Metastatic esophageal cancer presenting as bladder mass, a case report.

Metastatic esophageal cancer to urinary bladder is extremely rare and presents as an extremely poor prognosis. Herein, we describe the case of a 68 year-old female with history of resected adenocarcinoma of gastroesophageal junction in remission, who presented with gross hematuria and a bladder lesion. The patient underwent resection of the mass with final pathology consistent with metastatic adenocarcinoma of gastroesophageal junction.

Incisional hernia after cystectomy: incidence, risk factors and anthropometric predisposition.

INTRODUCTION: Postoperative incisional hernias (PIH) are an established complication of abdominal surgery with rates after radical cystectomy (RC) poorly defined. The objective of this analysis is to compare rates and risk factors of PIH after open (ORC) and robotic-assisted (RARC) cystectomy at a tertiary-care referral center. MATERIALS AND METHODS: We performed a retrospective review of patients undergoing ORC and RARC from 2000-2015 with pre and postoperative cross-sectional imaging available. Images were evaluated for anthropometric measurements and presence of postoperative radiographic PIH (RPIH). Patient demographics, type of urinary diversion and postoperative hernia repair (PHR) were also assessed. RESULTS: Of the patients that met inclusion criteria (n = 469), the incidence of RPIH and PHR were 14.3% and 9.0%, respectively. Between ORC and RARC, analysis revealed no statistically significant differences in rates of RPIH (13.6% versus 20.3%, p = 0.152) or PHR (8.2% versus 12.5%, p = 0.214). Body mass index was associated with a slightly increased likelihood of RPIH on univariate analysis alone (OR 1.08, p = 0.008). Ileal conduit was associated with a decreased likelihood of RPIH (OR 0.42, p = 0.034) and PHR (OR 0.36, p = 0.023). Supraumbilical rectus diastasis width (RDW) was an independent predictor of both RPIH (OR 1.52, p = 0.023) and PHR (OR 1.43, p = 0.039) on multivariate analysis. CONCLUSIONS: Patients undergoing RC are at significant risk of RPIH and PHR regardless of surgical approach. Anthropomorphic factors and urinary diversion type appear to be associated with PIH risk. Further research is needed to understand how risks of PIH can be reduced in patients undergoing cystectomy.

Partial nephrectomy is not associated with an overall survival advantage over radical nephrectomy in elderly patients with stage Ib-II renal masses: An analysis of the national cancer data base.

BACKGROUND: Partial nephrectomy (PN) is recommended for localized T1a (≤4 cm) renal masses and is preferred over radical nephrectomy (RN) for amenable T1b/T2 (>4 cm) tumors. The objective of the current study was to assess overall survival (OS) differences between PN and RN in patients with T1 and T2 renal cell carcinoma (RCC). METHODS: The National Cancer Data Base was queried for patients with T1 and T2 RCC who underwent PN or RN from 2004 to 2014. Trends in surgery were evaluated using Cochran-Armitage tests. Differences in OS were assessed using adjusted Kaplan-Meier methods. The effects of procedure on OS were analyzed using propensity score-based, weighted Cox proportional hazards models. RESULTS: In total, 212,016 patients with T1 and T2 RCC who underwent either RN (59.7%) or PN (40.3%) were included. The use of PN rose from 2004 to 2014 (T1a: from 40.6% to 71.4%; T1b/T2: from 8.4% to 26.5%; P < .01). Adjusted 5-year OS was longer for patients who underwent PN in both subsets, although effect magnitude was reduced in the T1b/T2 cohort (T1a: 89.6% vs 85.1%; hazard ratio [HR], 0.73; 95% confidence interval [CI], 0.70-0.75; P < .01; T1b/T2: 82.5% vs 80.8%; HR, 0.88; 95% CI, 0.83-0.94; P = .01). The benefit of PN on OS diminished as age and time from diagnosis increased; no OS improvement was observed in patients age ≥75 years who had T1b/T2 tumors (HR, 0.89; 95% CI, 0.76-1.06). CONCLUSIONS: Receipt of PN is associated with improved OS in patients with T1a RCC. No procedure-related differences in OS were observed for patients age ≥75 years who had tumors measuring >4 cm. Decisions to undergo PN for T1b/T2 tumors should be based on individualized risk assessment.

Use of administrative data for comparative effectiveness research in the treatment of non-prostate genitourinary malignancies.

