The Uniform grading tooL for flexIble ureterorenoscoPes (TULIP-tool): a Delphi consensus project on standardised evaluation of flexible ureterorenoscopes.

OBJECTIVE: To develop a standardised tool to evaluate flexible ureterorenoscopes (fURS). MATERIALS AND METHODS: A three-stage consensus building approach based on the modified Delphi technique was performed under guidance of a steering group. First, scope- and user-related parameters used to evaluate fURS were identified through a systematic scoping review. Then, the main categories and subcategories were defined, and the expert panel was selected. Finally, a two-step modified Delphi consensus project was conducted to firstly obtain consensus on the relevance and exact definition of each (sub)category necessary to evaluate fURS, and secondly on the evaluation method (setting, used tools and unit of outcome) of those (sub)categories. Consensus was reached at a predefined threshold of 80% high agreement. RESULTS: The panel consisted of 30 experts in the field of endourology. The first step of the modified Delphi consensus project consisted of two questionnaires with a response rate of 97% (n = 29) for both. Consensus was reached for the relevance and definition of six main categories and 12 subcategories. The second step consisted of three questionnaires (response rate of 90%, 97% and 100%, respectively). Consensus was reached on the method of measurement for all (sub)categories. CONCLUSION: This modified Delphi consensus project reached consensus on a standardised grading tool for the evaluation of fURS - The Uniform grading tooL for flexIble ureterorenoscoPes (TULIP) tool. This is a first step in creating uniformity in this field of research to facilitate future comparison of outcomes of the functionality and handling of fURS.

Over-the-Counter Alkali Agents to Raise Urine pH and Citrate Excretion: A Prospective Crossover Study in Healthy Adults.

OBJECTIVE: To assess the effect of 2 over-the-counter alkalizing agents on 24 hour urinary parameters. MATERIALS AND METHODS: Ten healthy volunteers without a history of kidney stones were recruited to complete a baseline 24 hour urinalysis with a 4 day diet inventory. Participants then maintained the same diet on either LithoLyte (20 mEq 2 times per day) or KSPtabs (1 tablet 2 times per day) and submitted another 24 hour urinalysis. The process was repeated with the other supplement. Urinary alkali parameters were compared to baseline, and side effects were elicited with a questionnaire. RESULTS: LithoLyte intake resulted in a non-significant increase in citrate (597-758 mg/day, P =.058, an increase in urine pH (6.46-6.66, P =.028), and a decrease in urine ammonium (41-36 mmol/day, P =.005) compared to baseline. KSPtabs resulted in an increase in citrate (597-797 mg/day, P =.037) and urine pH (6.46-6.86, P =.037), with a non-significant decrease in ammonium (41-34 mmol/day, P =.059). No significant differences were seen comparing urinary analytes between LithoLyte and KSPtabs. With Litholyte, no side effects, mild, moderate, and severe side effects were seen in 50%, 40%, 10%, and 0%, respectively. With KSPtabs, rates were 60%, 20%, 10%, and 10%, respectively. CONCLUSION: In healthy participants without a history of kidney stones, LithoLyte and KSPtabs are effective over-the-counter alkali supplements, with a similar side effect profile to prescription potassium citrate.

Ureteroscopy with thulium fiber laser lithotripsy results in shorter operating times and large cost savings.

PURPOSE: Prolonged ureteroscopy (URS) is associated with complications including ureteral perforation, stricture, and urosepsis. As laser lithotripsy is one of the most common urologic procedures, small cost savings per case can have a large financial impact. This retrospective study was designed to determine if Thulium fiber laser (TFL) lithotripsy decreases operative time and costs compared to standard Holmium:YAG (Ho:YAG) lithotripsy without pulse modulation. METHODS: A retrospective review of URS with laser lithotripsy was conducted for 152 cases performed from August 2020 to January 2021. Variables including cumulative stone size, location, chemical composition, prior ureteral stenting, and ureteral access sheath use were recorded for each case. A cost benefit analysis was performed to show projected cost savings due to potentially decreased operative times. RESULTS: Compared to Ho:YAG, use of TFL resulted in an average decrease of 12.9 min per case (p = .021, 95% CI [2.03-23.85]). In subgroup analysis of cases with cumulative stone diameter less than 15 mm, the difference was 14.0 min (p = .007, CI [3.95-23.95]). For cases less than 10 mm, the mean difference was 17.3 min in favor of TFL (p = .002, 95% CI [6.89-27.62]). This ~ 13 min reduction in operative time resulted in saving $440/case in direct operating room costs giving our institution a range of $294,000 to $381,900 savings per year. CONCLUSIONS: TFL has a significantly shorter operative time and decreased cost when compared to the standard Ho:YAG for equivalent kidney stone and patient characteristics. Longer term follow up is needed to see if recurrence rates are affected.

