proportion of subjects who had a decrease in Gleason score between biopsy and surgical specimens was greater in those on polyphenon E but was not statistically significant. The study's findings of low bioavailability and/or bioaccumulation of green tea polyphenols in prostate tissue and statistically insignificant changes in systemic and tissue biomarkers from 3 to 6 weeks of administration suggests that prostate cancer preventive activity of green tea polyphenols, if occurring, may be through indirect means and/or that the activity may need to be evaluated with longer intervention durations, repeated dosing, or in patients at earlier stages of the disease.

Feasibility of optical coherence tomography imaging to characterize renal neoplasms: limitations in resolution and depth of penetration.

UNLABELLED: What's known on the subject? and What does the study add? Optical coherence tomography has been used for the diagnosis of retinal disease and has been used experimentally for imaging of vascular plaques, gastrointestinal pathology, bladder cancer, prostate cancer, and recently to examine benign kidney microanatomy. It has not been previously used to image kidney cancer. This study presents the first data on the utility of OCT in the imaging for renal neoplasms. It found that OCT was most successful in distinguishing AML and TCC from normal parenchyma. OCT had more limited success at differentiating oncocytoma. Clear cell tumors and other renal cancer subtypes had a more heterogenous appearance, precluding reliable identification using OCT. The study shows that higher resolution versions of OCT, such as OCM, will be needed to allow optical coherence imaging to reach clinical utility in the assessment of renal neoplasms. OBJECTIVES: • To determine the appearance of normal and neoplastic renal tissue when imaged with optical coherence tomography (OCT). • To preliminarily assess the feasibility of using OCT to differentiate normal and neoplastic renal tissue. PATIENTS AND METHODS: • After radical or partial nephrectomy in 20 subjects, normal renal parenchyma and neoplastic tissue samples were obtained. • The tissue was evaluated with light microscopy and using a bench-top laboratory OCT system with a lateral resolution of 10 µm. • OCT images were compared with histological slides to evaluate the ability of OCT to differentiate renal neoplasms. RESULTS: • Pathological subtypes included eight clear-cell, three papillary and two chromophobe renal carcinomas; two oncocytomas; one angiomyolipoma (AML); two transitional cell carcinomas (TCCs); and one haematoma. • Using OCT, benign renal parenchyma showed recognizable glomeruli and tubules. • TCC had a distinctive appearance on OCT whereas AML showed a unique identifiable signature because of its fat content. Oncocytomas had a lobulated appearance, which appeared subtly different from renal carcinoma. • Renal carcinoma lacked recognizable anatomical elements and had a heterogeneous appearance making differentiation from normal parenchyma at times difficult. • Subtypes of renal cancer appeared to vary on OCT imaging although discrimination was unreliable. CONCLUSIONS: • OCT imaging for renal neoplasms was most successful in distinguishing AML and TCC from normal parenchyma and malignant tumours. Oncocytoma differed subtly from renal carcinoma, making distinction more challenging. • Clear-cell tumours and other renal carcinoma subtypes had a heterogeneous appearance on OCT, which precluded reliable differentiation from normal parenchyma and between renal carcinoma subtypes. • Higher resolution versions of optical coherence imaging, such as optical coherence microscopy, will be necessary to achieve clinical utility.

Reviewing radiographic images with patients: results of a trial on patient preferences, understanding, and satisfaction.