Comparative effectiveness research (CER) is imperative for objective and balanced assessment of treatment outcomes. CER that uses administrative databases (AD-CER) affords unique opportunities for large scale data analyses that potentially transcend limitations of small institutional datasets. Prostate cancer has received much attention from the AD-CER research community, whereas non-prostate genitourinary malignancies are less well-studied. The objective of this article is to review the currently available AD-CER that has been published in the non-prostate genitourinary malignancies space.

Contemporary practice patterns and survival outcomes for locally advanced urethral malignancies: A National Cancer Database Analysis.

PURPOSE: Primary urethral carcinoma (PUC) has an aggressive natural history; however, controversy exists regarding the role of multimodal therapy for its treatment. Our objective was to examine practice patterns and survival outcomes for locally advanced urethral cancers. METHODS: The National Cancer Database was queried for patients with T2-4 or N1-2M0 PUC with urothelial, squamous, or adenocarcinoma histology from 2004 to 2013. Temporal trends for receipt of local or definitive surgery, radiotherapy (XRT), and systemic therapy were assessed. Adjusting for clinicopathologic characteristics, we evaluated the effect of tumor stage and histology on receipt of definitive multimodal therapy (cystectomy + chemotherapy ± XRT) and effects of treatment on overall survival. RESULTS: A total of 1,749 patients met inclusion criteria (22.2% adenocarcinoma, 29.3% squamous, and 48.5% urothelial). Only 29.6% underwent cystectomy ± XRT, and 15.6% underwent definitive multimodal therapy. Following adjustment, older patients (age 50-75: odds ratio [OR] = 0.42 [95% CI: 0.28-0.63]; age 75+: OR = 0.06 [95% CI: 0.03-0.13]) and those with squamous histology (OR = 0.46 [95% CI: 0.3-0.7]) were less likely to receive definitive multimodal therapy. More advanced stage (T3: OR = 1.66 [95% CI: 1.15-2.41]; T4: OR = 3.57 [95% CI: 2.47-5.16]); and N2 status (OR = 1.88 [95% CI: 1.27-2.78]) were more likely to receive definitive multimodal therapy. On adjusted analysis, an overall survival benefit was only observed with definitive multimodal therapy for PUC of urothelial origin (hazard ratio = 0.61 [95% CI: 0.45-0.83]). CONCLUSIONS: Despite a survival benefit, most patients with locally advanced PUC do not undergo definitive multimodal therapy. We advocate for a multidisciplinary-based treatment approach for these patients. Future prospective trials of multimodal therapy are crucial.

Contemporary use trends and survival outcomes in patients undergoing radical cystectomy or bladder-preservation therapy for muscle-invasive bladder cancer.

BACKGROUND: The current study was performed to examine temporal trends and compare overall survival (OS) in patients undergoing radical cystectomy (RC) or bladder-preservation therapy (BPT) for muscle-invasive urothelial carcinoma of the bladder. METHODS: The authors reviewed the National Cancer Data Base to identify patients with AJCC stage II to III urothelial carcinoma of the bladder from 2004 through 2013. Patients receiving BPT were stratified as having received any external-beam radiotherapy (any XRT), definitive XRT (50-80 grays), and definitive XRT with chemotherapy (CRT). Treatment trends and OS outcomes for the BPT and RC cohorts were evaluated using Cochran-Armitage tests, unadjusted Kaplan-Meier curves, adjusted Cox multivariate regression, and propensity score matching, using increasingly stringent selection criteria. RESULTS: A total of 32,300 patients met the inclusion criteria and were treated with RC (22,680 patients) or BPT (9620 patients). Of the patients treated with BPT, 26.4% (2540 patients) and 15.5% (1489 patients), respectively, were treated with definitive XRT and CRT. Improved OS was observed for RC in all groups. After adjustments with more rigorous statistical models controlling for confounders and with more restrictive BPT cohorts, the magnitude of the OS benefit became attenuated on multivariate (any XRT: hazard ratio [HR], 2.115 [95% confidence interval [95% CI], 2.045-2.188]; definitive XRT: HR, 1.870 [95% CI, 1.773-1.972]; and CRT: HR, 1.578 [95% CI, 1.474-1.691]) and propensity score (any XRT: HR, 2.008 [95% CI, 1.871-2.154]; definitive XRT: HR, 1.606 [95% CI, 1.453-1.776]; and CRT: HR, 1.406 [95% CI, 1.235-1.601]) analyses. CONCLUSIONS: In the National Cancer Data Base, receipt of BPT was associated with decreased OS compared with RC in patients with stage II to III urothelial carcinoma. Increasingly stringent definitions of BPT and more rigorous statistical methods adjusting for selection biases attenuated observed survival differences. Cancer 2017;123:4337-45. © 2017 American Cancer Society.

