Wisely Choosing a Fast-Food Burger Meal Results in Meaningful Reduction in Sodium: Implications for Kidney Stone Patients.

OBJECTIVE: Stone formers trying to limit dietary sodium may be unable to give up fast food. For the classic American hamburger, it is unclear if lower sodium preparations of this item are available and how this could affect sodium intake. We determined the impact of careful selection at national chains. METHODS: Nutritional guides for 14 national chains were analyzed for all beef-based burgers and french fries. A meal was defined as 1 burger and an order of fries. The daily sodium limit (recommended daily sodium allowance [RDA]) was considered to be 2,300 mg. The maximal sodium reduction was defined as the difference between the highest and lowest sodium-containing meals. The Kruskal-Wallis test with Dunn's method was used to compare food items among the chains. RESULTS: Of the total 263 different burgers and 74 different fries, median sodium was 1130 mg (range 180-3520) and 565 mg (range 30-1480), respectively. Mean sodium for burgers at individual chains ranged from a low of 590 mg to a high of 1721 mg (P < .001). The mean sodium for fries at individual chains ranged from a low of 245 mg to a high of 947 mg (P < .001). Post-hoc testing revealed 26 significant differences between pairs of restaurants for sodium content of burgers with P < .05 for each. The median maximal sodium reduction among the different chains was 1925 mg. Depending on the chain, sodium content of 1 meal could be reduced by as little as 830 mg (36% RDA) or as much as 3360 mg (146% RDA) by careful selection. CONCLUSION: Stone formers should be aware of significant variation in sodium content of burgers and fries among chains and within a chain. Wisely selecting just 1 fast-food burger meal can significantly reduce sodium intake.

Trends in United States Prostate Cancer Incidence Rates by Age and Stage, 1995-2012.

BACKGROUND: The advent of PSA testing in the late 1980s substantially increased prostate cancer incidence rates. Concerns about overscreening and overdiagnosis subsequently led professional guidelines (circa 2000 and later) to recommend against routine PSA testing. We evaluated trends in prostate cancer incidence, including late-stage diagnoses, from 1995 through 2012. METHODS: We used joinpoint regression analyses to evaluate all-, localized/regional-, and distant-stage prostate cancer incidence trends based on Surveillance, Epidemiology, and End Results (SEER) data. We stratified analyses by age (50-69, 70+). We reported incidence trends as annual percent change (APC). RESULTS: Overall age-adjusted incidence rates for localized/regional stage prostate cancer have been declining since 2001, sharply from 2010 to 2012 [APC, -13.1; 95% confidence intervals (CI), -23.5 to -1.3]. Distant-stage incidence rates have declined since 1995, with greater declines from 1995 to 1997 (APC, -8.4; 95% CI, -2.3 to -14.1) than from 2003 to 2012 (APC, -1.0; 95% CI, -1.7 to -0.4). Distant-stage incidence rates declined for men ages 70+ from 1995 to 2012, but increased in men ages 50 to 69 years from 2004 to 2012 (APC, 1.7; 95% CI, 0.2 to 3.2). CONCLUSIONS: Guidelines discouraging routine prostate cancer screening were temporally associated with declining localized/regional prostate cancer incidence rates; however, incidence rates of distant-stage disease are now increasing in younger men. IMPACT: This trend may adversely affect prostate cancer mortality rates.

Urinary symptoms after robotic prostatectomy in men with median lobes.

BACKGROUND: We report on the natural history of lower urinary tract symptoms (LUTS) and urinary continence in patients with median lobe enlargement (MLE) after robotic radical prostatectomy (RP). METHODS: Patients treated with RP from October 2008 to March 2012 completed American Urological Association symptom index (AUAI) and continence assessments at the preoperative visit and each postoperative visit. Two cohorts were established based on the presence or absence of a median lobe intraoperatively. RESULTS: A total of 698 validated questionnaires were completed by 175 patients with a median of 4 AUAI scores per patient. The 36 patients (21%) with MLE required a longer time to achieve urinary continence (P = .05, log-rank test), although ultimately, no difference was seen in long-term continence probability between the two cohorts (P = .63). On multivariate analysis, the presence of a median lobe reduced the odds of early continence recovery (P = .02). By use of a generalized estimating equation, the cohort-average AUAI scores after RP are presented. Patients with MLE had faster improvement in LUTS after surgery, whereas those without MLE had temporary worsening in LUTS before improvement. CONCLUSION: Patients with MLE have a different natural history of LUTS and continence after RP as compared with patients without this finding. Therefore, radiographic or cystoscopic evaluation for the presence of a median lobe before RP may improve patient counseling about urinary outcomes.