Subsequent urinary stone events are predicted by the magnitude of urinary oxalate excretion in enteric hyperoxaluria.

Data directly demonstrating the relationship between urinary oxalate (UOx) excretion and stone events in those with enteric hyperoxaluria (EH) are limited. Therefore, we assessed the relationship between UOx excretion and risk of kidney stone events in a retrospective population-based EH cohort. In all, 297 patients from Olmsted County, Minnesota were identified with EH based upon having a 24-h UOx ≥40 mg/24 h preceded by a diagnosis or procedure associated with malabsorption. Diagnostic codes and urologic procedures consistent with kidney stones during follow-up after baseline UOx were considered a new stone event. Logistic regression and accelerated failure time modeling were performed as a function of UOx excretion to predict the probability of new stone event and the annual rate of stone events, respectively, with adjustment for urine calcium and citrate. Mean ± standard deviation age was 51.4 ± 11.4 years and 68% were female. Median (interquartile range) UOx was 55.4 (46.6-73.0) mg/24 h and 81 patients had one or more stone event during a median follow-up time of 4.9 (2.8-7.8) years. Higher UOx was associated with a higher probability of developing a stone event (P < 0.01) and predicted an increased annual risk of kidney stones (P = 0.001). Estimates derived from these analyses suggest that a 20% decrease in UOx is associated with 25% reduction in the annual odds of a future stone event. Thus, these data demonstrate an association between baseline UOx and stone events in EH patients and highlight the potential benefit of strategies to reduce UOx in this patient group. BACKGROUND: Data directly demonstrating the relationship between urinary oxalate (UOx) excretion and stone events in those with enteric hyperoxaluria (EH) are limited. METHODS: We assessed the relationship between UOx excretion and risk of kidney stone events in a retrospective population-based EH cohort. In all, 297 patients from Olmsted County, Minnesota were identified with EH based upon having a 24-h UOx ≥40 mg/24 h preceded by a diagnosis or procedure associated with malabsorption. Diagnostic codes and urologic procedures consistent with kidney stones during follow-up after baseline UOx were considered a new stone event. Logistic regression and accelerated failure time modeling were performed as a function of UOx excretion to predict the probability of new stone event and the annual rate of stone events, respectively, with adjustment for urine calcium and citrate. RESULTS: Mean ± SD age was 51.4 ± 11.4 years and 68% were female. Median (interquartile range) UOx was 55.4 (46.6-73.0) mg/24 h and 81 patients had ≥1 stone event during a median follow-up time of 4.9 (2.8-7.8) years. Higher UOx was associated with a higher probability of developing a stone event (P < 0.01) and predicted an increased annual risk of kidney stones (P = 0.001). Estimates derived from these analyses suggest that a 20% decrease in UOx is associated with 25% reduction in the annual odds of a future stone event. CONCLUSIONS: These data demonstrate an association between baseline UOx and stone events in EH patients and highlight the potential benefit of strategies to reduce UOx in this patient group.

Renal Neuroendocrine Neoplasms: A Single-center Experience.

BACKGROUND: Primary neuroendocrine neoplasms (NENs) of the kidney are exceedingly rare malignancies and the available literature is very limited. The natural history and response to treatments is not well characterized. We aimed to describe the presenting features, demographics, tumor characteristics, and treatment outcomes of patients with renal NENs. PATIENTS AND METHODS: We performed a retrospective analysis of all Mayo Clinic patient records with a tissue diagnosis of a primary renal NEN. Baseline patient and surgical pathologic features and treatment modalities were collected. Time to recurrence after resection and overall survival (OS) were estimated using with survival analysis. Surveillance, Epidemiology, and End Results data were used to estimate the population-wide incidence and OS. RESULTS: A total of 17 patients were included in the present study, with a median follow-up of 62.8 months. Distant metastasis was present in 29% at diagnosis, with 76% experiencing distant metastasis at any point; 24% had a horseshoe kidney. Of the 17 patients, 14 had undergone surgical resection with no evidence of disease postoperatively. Ten of these patients had documented recurrence. The median time to recurrence was 18 months (95% confidence interval, 9-46 months). Only 1 of the 10 patients showed a radiographic response to systemic therapy. Of 9 patients, 4 had stable disease with somatostatin analogs. The median OS was 143 months (95% confidence interval, 50-143 months). CONCLUSIONS: Renal NENs are rare malignancies affecting mostly middle-age patients, with distant metastasis being common. Approximately one half of patients experience stable disease with somatostatin analogs. The OS usually exceeds 5 years.

