Propensity-score matched oncological outcomes and patterns of recurrence following open and minimally-invasive partial nephrectomy for renal cell carcinoma.

BACKGROUND: Oncological equivalency of minimally-invasive partial nephrectomy compared to open partial nephrectomy (OPN) continues to be challenged by proponents of open urologic oncology surgery. OBJECTIVE: To compare patterns of recurrence, recurrence-free survival, cancer-specific survival, and overall survival between patients who underwent open or minimally-invasive partial nephrectomy. MATERIALS AND METHODS: Data from prospectively maintained databases from 2 urban quaternary referral centers was retrospectively collected from 2003 to 2018. Patients who underwent either open or minimally-invasive (laparoscopic or robotic-assisted) partial nephrectomy and found to have malignant pathology were included. The groups subsequently underwent propensity-score matching to ensure homogeneity prior to analysis. The primary outcomes were incidence of recurrence, time to recurrence, time from recurrence to death, location of recurrence, and recurrence-free survival. Secondary outcomes included overall survival and cancer-specific survival. RESULTS: A total of 190 patients underwent OPN and 190 underwent minimally-invasive partial nephrectomy. Recurrence was more common in patients undergoing OPN (10% vs. 3.2%, P = 0.01), but surgical approach was not predictive of location of recurrence (P = 1) or time to recurrence (23.8 vs. 26.3 months, P = 0.73). All-cause mortality was more common in the OPN group (10.5% vs. 2.6%, P = 0.003). On multivariable analysis, only surgical approach was associated with increased risk for recurrence (OR 3.88, P = 0.009). CONCLUSION: This propensity-score matched analysis of patients undergoing partial nephrectomy suggests that minimally invasive surgical approach is resulted in decreased risk of recurrence and overall survival, and does not increase the risk for atypical sites of recurrence.

Novel treatment of upper tract urothelial carcinoma in situ with docetaxel in BCG refractory patients.

INTRODUCTION: Patients with upper-tract carcinoma in situ (UT-CIS) that have failed treatment with BCG are recommended for radical nephroureterectomy (RNU). We describe a cohort of patients with BCG-refractory UT-CIS that were treated with docetaxel, a novel agent in the approach to topical therapy. METHODS: Patients with pathologically proven UT-CIS from 2012 to 2020 with an imperative indication for organ preservation and history of BCG-refractory disease were included. Each patient underwent ureteroscopy with biopsy and selective cytology pre- and postinduction, and after each maintenance course. Complete response (CR) was defined as the absence of visualized lesions on ureteroscopy, negative selective cytology, and absence of clinical progression. No response (NR) was defined as persistence of lesions after induction or absence of visualized lesions with persistently positive cytology. RESULTS: Seven patients and 10 renal units were treated. Six of the 10 renal units had initial CR (60%). Three patients with NR went on to have RNU, one of which subsequently died due to cancer-specific mortality. One patient with bilateral disease had NR in 10 renal unit and cure in the other. This patient subsequently developed recurrence in his remaining renal unit. A second patient had CR in both kidneys for 6 years, but 1 year after finishing maintenance regimen developed HG disease in 1 ureter. Average follow-up was 33 months. CONCLUSION: This study demonstrates efficacy of docetaxel as a treatment option for patients with UT-CIS with a contraindication to RNU after failing BCG. Response rates of 60% appear to be similar to those of BCG-refractory bladder CIS.

Long-Term Outcomes of Laser Incision and Triamcinolone Injection for the Management of Ureteroenteric Anastomotic Strictures.