Randomized evaluation of a web based interview process for urology resident selection.

PURPOSE: We determined whether a web based interview process for resident selection could effectively replace the traditional on-site interview. MATERIALS AND METHODS: For the 2010 to 2011 match cycle, applicants to the University of New Mexico urology residency program were randomized to participate in a web based interview process via Skype or a traditional on-site interview process. Both methods included interviews with the faculty, a tour of facilities and the opportunity to ask current residents any questions. To maintain fairness the applicants were then reinterviewed via the opposite process several weeks later. We assessed comparative effectiveness, cost, convenience and satisfaction using anonymous surveys largely scored on a 5-point Likert scale. RESULTS: Of 39 total participants (33 applicants and 6 faculty) 95% completed the surveys. The web based interview was less costly to applicants (mean $171 vs $364, p=0.05) and required less time away from school (10% missing 1 or more days vs 30%, p=0.04) compared to traditional on-site interview. However, applicants perceived the web based interview process as less effective than traditional on-site interview, with a mean 6-item summative effectiveness score of 21.3 vs 25.6 (p=0.003). Applicants and faculty favored continuing the web based interview process in the future as an adjunct to on-site interviews. CONCLUSIONS: Residency interviews can be successfully conducted via the Internet. The web based interview process reduced costs and improved convenience. The findings of this study support the use of videoconferencing as an adjunct to traditional interview methods rather than as a replacement.

Early growth response 1 and fatty acid synthase expression is altered in tumor adjacent prostate tissue and indicates field cancerization.

BACKGROUND: Field cancerization denotes the occurrence of molecular alterations in histologically normal tissues adjacent to tumors. In prostate cancer, identification of field cancerization has several potential clinical applications. However, prostate field cancerization remains ill defined. Our previous work has shown up-regulated mRNA of the transcription factor early growth response 1 (EGR-1) and the lipogenic enzyme fatty acid synthase (FAS) in tissues adjacent to prostate cancer. METHODS: Immunofluorescence data were analyzed quantitatively by spectral imaging and linear unmixing to determine the protein expression levels of EGR-1 and FAS in human cancerous, histologically normal adjacent, and disease-free prostate tissues. RESULTS: EGR-1 expression was elevated in both structurally intact tumor adjacent (1.6× on average) and in tumor (3.0× on average) tissues compared to disease-free tissues. In addition, the ratio of cytoplasmic versus nuclear EGR-1 expression was elevated in both tumor adjacent and tumor tissues. Similarly, FAS expression was elevated in both tumor adjacent (2.7× on average) and in tumor (2.5× on average) compared to disease-free tissues. CONCLUSIONS: EGR-1 and FAS expression is similarly deregulated in tumor and structurally intact adjacent prostate tissues and defines field cancerization. In cases with high suspicion of prostate cancer but negative biopsy, identification of field cancerization could help clinicians target areas for repeat biopsy. Field cancerization at surgical margins on prostatectomy specimen should also be looked at as a predictor of cancer recurrence. EGR-1 and FAS could also serve as molecular targets for chemoprevention.

SEER coding standards result in underestimation of positive surgical margin incidence at radical prostatectomy: results of a systematic audit.