Endourologic Management of Stent Retained Over 22 Years in Patient with Duplicated Collecting System.

Background: Retained and subsequently encrusted stents can lead to a number of complications, the most dire being deterioration of renal function. Limited literature exists concerning endourologic management of stents retained for extreme durations and few that concerns patients with abnormal renal anatomy. Case Presentation: A 70-year-old man with history of Crohn's disease and partially duplicated collecting system presented with rising creatinine and was found to have bilateral retained Double-J stents, originally placed before small bowel resection 22 years prior. The patient underwent staged bilateral percutaneous nephrolithotomy with ultimate effective removal of both stents. The patient has had subsequent improvement in renal function and has not required dialysis. Conclusion: Removal of ureteral stents in a timely manner is paramount to prevent long-term retention and complication, but when required retained stents can be safely managed with a well-planned endourologic approach, even if significant deterioration in renal function has occurred.

Increasing stone complexity does not affect fluoroscopy time in percutaneous nephrolithotomy.

BACKGROUND: The aim of this work was to assess whether stone complexity with the Guy's stone score (GSS) is associated with increased intraoperative fluoroscopy time. METHODS: We retrospectively reviewed records of 261 consecutive patients undergoing percutaneous nephrolithotomy between 2007 and 2015. Of these, 203 had both preoperative computed tomography for accurate staging and full intraoperative fluoroscopy and radiation dosimetry data were available. Stone complexity was assessed using GSS. A correlation between fluoroscopy time (FT) and GSS was assessed in a univariate and multivariate fashion, including parameters such as age, sex, body mass index (BMI), and number of accesses. RESULTS: The overall mean FT was 3.69 min [standard deviation (SD) 2.77]. The overall mean Guy's score was 2.5 (SD 1). There was a statistically significant correlation between operative time and FT (r = 0.34, p < 0.0001). There was a trend towards increasing operative time with increasing GSS (r = 0.12, p = 0.08), but there was no statistically significant correlation. There was no correlation between FT and GSS (r = 0.04, p = 0.55). On multivariable regression, accounting for sex, BMI, age, and singular versus multiple accesses, there was no significant correlation between stone complexity and FT (p = 0.893). CONCLUSIONS: In the setting of conscious efforts to reduce intraoperative radiation exposure, increasing stone complexity, as classified by GSS, did not correlate with FT on univariate or multivariate analysis. Thus, treatment of more complex stones may be undertaken without concern that there is an inevitable need for significantly increased fluoroscopy exposure to the patient or operating room staff.

Does Travel Time to a Radiation Facility Impact Patient Decision-Making Regarding Treatment for Prostate Cancer? A Study of the New Hampshire State Cancer Registry.

PURPOSE: We sought to determine whether further distance from a radiation center is associated with lower utilization of external beam radiation therapy (XRT). METHODS: We retrospectively identified patients with a new diagnosis of localized prostate cancer (CaP) within the New Hampshire State Cancer Registry from 2004 to 2011. Patients were categorized by age, D'Amico risk category, year of treatment, marital status, season of diagnosis, urban/rural residence, and driving time to the nearest radiation facility. Treatment decisions were stratified into those requiring multiple trips (XRT) or a single trip (surgery or brachytherapy). Multivariable regression analysis was performed. RESULTS: A total of 4,731 patients underwent treatment for newly diagnosed CaP during the study period, including 1,575 multitrip (XRT) and 3,156 single-trip treatments. Of these, 87.6% lived within a 30-minute drive to a radiation facility. In multivariable analysis, time to the nearest radiation facility was not associated with treatment decisions (P = .26). However, higher risk category, older age, married status, and winter diagnosis were associated with XRT (P < .05). More recent year of diagnosis and urban residence were associated with single-trip therapy (primarily surgery) (P < .05). There was a significant interaction between travel time and season of diagnosis (P = .03), as well as a marginally significant interaction with urban/rural status (P = .07). CONCLUSION: Overall, further travel time to a radiation facility was not associated with lower utilization of XRT. These data are encouraging regarding access to care for CaP in New Hampshire.