PURPOSE: To evaluate patient preferences, understanding, and satisfaction regarding visual review of radiographic images during counseling. PATIENTS AND METHODS: 101 urologic patients who presented for counseling where images impacted decision making were randomized into group A, shown their images, and group B, shown a diagram. Both completed a satisfaction survey blinded to the study's purpose. A second unblinded survey evaluated patient comprehension of and preferences regarding images. Comparison of intervention and control groups for differences in satisfaction and analysis of patient self-reported preferences and understanding regarding radiographic images was performed. RESULTS: Group A had higher satisfaction scores but did not reach statistical significance. Both groups reported comprehension of images (100%, 97.9%), improvement in understanding of their condition and treatment because of viewing images (98%, 95.8%), and felt images should be shown to all patients (92%, 89.6%). Multivariate analysis identified female sex to independently predict greater understanding of images and belief that all patients should be shown their images. CONCLUSIONS: Almost all patients reported comprehension of images, improvement in understanding because of review of images, and preference for being shown images. Female patients expressed greater understanding and preference for all patients to be shown their images. Review of radiographic images represents a potentially useful additional modality for patient counseling whose usefulness for improving satisfaction will need to be confirmed in further studies.

Gender and renal cancer: do variations in clinical presentation and imaging patterns explain observed differences between males and females?

OBJECTIVES: To determine whether gender variations in imaging and healthcare access are contributing to observed differences in renal cancer, we examine the initial events in the diagnosis of renal masses in a cohort of patients and correlate it with detailed data on imaging patterns over the same period. METHODS: A total of 308 patients diagnosed with a renal mass over 11 years were reviewed. Information on symptoms, imaging, diagnosing physician, demographics, and pathology was gathered. Data on imaging for 1 862 485 patients at our institution over the same period were also collected. The data were analyzed for temporal trends, gender variations, and differences between incidental and nonincidental masses. RESULTS: Females presented with smaller masses (4.8 vs 6.0 cm, P = .0064), and were less likely to have clear cell tumors (58.7% vs 63.4%, P = .049). A total of 66.9% of female and 61.1% of male cases were incidental (not significant). In both males and females, primary care physicians were the most common diagnosing physicians (47.4% and 49.6%, respectively). Gynecologic complaints were an uncommon cause of diagnosis for women (5.3%). Computerized tomography was the most common diagnosing modality for both males and females (69.1% and 63.2%, respectively). Ultrasound as the diagnosing modality did not reach statistical significance between males and females (23.4% and 28.6%, respectively). During the 11- year period, women underwent more imaging studies overall than men (19.7% difference), but the difference was lower when only considering studies that can diagnose renal masses (6.4% difference). CONCLUSIONS: Gender variations in imaging rates and presentation for obstetrics/gynecology concerns by females did not lead to a significant difference in incidental diagnosis and do not appear adequate to explain gender differences in renal cancer presentation.

Coded tumor size may be unreliable for small metastatic renal cancers in the Surveillance, Epidemiology, and End Results dataset.

OBJECTIVES: To report a weakness in the April 2006 release of the Surveillance, Epidemiology, and End Results (SEER) dataset, in which the primary tumor size of small (< 1.8 cm) metastatic renal cancers was often incorrectly coded into the dataset from the measurement as listed in the patient's chart. METHODS: In the SEER dataset, 167 patients with tumor size < or = 2.5 cm had metastatic disease at presentation in 1998-2003. Each patient's chart was individually re-examined by SEER registries to determine the correct primary tumor size. This confirmed data were compared with the coded tumor size in the SEER dataset. RESULTS: Of the 167 re-examined cases, 2 had incorrect histology and 6 could not be verified. Of the remaining 159 cases, 87 (55%) were correctly coded for primary tumor size while 72 (45%) were incorrect. The error rate decreased with increasing size; for tumors < or = 1 cm, > 1-2 cm, and > 2-2.5 cm, error rates were 88%, 53%, and 6.8%, respectively (P < .001). A breakpoint in error rate occurred between tumor sizes < 1.8 cm (78%) and > or = 1.8 cm (10%) (P < .001). Most errors (72%) were miscoded by a factor of 10. Analysis of the latest April 2009 release suggests that most corrections have been incorporated into the public access dataset. CONCLUSIONS: Coded primary tumor sizes in the April 2006 release SEER dataset for metastatic renal tumors < 1.8 cm from 1998 to 2003 were often inaccurate. Verification of tumor size in this subset was essential to insure data accuracy and quality of research. Researchers should recognize potential limitations of population-based cancer registries.