PURPOSE: SEER (Surveillance, Epidemiology and End Results) is the leading source of population level data on prostate cancer, including the positive surgical margin incidence at radical prostatectomy. Recently studies showed wide ranges in positive surgical margin rates among individual registries, which we hypothesized was the result of coding inaccuracies. Thus, we systematically audited SEER prostate cancer data. MATERIALS AND METHODS: The New Mexico Tumor Registry, a SEER core registry, was queried for incident prostate cancer cases in 2007 that met certain criteria, including 1) adenocarcinoma histology, 2) malignant behavior and 3) radical prostatectomy as the first course of therapy. Pathological stage codes were audited by examining original radical prostatectomy pathology reports in accordance with SEER coding guidelines. The incidence and sites of positive surgical margins were critically analyzed. RESULTS: Of the 305 cases that met all study inclusion criteria with complete source documents available 92 (30%) were coded incorrectly. The most common error was failure to properly account for surgical margin status (46 of 92 cases or 50%). The incidence of positive surgical margins in organ confined disease cases was 13% by SEER coding rules but 28% by a more clinical definition of positive surgical margins (p<0.001). In organ confined cases positive surgical margins occurred principally at the apex but in nonorgan confined cases most were multifocal. CONCLUSIONS: In this SEER registry 30% of radical prostatectomy cases in 2007 were coded inaccurately. SEER coding guidelines result in underestimating the positive surgical margin incidence. Clinicians and investigators should recognize the limitations of tumor registry data on positive surgical margins.

Percutaneous ureteral elevation in laparoendoscopic single-site radical nephrectomy.

BACKGROUND AND OBJECTIVES: To describe our technique of suture-assisted ureteral retraction during Laparoendoscopic Single-Site (LESS) radical nephrectomy. MATERIALS AND METHODS: A healthy, 39-year-old woman with an incidental 5-cm enhancing left renal mass elected to undergo radical nephrectomy. A 2-cm skin incision was made in the left upper quadrant of the abdomen, and a Covidien SILS port was introduced using standard Hasson techniques. Straight and angled laparoscopic instruments were used to mobilize the kidney outside of Gerota's fascia. To place the renal vessels on stretch and facilitate hilar dissection, the ureter and lower pole attachments were encircled with a 0-Vicryl suture inserted percutaneously via a disposable fascial closure device. The kidney was bagged and removed intact. RESULTS: The procedure was performed without complication with a total operative time of 265 minutes. EBL was minimal at 25 mL. The patient was discharged home on postoperative day 1, and final pathology revealed stage pT1b chromophobe renal cell carcinoma with negative surgical margins. CONCLUSION: LESS radical nephrectomy is feasible in select patients. Suture-assisted retraction of the ureter and lower pole attachments using a fascial closure device facilitates safe dissection and control of the renal hilum.

Outcomes of laparoscopic partial nephrectomy after fellowship training.

BACKGROUND AND OBJECTIVES: Experienced surgeons at select high-volume centers have reported favorable outcomes of laparoscopic partial nephrectomy (LPN) in their contemporary experience. However, it is unclear whether recently fellowship-trained surgeons can replicate such outcomes. We evaluated LPNs performed by 3 surgeons in their initial years of independent practice following laparoscopic fellowship training. METHODS: Prospectively maintained databases were queried for LPNs performed during the first 3.5 years of practice. Intraoperative parameters, oncological efficacy, and postoperative complications were analyzed. RESULTS: Of 138 total LPNs (76 left, 62 right), the mean patient age was 57 years, mean tumor size was 2.52cm, and mean depth of invasion was 1.68cm. Mean OR time was 252 minutes, mean warm ischemia time (WIT) was 26 minutes, and mean estimated blood loss (EBL) was 202 mL. Complications occurred in 7 patients (5%), and conversions occurred in 9 patients (7%). Comparison of the first 15 vs. the last 15 cases demonstrated a significant reduction in mean OR time (204 min vs. 253 min, P=0.007), and mean WIT (24 min vs. 32 min, P<0.001). No significant change was demonstrated for tumor size (2.6 cm vs. 2.4 cm, P=0.390) or EBL (226 mL vs. 220 mL, P=0.922). CONCLUSION: Newly fellowship-trained surgeons performing LPN achieve initial outcomes comparable to those reported by highly experienced surgeons. Further experience reduced total operative and warm ischemia times.

Estimation and prediction of renal function in patients with renal tumor.