Same-Session Bilateral Ureteroscopy: Safety and Outcomes.

OBJECTIVE: To assess the complications and outcomes associated with same-session bilateral ureteroscopy in a tertiary referral center, as same-session bilateral ureteroscopy for stone disease has been critiqued for the theoretical risk of injury to both ureters with subsequent risk to renal function. METHODS: We retrospectively reviewed all cases of bilateral ureteroscopy performed for urolithiasis by a single surgeon at out institution between 2009 and 2014. These were compared to a prospective unilateral ureteroscopy database. RESULTS: There were 117 same-session bilateral ureteroscopic procedures performed in 113 patients totaling 234 ureteroscopies. A flexible ureteroscope was used in 228 ureters (97.4%), and 6 (2.6%) were semirigid only. Ureteral dilators were required in 8 (6.8%) cases. Pre-stenting was performed in 23 (19.6%) patients. Short-term complications were observed following 19 (16.2%) procedures, including 11 (9.4%) Clavien I, 4 (3.4%) Clavien II, and 4 (3.4%) Clavien III. Of the 84 (71.8%) patients who completed a 6-week follow-up, there were no long-term complications. Stone-free rates were 91.4% for patients imaged with abdominal x-ray and ultrasound, and 84.2% for those imaged with computed tomography scans. Neither complications nor re-admissions were significantly different in the unilateral group. Median length of follow-up for the entire cohort was 2.8 years (range 0-7 years). CONCLUSION: Bilateral ureteroscopy can be performed safely with short-term complications, consistent with published literature. We found no long-term complications and high stone-free rates. Bilateral ureteroscopy in a single procedure represents a viable standard of care for patients with bilateral stone disease.

The Effect of Anticoagulation on Bleeding-related Complications Following Ureteroscopy.

OBJECTIVE: To analyze bleeding-related complications among patients on long-term anticoagulation (AC) undergoing ureteroscopy (URS). Current American Urological Association/International Consultation on Urological Diseases guidelines state that it is safe to continue AC in routine URS; however, these recommendations are based on small case series. PATIENTS AND METHODS: There were 4799 identified URS procedures performed at our institution between June 2009 and February 2016. Records were then retrospectively reviewed to confirm AC use and identify periprocedural complications. Anticoagulant agents evaluated included warfarin, enoxaparin, and non-vitamin K antagonists (ie, rivaroxaban, dabigatran, apibaxan). Patients were excluded if they were taking a concurrent antiplatelet (AP) agent or if additional non-URS procedures were performed. RESULTS: Of the 4799 URS procedures, 272 (5.6%) were done on patients taking chronic AC. Of these, 193 (71%) held AC, 53 (19%) were bridged with enoxaparin, and 26 (10%) continued AC. The median age was 70.2 years and the majority of patients (64.2%) underwent a stone procedure with a stone-free rate of 73%. The overall bleeding-related complication rate was 8.1% whereas the significant bleeding-related event rate was 5.9%. Patients continuing AC had the highest significant bleeding-related event rate at 15.4% compared to 9% and 3% for those bridged with enoxaparin and those who held, respectively (P = .01). CONCLUSION: Continuation or bridging of AC may increase the risk of perioperative bleeding. The risks and benefits of proceeding with URS on AC must be weighed carefully. Pending external validation, this information may be used for patient counseling and risk stratification.

Successful Percutaneous Nephrolithotomy in Patients with Immune-Mediated Thrombocytopenia Treated with Romiplostim.

BACKGROUND: Percutaneous nephrolithotomy (PCNL) for large stone burden can be problematic in patients with significant risk of bleeding complications, specifically thrombocytopenia. This report demonstrates effective correction of two patients' thrombocytopenia, subsequently leading to removal of large stone burden through PCNL. CASE PRESENTATION: We present two Middle Eastern patients who presented with medical histories significant for thrombocytopenia, secondary to splenomegaly and hepatic vein thrombosis, and large volume nephrolithiasis. Patient 1 is a 65-year-old female with a right 5 cm stone and a platelet count of 34,000. Patient 2 is a 45-year-old female with a 3 cm left staghorn stone and a platelet count of 44,000. After consultation with hematology, both underwent therapy with prednisone and intravenous immunoglobulin without improvement in their platelet count. They then received 3 µg/kg/dose of romiplostim weekly that improved their platelet counts to 133,000 and 195,000 in 2 weeks, respectively. Patient 1's PCNL was completed in a single-stage procedure with stone-free status shown on CT postoperative day 1. Patient 2 underwent PCNL and a secondary ureteroscopy for residual stone fragments on postoperative day 2. Both patients experienced no complication during the procedure, hospital stay, or postoperative course. Both continued romiplostim for 20 days postoperatively with platelet levels returning to their baseline range after 1 month. CONCLUSION: In the appropriately selected patient, romiplostim can correct thrombocytopenia enough to safely and effectively perform PCNL in patients with underlying hematologic disorders. Close coordination between urology and hematology is imperative to ensure an effective outcome in this challenging patient population.