Laparoscopic assisted ileal ureter: technique, outcomes and comparison to the open procedure.

PURPOSE: Ureteral replacement with interposition of a bowel segment has traditionally required a large incision with substantial associated morbidity and prolonged time to convalescence. During the last 7 years a technique for laparoscopic assisted ileal interposition has evolved that mimics our open approach. We present a comparative analysis of functional and perioperative outcomes between patients undergoing laparoscopic or open ileal ureter replacement at our institution. MATERIALS AND METHODS: A search of all procedures from 1980 to the present revealed 7 patients undergoing laparoscopic and 7 undergoing open ileal interposition. Functional and perioperative data from these patients are compared, and a detailed description of technique for the laparoscopic procedure is presented. RESULTS: Narcotic analgesic use in morphine equivalents (median 38.9 vs 322.2 mg, p = 0.035) and time to convalescence (median 4 vs 5.5 weeks, p = 0.03) were significantly less in the laparoscopic group. A trend toward shorter hospital stay (median 5 vs 8 days, p = 0.101) was also noted in patients in the laparoscopic group. There was no evidence of anastomotic stricture for patients in either group at last followup. CONCLUSIONS: Despite the small number of subjects involved a significant advantage was noted for postoperative recovery after laparoscopic compared to open ileal interposition. A detailed understanding of this complicated procedure can help prevent inherent pitfalls.

MR determination of glomerular filtration rate in subjects with solitary kidneys in comparison to clinical standards of renal function: feasibility and preliminary report.

This study was conducted to demonstrate the feasibility of quantifying single kidney glomerular filtration rate (skGFR) by magnetic resonance (MR) by comparison to the clinical estimates of GFR in volunteer subjects with a single kidney. Seven IRB-approved subjects with a solitary kidney, stable serum creatinine (SCr) and a 24 h creatinine clearance (CrCl) volunteered to undergo an MR examination that determined renal extraction fraction (EF) with a breathhold inversion recovery echo planar pulse sequence and renal blood flow with a velocity encoded phase imaging sequence. The product of EF and blood flow determines GFR. These values were compared with the 24 h CrCl, estimated GFR by the modification of diet in renal disease (MDRD) regression analysis and the Cockroft-Gault (CG) determination of CrCl. The mean and standard deviation of differences between the MR GFR, MDRD and CG vs the 24 h CrCl were 12.3+/-35.7, -8.9+/-18.5 and 1.2+/-19.6, respectively. The Student t-test showed that none of the mean differences were statistically significant between techniques. This clinical investigation shows that MR can be used for skGFR determination in human subjects with comparable values to those derived from clinically used serum-based GFR estimation techniques.

Kidney cancer: the new landscape.

PURPOSE OF REVIEW: The approach to treatment of renal cancer has shifted dramatically from radical surgery to a current emphasis on nephron-sparing treatment. We review the changes in renal cancer presentation and our understanding of its clinical behavior that have driven this shift in treatment philosophy. RECENT FINDINGS: Renal cancer incidence has increased progressively in the USA. In Europe, incidence trends have been variable. Renal cancers are increasingly being diagnosed incidentally. Increasing utilization of abdominal imaging will likely continue this trend. Renal cancer size at presentation has decreased. Fewer cases are presenting with metastasis. Mean age at diagnosis has increased slightly. Experience with active surveillance suggests that a significant percentage of small renal masses are indolent and possess a low metastatic risk. SUMMARY: The presentation of renal cancer has evolved. There has been an increase in the incidence of cases in the USA and several European countries and at the same time a shift to incidentally diagnosed, smaller, localized tumors in a slightly older population. This new landscape of renal cancer patients can be offered an expanded list of treatment options, including focal therapies, with an increased treatment priority on preservation of renal function and minimization of treatment morbidity.