Purpose: Benign ureteroenteric anastomotic stricture (UEAS) is a common postoperative complication after urinary diversion with an incidence of 3%-10%. Our objective is to report long-term follow-up of our technique for endoscopically managing UEAS after cystectomy. Materials and Methods: Patients with endoscopically managed benign UEAS after cystectomy were included. Intervention entailed anetegrade flexible ureteroscopy with biopsy followed by laser incision of the stricture and of periureteral and peri-ileal tissues 1 cm below and 1 cm above the stricture into fat. Triamcinolone injection was then performed, followed by balloon dilation of the incised area to 24F. Parallel Double-J ureteral stents or upside down nephrostomy tubes were placed for 6 weeks. CT scans were obtained at 3 months and 1 year after surgery, and renal ultrasound at 6 and 9 months, and then annually. Results: Twenty-one patients, and a total of 24 UEAS were treated. Urinary diversion included ileal conduit (n = 12), neobladder (n = 7), and Indiana pouch (n = 2). Twenty out of 24 strictures had no recurrence, including three patients who had bilateral disease, yielding an overall success rate of 83.3%. The remaining three patients with recurrence had evidence of stricture within 3 months. Follow-up ranged from 8 to 102 months, with a median of 30 months. Conclusions: Patients treated endoscopically for UEAS have been shown to have acceptable immediate success with less morbidity when compared with ureteral reimplantation. Our technique of laser incision, triamcinolone injection, balloon dilation, and temporary stent placement has a success rate of over 80% and is unique in that long-term data confirms the durability of this endoscopic procedure.

The effect of tumor location on overall survival for pT2-4 bladder and upper tract urothelial carcinoma following radical surgery.

INTRODUCTION: Historically, staging and treatment for upper tract urothelial carcinoma were extrapolated from bladder urothelial carcinoma literature. However, embryological, genetic, and anatomical differences exist between them. We sought to explore the relationship between location of urothelial cancer and overall survival (OS). METHODS: Data was culled from the National Cancer Database from 2004-2015. Patients with pT2-pT4 treated with definitive surgery were included; those with metastatic disease or who received neoadjuvant or adjuvant treatment were excluded. Patients were stratified by tumor location and pathological stage. The primary outcome was OS. Secondary outcomes were predictors of mortality in each pT stage stratum. RESULTS: A total of 11 330 patients with bladder, 954 patients with ureteral, and 1943 patients with renal pelvis urothelial carcinoma were analyzed. Mean followup was 43.3, 39.4, and 41.4 months for bladder, ureteral, and renal pelvis, respectively. On univariable analysis, ureteral pT2 was associated with worse OS compared to both bladder (61.3 vs. 80.4 months, p=0.007) and renal pelvis (61.3 vs. 80.5 months, p=0.014). Renal pelvis pT3 was associated with improved OS compared to both bladder (42.5 vs. 28.6 months, p=0.003) and ureteral (42.5 vs. 25.7 months, p<0.001). Renal pelvis pT4 had decreased survival compared to bladder (11.4 vs. 17.7 months, p<0.001). On multivariable Cox regression, only renal pelvis pT3 was associated with a 20% decreased risk of mortality compared to bladder pT3 (hazard ratio 0.80, 95% confidence interval 0.72-0.88, p<0.001). CONCLUSIONS: Renal pelvis pT3 is associated with lower mortality. Mutational and embryological differences may play a role in this disparity.

Changes observed in prostate biopsy practices in an inner city hospital with a high risk patient population following the 2012 USPSTF PSA screening recommendations

ABSTRACT Introduction: We compared characteristics of patients undergoing prostate biopsy in a high-risk inner city population before and after the 2012 USPSTF recommendation against PSA based prostate cancer screening to determine its effect on prostate biopsy practices. Materials and Methods: This was a retrospective study including patients who received biopsies after an abnormal PSA measurement from October 2008-December 2015. Patients with previously diagnosed prostate cancer were excluded. Chi-square tests of independence, two sample t-tests, Mann-Whitney U tests, and Fisher's exact tests were performed. Results: There were 202 and 208 patients in the pre-USPSTF and post-USPSTF recommendation cohorts, respectively. The post-USPSTF cohort had higher median PSA (7.8 versus 7.1ng/mL, p=0.05), greater proportion of patients who were black (96.6% versus 90.5%, p=0.01), and greater percentage of biopsy cores positive for disease (58% versus 29.5%, p<0.001). Multivariable analysis supported that the increase in PSA was independent of the increase in the proportion of patients who were black. The proportion of patients who were classified as D'Amico intermediate and high-risk disease increased in the post-USPSTF cohort and approached statistical significance (70.1% versus 58.8%, p=0.12). Conclusions: Our study suggests that the USPSTF recommendations may have led to an increase in pre-biopsy PSA as well as greater volume of disease. Also, a greater proportion of patients were being classified with intermediate or high risk disease. While the clinical significance of these findings is unknown, what the data suggests is somewhat troubling. Future research should further examine these changes in a larger cohort as well as resultant long-term outcomes.