Special situations in ureteroscopy.

Ureteroscopy is the treatment of choice for small ureteral or renal calculi and for diagnosis of ureteral abnormalities suspicious for urothelial carcinoma. In certain scenarios ureteroscopy may be used to treat large stones or tumors when other more favorable treatment modalities are not possible. In such situations ureteroscopy can prove to be a challenging procedure. Specific patient anatomic and physiological characteristics can make even a simple ureteroscopy a difficult procedure. Such situations include surgically altered urinary tract anatomy, congenital anomalies and obesity. Pathologic and iatrogenic bleeding diatheses are examples of where pathophysiology can adversely affect the procedure. Finally, pregnancy is an example of where a normal physiologic condition can make diagnosis and treatment of urolithiasis difficult due to concerns for the fetus. In this review we will discuss the use of ureteroscopy in such challenging patient scenarios.

The Effect of Antiplatelet Agents on Bleeding-Related Complications After Ureteroscopy.

INTRODUCTION: The American Urological Association (AUA) guidelines state that continuing anticoagulation and antiplatelet agents in routine ureteroscopy (URS) is safe and without increased risk of complications. However, these recommendations are based on small case series; thus, we sought to analyze bleeding-related complications among patients on antiplatelet therapy (APT). MATERIALS AND METHODS: Overall, 4799 URS procedures performed at our institution between June 2009 and February 2016 were identified. Records were then retrospectively reviewed to confirm APT use and to identify periprocedural complications. Antiplatelet agents evaluated included aspirin (low dose and full dose) and P2Y12 receptor antagonists (clopidogrel, prasugugrel, ticagrelor). Patients were excluded if they were taking a concurrent anticoagulant agent or if additional non-URS procedures were performed. RESULTS: Of 4799 URS procedures, 314 (6.5%) were performed on patients taking APT, of which 234 (74.5%) held APT, 63 (20.1%) continued APT, and 17 (5.4%) continued dual APT. The mean age was 70.1 years, and the majority of patients (69.6%) underwent a stone procedure with a stone-free rate of 80.2%. The overall bleeding-related complication rate was 1.9%, whereas the significant bleeding-related event rate was 1.6% and this did not differ among the groups (p = 0.3). The power to detect a 3% difference in bleeding between the groups was 0.95. CONCLUSIONS: Continuing APT in patients on chronic therapy does not appear to pose an increased risk of bleeding-related complications. Our findings support the current AUA guidelines as they relate to APT.

Is age an independent risk factor for medical complications following minimally invasive radical prostatectomy? An evaluation of contemporary American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) data.

While robotic-assisted laparoscopic radical prostatectomy (RALRP) is an effective treatment for localized prostate cancer, the risk of complications in older patients can be a deterrent to surgery. We evaluated the rate of medical complications following RALRP in a national dataset of safety events, and assessed whether age is an independent risk factor for these complications. Retrospective analysis of patients undergoing RALRP between 2009 and 2012 in the prospectively maintained American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database was performed. Demographic and comorbid data were collated, medical complications occurring during the 30-day post-operative period were identified. We identified age-related comorbidities, and complications associated with these comorbidities. A binary logistic regression model with age and age-related comorbidities as predictors and specific complication as outcome, was used to evaluate whether age is an independent risk factor for these complications. 12,123 patients underwent RALRP between 2009 and 2012, with a mean age of 62 (22-92). Post-operative medical complications included urinary tract infection (UTI) (1.77 %), deep venous thrombosis (DVT) (0.67 %), pulmonary embolism (PE) (0.45 %), pneumonia (PNA) (0.27 %), myocardial infarction (MI) (0.12 %), and cerebrovascular accident (CVA) (0.01 %). Nine comorbidities were positively correlated with age (p < 0.05). Four medical complications were associated with these age-related comorbidities: MI, CVA, PNA, and UTI. On multivariate analysis, age was an independent risk factor for post-operative PNA (p < 0.05), but not for MI (p = 0.09), UTI (p = 0.3) or CVA (p = 0.2). Patient age was independently associated with post-operative pneumonia only. These data suggest that RALRP can be considered as a treatment option in selected older patients with minimal increased risk for post-operative complications.