Safety and early effectiveness of robot-assisted partial nephrectomy for large angiomyolipomas.

OBJECTIVE: To evaluate a multicentre series of robot-assisted partial nephrectomy (RAPN) performed for the treatment of large angiomyolipomas (AMLs). PATIENTS AND METHODS: Between 2005 and 2016, 40 patients with large or symptomatic AMLs underwent RAPN at five academic centres in the USA. Patient demographics, AML characteristics, operative and postoperative clinical outcomes were recorded and analysed. Surgical outcomes were compared between patients who underwent selective arterial embolisation (SAE) before RAPN and patients who did not undergo pre-RAPN SAE. RESULTS: The median (interquartile range [IQR]) tumour diameter was 7.2 (5-8.5) cm, and the median (IQR) nephrometry score was 9 (7-10). Six patients (15%) had a history of tuberous sclerosis and 11 (28%) had previously undergone SAE. The median (IQR) operative time and warm ischaemia time was 207 (180-231) and 22.5 (16-28) min, respectively. A non-clamping technique was used in eight (20%) patients. The median (IQR) estimated blood loss was 200 (100-245) mL, and four patients (10%) received blood transfusion postoperatively. One intraoperative complication occurred (2.5%), and seven postoperative complications occurred in six patients (15%). During a median (IQR) follow-up of 8 (1-15) months, none of the patients developed AML-related symptoms. The median estimated glomerular filtration rate preservation rate was 95%. There were no differences in operative or perioperative outcomes between patients who underwent SAE before RAPN and those who did not. CONCLUSIONS: Robot-assisted partial nephrectomy appears to be a safe primary or secondary (post-SAE) treatment for large AMLs, with a favourable perioperative morbidity profile and excellent functional preservation. Longer follow-up is required to fully evaluate therapeutic efficacy.

Bladder Preservation Therapy: A Review of the Literature and Future Directions.

Trimodal bladder preservation therapy (ie, transurethral resection followed by chemoradiotherapy) may be an acceptable treatment alternative to radical cystectomy with urinary diversion in the carefully selected patient with muscle invasive bladder cancer. Although no head-to-head randomized controlled trials have been performed, large retrospective cohort reviews and observational data analyses suggest comparable oncologic outcomes in select patients with the additional benefit of maximizing quality of life and maintaining the patient's native bladder. In this review, we discuss the evolution and clinical outcomes of bladder preservation therapy, highlighting its role in the contemporary management of muscle invasive bladder cancer.

Predicting Acute Urinary Retention in Patients with Elevated Post-Void Residuals.

OBJECTIVES: To perform a retrospective analysis evaluating factors that may predict which men with elevated post-void residuals (PVRs) that were at increased risk to develop acute urinary retention (AUR). METHODS: We retrospectively analyzed the records of 44 male patients who had 2 consecutive PVRs greater than 100 ml over a 6-month period. Using regression analysis, we evaluated patient's age, PVR volume, prostate specific antigen (PSA) and transrectal ultrasound prostate volume with respect to development of AUR over 24 months. RESULTS: Of the 44 patients, 4 developed AUR. When all factors were considered, prostate volume was determined to be the only that was statistically significant (p = 0.003). A 1-SD increase in prostate volume (12 ml) led to a 19.6% increased risk of developing AUR. There was a strong correlation between PSA and prostate volume (0.787). A regression analysis was then repeated excluding prostate volume. PSA then became a statistically significant predictor of AUR (p = 0.007). A 1-SD increase in PSA (1.377 ng/ml) increased the patients' risk of developing AUR by 12.3%. CONCLUSION: In men with an elevated PVR, increased transrectal ultrasound prostate volume or PSA may help predict which patients have an elevated risk of developing AUR within the next 24 months. This information may influence which patients need early surgical intervention versus medical therapy.