Effect of renal cancer size on the prevalence of metastasis at diagnosis and mortality.

PURPOSE: We determined the relationship between the prevalence of metastasis at presentation and cancer specific mortality with tumor size in renal cancer cases using a large cancer database. MATERIALS AND METHODS: The Surveillance, Epidemiology and End Results data set was analyzed for renal tumors diagnosed from 1998 to 2003. A total of 24,253 patients were included. The prevalence of metastasis and cancer specific survival as a function of tumor size were evaluated using linear and nonlinear curve fitting methods. Metastatic cases with tumors 2.5 cm or less were individually reconfirmed case by case for accuracy. RESULTS: Increasing tumor size correlated with a higher prevalence of metastasis at diagnosis (range 1.4% for tumors 1 cm or less to 50.9% for tumors greater than 15 cm). Five-year cancer specific mortality in treated patients was also closely related to tumor size (range 3.5% for tumors 1 cm or less to 50.9% for tumors greater than 15 cm). In each instance the relationship was sigmoidal rather than linear and it was best modeled using a quadratic function. The most rapid increase in the prevalence of metastasis and mortality was noted for tumors 4 to 12 cm. In treated patients with tumors 1 cm or less, 1.1 to 2, 2.1 to 3 and 3.1 to 4 the prevalence of metastasis at diagnosis was 1.4%, 2.5%, 4.7% and 7.4%, and the 5-year cancer specific mortality rate was 3.5%, 3.8%, 4.1% and 5.3%, respectively. CONCLUSIONS: In cases of renal cancer the prevalence of metastasis at presentation and 5-year cancer specific mortality increase in a nonlinear sigmoidal relationship with tumor size.

Common bile duct injury during urologic laparoscopy.

Iatrogenic injuries to the extrahepatic biliary tract are rare during urologic laparoscopy. A few cases of gallbladder injury have been reported; however, to our knowledge, no instance of common bile duct (CBD) injury during urologic laparoscopy has hitherto been described. Out of 2866 transperitoneal laparoscopic urologic procedures between 1997 and 2007, we present two patients who sustained iatrogenic CBD injury, one during laparoscopic anterior pelvic exenteration and Indiana pouch diversion, and the other during laparoscopic partial nephrectomy. Etiology, management, and preventive strategies are summarized.

Laparoscopic pyeloplasty with concomitant pyelolithotomy: technique and outcomes.

BACKGROUND AND PURPOSE: Coexisting renal calculus disease may pose technical challenges in the surgical management of ureteropelvic junction obstruction. We report our experience with laparoscopic pyelolithotomy at the time of laparoscopic pyeloplasty and compare outcome data with a cohort of patients undergoing laparoscopic pyeloplasty without coexistent stone disease. PATIENTS AND METHODS: We reviewed data on 117 patients undergoing laparoscopic pyeloplasty in the last 3 years at our institution. Fifteen (10.6%) patients underwent concomitant ipsilateral pyelolithotomy at the time of laparoscopic pyeloplasty. Laparoscopic graspers alone were used in 11 (73.3%) patients, flexible nephroscopy in 2 (13.3%) patients, and laparoscopic irrigation in 2 (13.3%) patients for renal stone removal. Patients in the group undergoing pyelolithotomy were compared with 15 matched patients undergoing laparoscopic pyeloplasty without concomitant calculus disease. Preoperative, intraoperative, and postoperative parameters were compared between the groups. RESULTS: Overall stone-free rate after laparoscopic pyelolithotomy was 80%. Mean operative time was 174 minutes nu 170 minutes for the pyelolithotomy nu control group, respectively (P = 0.81). CONCLUSIONS: Laparoscopic pyelolithotomy, primarily using laparoscopic graspers, is an efficient procedure with associated high stone-free rates without significant increase in operative time or morbidity. Intraoperative flexible nephroscopy may be necessary only occasionally for stone retrieval.