Diagnosis and Management of Nephrolithiasis.

Nephrolithiasis is a common affliction, affecting approximately 10% of adults. Potentially presenting with acute abdominal or flank pain, nausea, or emesis, it may pose as a general surgical condition. Therefore, recognition, diagnosis, and management concerns are pertinent to the general surgeon. Furthermore, the risk of nephrolithiasis is increased in common general surgical conditions, including inflammatory bowel disease, hyperparathyroidism, and short gut. Nephrolithiasis may be induced as a result of general surgical interventions, including gastric bypass and bowel resection with ileostomy. An understanding of this common disease will improve coordination of patient care between urologists and general surgeons.

Occupation as a risk factor for renal cell cancer: a nationwide, prospective epidemiological study.

Objective Using centralized registries in Iceland, the aim of this study was to prospectively investigate multiple risk factors for renal cell carcinoma (RCC), including occupational history. Materials and methods From the Reykjavik study database, 18,840 men and women born in the period 1907-1935 were linked with a population-based registry containing all RCCs diagnosed in Iceland from 1971 to 2005 (n = 910). From this cross-reference, altogether 225 cases were identified. A prospective analysis of the risk factors for RCC was performed using Cox regression analysis, from the time of entry into the Reykjavik study to the diagnosis of RCC, death or end of follow-up, with a median follow-up time of 25 years. The hazard ratio (HR) was then calculated for multiple risk factors including occupational history. Results Male gender [HR 1.65, 95% confidence interval (CI) 1.14-2.38], body mass index (BMI) over 25 kg/m² (HR 1.41, 95% CI 1.06-1.88) and age (HR 1.04, 95% CI 1.03-1.07) increased the risk of RCC, as did severe hypertension (>160/100 mmHg) (HR 1.46, 95% CI 1.05-2.03) and history of kidney disease (HR 1.55, 95% CI 1.11-2.16); however, smoking and type 2 diabetes were not significantly associated with the disease. The risk of RCC was significantly increased in painters (HR 2.97, 95% CI 1.31-6.74), aircraft mechanics (HR 4.51, 95% CI 1.11-18.28) and shipbuilders (HR 2.03, 95% CI 1.06-3.84). Conclusions Together with male gender, advanced age, hypertension, BMI over 25 kg/m² and history of kidney disease, the risk of RCC was significantly increased in painters, aircraft mechanics and shipbuilders, suggesting a link to occupational exposure.

Trends in initial management of prostate cancer in New Hampshire.

PURPOSE: Prostate cancer management strategies are evolving with increased understanding of the disease. Specifically, there is emerging evidence that "low-risk" cancer is best treated with observation, while localized "high-risk" cancer requires aggressive curative therapy. In this study, we evaluated trends in management of prostate cancer in New Hampshire to determine adherence to evidence-based practice. METHODS: From the New Hampshire State Cancer Registry, cases of clinically localized prostate cancer diagnosed in 2004-2011 were identified and classified according to D'Amico criteria. Initial treatment modality was recorded as surgery, radiation therapy, expectant management, or hormone therapy. Temporal trends were assessed by Chi-square for trend. RESULTS: Of 6,203 clinically localized prostate cancers meeting inclusion criteria, 34, 30, and 28% were low-, intermediate-, and high-risk disease, respectively. For low-risk disease, use of expectant management (17-42%, p < 0.001) and surgery (29-39%, p < 0.001) increased, while use of radiation therapy decreased (49-19 %, p < 0.001). For intermediate-risk disease, use of surgery increased (24-50%, p < 0.001), while radiation decreased (58-34%, p < 0.001). Hormonal therapy alone was rarely used for low- and intermediate-risk disease. For high-risk patients, surgery increased (38-47%, p = 0.003) and radiation decreased (41-38%, p = 0.026), while hormonal therapy and expectant management remained stable. DISCUSSION: There are encouraging trends in the management of clinically localized prostate cancer in New Hampshire, including less aggressive treatment of low-risk cancer and increasing surgical treatment of high-risk disease.