PURPOSE: The goals of surgery for renal tumors include the preservation of renal function. When considering surgical options, it is important to accurately assess renal function and the risk of postoperative chronic kidney disease. MATERIALS AND METHODS: An institutional database was used to identify 359 patients who underwent nephrectomy or partial nephrectomy. Creatinine clearance was estimated using 14 previously published models and compared with creatinine clearance measured using a 24-hour urine collection. Models were generated for predicting renal function following nephrectomy or partial nephrectomy. All models were validated with an external data set of 245 patients. RESULTS: Models that accurately estimated creatinine clearance preoperatively and postoperatively were the Cockcroft-Gault model based on actual weight, and the Mawer, Björnsson, Hull and Martin models. In patients with an estimated creatinine clearance between 60 and 89 ml per minute preoperatively the risk of chronic kidney disease (creatinine clearance less than 60 ml per minute) after nephrectomy and partial nephrectomy was 58% and 15%, respectively (p <0.001). In patients undergoing nephrectomy age and weight were independent predictors of decreased creatinine clearance. A predictive model based on age and weight was highly accurate when applied to an external population (R = 0.757). A model for predicting renal function after partial nephrectomy based on age and tumor size was highly accurate in the external population (R = 0.848). A Web based tool was developed to estimate current and predict postoperative creatinine clearance (http://www.roswellpark.org/Patient_Care/Specialized_Services/Renal_Function_Estimator). CONCLUSIONS: The Cockcroft-Gault model based on actual weight is 1 of 5 models that accurately estimates renal function in patients with a kidney tumor. Models were developed and externally validated to predict renal function following nephrectomy.

Phase II study of Dutasteride for recurrent prostate cancer during androgen deprivation therapy.

PURPOSE: We determined the response rate to and safety of a dual 5alpha-reductase inhibitor, dutasteride, in men with castration recurrent prostate cancer. MATERIALS AND METHODS: A total of 28 men with asymptomatic castration recurrent prostate cancer were treated with 3.5 mg dutasteride daily (luteinizing hormone-releasing hormone treatment continued), and evaluated monthly for response and toxicity. Eligibility included appropriate duration antiandrogen withdrawal, baseline prostate specific antigen 2.0 ng/ml or greater and a new lesion on bone scan, increase in measurable disease using Response Evaluation Criteria in Solid Tumors criteria, or 2 or more consecutive prostate specific antigen measurements increased over baseline. Outcomes were progression, stable disease, partial response (prostate specific antigen less than 50% of enrollment for 4 or more weeks) or complete response. RESULTS: There were 25 evaluable men with a mean age of 70 years (range 57 to 88), a mean prostate specific antigen of 61.9 ng/ml (range 5.0 to 488.9) and mean Gleason score 8 (range 6 to 10), 15 of whom had bone metastases. Eight men had 10 grade 3 or higher adverse events using National Cancer Institute Common Terminology Criteria, all of which were judged to be unrelated to treatment. Of the 25 men 14 had disease progression by 2 months, 9 had stable (2.5, 3, 3, 4, 4, 5, 5, 8.5, 9 months) disease, 2 had a partial response and none had a complete response. Overall median time to progression was 1.87 months (range 1 to 10, 95% CI 1.15-3.91). CONCLUSIONS: Dutasteride rarely produces biochemical responses in men with castration recurrent prostate cancer. However, further study is warranted given its favorable safety profile.

Vessel length following laparoscopic donor nephrectomy: impact of vascular ligation technique on allograft vessel length.

PURPOSE: A variety of techniques have been used to secure the renal artery and vein during laparoscopic donor nephrectomy. The purpose of this study is to compare the amount of vessel length lost when the artery and vein are secured with four different techniques. METHODS: A model was constructed to simulate a left laparoscopic donor nephrectomy. In this model vessel length lost was determined when veins were secured using polymer locking (PL) clips, the endo-GIA stapling device, and the endo-TA stapling device. Arterial length lost was determined for the same three techniques, as well as securing the artery with titanium (Ti) clips. RESULTS: The mean arterial length lost for the PL clips, Ti clips, endo-TA, and endo-GIA stapling devices was 6.2, 6.3, 9.8, and 10.0 mm, respectively. Both clip types produced less loss of arterial length than both types of stapling devices (P<0.001), and there was no difference between the two types of stapling devices (P=0.73) or clips (P=0.85). The mean venous length lost for the PL clip, endo-GIA, and endo-TA stapling devices was 5.7, 10.1, and 9.4 mm, respectively. The PL clips resulted in significantly less vessel loss compared to both stapling devices (P<0.001), and there was no difference between the two stapling devices (P=0.40). CONCLUSIONS: Both types of clips resulted in longer graft arterial lengths compared to both stapling devices. PL clips resulted in longer graft vein length compared to the two stapling devices. The endo-TA stapling device was limited in this model by its inability to articulate.