Changes observed in prostate biopsy practices in an inner city hospital with a high risk patient population following the 2012 uspstf psa screening recommendations.

INTRODUCTION: We compared characteristics of patients undergoing prostate biopsy in a high-risk inner city population before and after the 2012 USPSTF recommendation against PSA based prostate cancer screening to determine its effect on prostate biopsy practices. MATERIALS AND METHODS: This was a retrospective study including patients who received biopsies after an abnormal PSA measurement from October 2008-December 2015. Patients with previously diagnosed prostate cancer were excluded. Chi-square tests of independence, two sample t-tests, Mann-Whitney U tests, and Fisher's exact tests were performed. RESULTS: There were 202 and 208 patients in the pre-USPSTF and post-USPSTF recommendation cohorts, respectively. The post-USPSTF cohort had higher median PSA (7.8 versus 7.1ng/mL, p=0.05), greater proportion of patients who were black (96.6% versus 90.5%, p=0.01), and greater percentage of biopsy cores positive for disease (58% versus 29.5%, p<0.001). Multivariable analysis supported that the increase in PSA was independent of the increase in the proportion of patients who were black. The proportion of patients who were classified as D'Amico intermediate and high-risk disease increased in the post-USPSTF cohort and approached statistical significance (70.1% versus 58.8%, p=0.12). CONCLUSIONS: Our study suggests that the USPSTF recommendations may have led to na increase in pre-biopsy PSA as well as greater volume of disease. Also, a greater proportion of patients were being classified with intermediate or high risk disease. While the clinical significance of these findings is unknown, what the data suggests is somewhat troubling. Future research should further examine these changes in a larger cohort as well as resultant long-term outcomes.

Safety and Efficacy of GreenLight XPS Laser Vapoenucleation in Prostates Measuring Over 150 mL.

INTRODUCTION: The GreenLight™ XPS Laser System (GL-XPS) is a safe and efficacious treatment for lower urinary tract symptoms due to benign prostatic hyperplasia (BPH), but there is limited evidence on its use in prostates over 150 mL. We demonstrate the safety and efficacy of the GL-XPS system using a vapoenucleation technique in prostate glands measuring over 150 mL. METHODS: We prospectively collected data on all consecutive patients with prostates measuring over 150 mL on transrectal ultrasound treated with the GL-XPS (AMS, Inc., Minnetonka, MN) at a tertiary referral center from September 2011 to October 2015. Data collected include prostate volume, International Prostate Symptom Score (IPSS) and quality of life (QoL) scores, maximum urinary flow rate (Qmax), postvoid residual (PVR), prostate-specific antigen, complications, and reintervention rates. RESULTS: Seventy male patients with a median prostate size of 202 mL (range 152-376 mL) were included. There were 41 patients (59%) in preoperative urinary retention with an indwelling catheter preoperatively. Thirty-seven (53%) patients were American Society of Anesthesiologists (ASA) class 2 and 33 (47%) were class 3. Median operative time was 180 minutes, laser time 97 minutes, energy utilization 674 kJ, and energy density 3.3 kJ/mL, with median 3 fibers used per case. Median length of stay and length of catheterization were 1 day. IPSS and QoL scores demonstrated significant improvements from baseline at all endpoints, improving from 16 to 3.5 and from 4 to 1 at 24 months, respectively (p = 0.001). At 12 months, Qmax and PVR improved from 10.1 to 22.4 mL/s (p = 0.043) and from 84 to 31.4 mL (p = 0.015), respectively. Retreatment was required in two patients (2.9%). CONCLUSION: GL-XPS vapoenucleation provided durable subjective and objective improvements in symptoms and voiding parameters, with no serious adverse events in men with prostates >150 mL.