Open prostatolithotomy for the management of giant prostatic calculi.

Giant prostatic calculi are very rare. We present the case of a 45-year-old man with multiple prostatic urethral calculi that replaced the entire gland. He underwent an open "prostatolithotomy," a novel method of stone removal akin to a simple retropubic prostatectomy. Eight stones weighing a total of 59 g were removed from the prostate. For certain patients, adjunctive vesical neck revision and deliberate drainage of the prostatic fossa may be beneficial in addition to stone extraction.

Laparoscopic nephrectomy for pediatric giant hydronephrosis.

OBJECTIVES: To describe our experience with pediatric laparoscopic nephrectomy (LN) and laparoscopic nephroureterectomy (LNU) for giant hydronephrosis. METHODS: A retrospective review was conducted of all pediatric patients undergoing a transperitoneal LN or LNU. Five of these patients had giant hydronephrosis in a nonfunctioning kidney. Because of chronic infection and the massive nature of hydronephrosis, the system was internally decompressed with an end-hole stent. Partial decompression provided space in the abdomen for adequate visualization while maintaining enough turgidity to facilitate dissection. RESULTS: Three LNs and two LNUs were performed in children with giant hydronephrosis. All cases were completed laparoscopically. Vascular anatomy and/or orientation were anomalous in all cases because of mass effect. Mean patient age was 9 years (range, 3 to 17 years). Average surgery time was 281 minutes (range, 225 to 410 minutes), and mean estimated blood loss was 27 mL (range, 5 to 50 mL). Mean time to oral intake was 6.5 hours (range, 4 to 11 hours). All patients were discharged on postoperative day 3, and there were no major or minor complications. CONCLUSIONS: Although pediatric LN and LNU for giant hydronephrosis present unique challenges owing to the large renal volume in a small abdominal cavity, these procedures can be safely performed with careful attention to the altered anatomic relationships.

Urothelial carcinoma after external beam radiation therapy for prostate cancer.

PURPOSE: We reviewed the clinical course of patients in whom urothelial carcinoma developed following radiation therapy for prostate cancer. MATERIALS AND METHODS: A retrospective review of all patients between 1990 and 2005 with the diagnosis of bladder and prostate cancer was performed. Of 125 total patients new onset urothelial carcinoma developed in 11 after undergoing external beam radiation therapy for prostate cancer. RESULTS: Whole pelvis external beam radiation therapy with a proton boost to the prostate was the radiation modality in 7 of the 11 patients (64%), while the remaining 4 patients received standard external beam radiation only. Urothelial carcinoma was detected a mean of 3.07 years after completion of radiation therapy in the proton group, compared to a mean latency period of 5.75 years in the standard radiation group (p = 0.09). Average patient age at diagnosis was 72 years (range 64 to 84). All patients presented with gross hematuria and had cystoscopic findings of coexisting radiation cystitis. Of the 11 patients 5 (45%) presented with grade 3 carcinoma and eventually 7 (64%) required radical cystectomy. Urothelial tumors with sarcomatoid features (carcinosarcoma and spindle cell sarcomatoid) developed in 2 patients (18%). Of the 11 patients 10 (91%) were nonsmokers at the time of urothelial carcinoma diagnosis. CONCLUSIONS: Urothelial carcinoma in patients with previous radiation therapy for prostate cancer is often high grade, and the majority of patients have cancer progression requiring cystectomy. A high incidence of urothelial carcinoma with sarcomatoid features was seen in these patients.