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INTRODUCTION AND OBJECTIVE:Next Generation Sequencing (NGS) of non-muscle invasive bladder cancer (NMIBC) specimens have shown that mutations in ARID1A, a chromatin remodeling gene, are associated ...

Detection of methylated DNA has been shown to be a good biomarker for bladder cancer. Bladder cancer has the highest recurrence rate of any cancer and, as such, patients are regularly monitored using invasive diagnostic techniques. As urine is easily attainable, bladder cancer is an optimal cancer to detect using DNA methylation. DNA methylation is highly specific in cancer detection. However, it is difficult to detect because of the limited amount of DNA present in the urine of patients with bladder cancer. Therefore, an improved, sensitive and noninvasive diagnostic test is needed.We developed a highly specific and sensitive nested methylation specific polymerase chain reaction assay to detect the presence of bladder cancer in small volumes of patient urine. The genes assayed for DNA methylation are BCL2, CDKN2A and NID2. The regions surrounding the DNA methylation sites were amplified in a methylation independent first round polymerase chain reaction and the amplification product from the first polymerase chain reaction was used in a real-time methylation specific polymerase chain reaction. Urine samples were collected from patients receiving treatment at Wolfson Medical Center in Holon, Israel.In a pilot clinical study using patient urine samples we were able to differentiate bladder cancer from other urogenital malignancies and nonmalignant conditions with a sensitivity of 80.9% and a specificity of 86.4%.We developed a novel methylation specific polymerase chain reaction assay for the detection and monitoring of bladder cancer using DNA extracted from patient urine. The assay may also be combined with other diagnostic tests to improve accuracy.

INTRODUCTION AND OBJECTIVES: In addition to promoting quality, new payment models are emerging with a mandate to control healthcare costs. On a national level, there is significant variation in the cost of major index cancer operations. Accurate cost accounting, clinician-defined metrics, risk-adjustment, and feedback of data are essential steps in using cost data for quality improvement. We sought to account for institutional direct costs incurred during radical cystectomy, identify the main cost drivers in the index hospitalization, and examine surgeon variability in the main cost drivers within the context of patient characteristics. METHODS: Direct itemized institutional cost data for 321 consecutive radical cystectomies performed by 5 de-identified surgeons was obtained. Costs were adjusted using a multiplier equal to the ratio of normalized Medicare reimbursement over institutional reported cost. Interactive web-based dashboards were created to feedback patient characteristics, outcomes, cost components, and anonymized surgeon cost comparisons. Analysis of variance was used to compare patient characteristics and cost components across surgeons. Multivariable logistic regression was used to model above average costs on surgeon and patient specific factors. RESULTS: The median adjusted total cost per case was $13009.57 (interquartile range $11254.82, $15730.53). Inpatient, anesthesia, disposable device, operating room, and physician costs accounted for the majority of the total costs incurred. Inpatient costs were not significantly different across surgeons, however maximum differences between cost means for anesthesia ($93.62, p1⁄40.0039), disposable device (energy devices, $279.48, p

Laparoscopic surgery is rapidly gaining widespread acceptance among urologists, including extensive application in malignant conditions. However, untoward occurrences of port site metastases have not eluded to urological applications. This up-to-date review on port site metastases in urology delineates possible contributing factors and describes techniques to prevent it.We comprehensively reviewed published experimental and clinical studies with special emphasis on the incidence, pathophysiology and prevention of port site metastases.Nine cases of port site metastases after urological laparoscopy have been described in clinical and experimental studies. Etiological factors include natural malignant disease behavior, host immune status, local wound factors, laparoscopy related factors such as aerosolization of tumor cells (the use of gas, type of gas, insufflation and desufflation, and pneumoperitoneum) and sufficient technical experience of the surgeons and operating team (adequate laparoscopic equipment, skill, minimal handling of the tumor, surgical manipulation and wound contamination during instruments change, organ morcellation and specimen removal).Port site metastases is a multifactorial phenomenon with an as yet undetermined incidence. The problem is influenced to some extent by surgeon and operating team experience and, therefore, it could be partially prevented. The suggested preventive steps are avoiding laparoscopic surgery when there are ascites, trocar fixation to prevent dislodgment, avoiding gas leakage along and around the trocar, sufficient technical readiness of the operating team (adequate laparoscopic equipment and technique, minimal handling and avoiding tumor boundary violation of the tumor), using a bag for specimen removal, placing drainage when needed before desufflation, povidone-iodine irrigation of instruments, trocars and port site wounds, and suturing 10 mm. and larger trocar wounds.

The tension-free vaginal tape (TVT) procedure is a recent modality for managing female stress urinary incontinence. While this procedure is rapidly gaining popularity worldwide, little has been written about its complications. We describe our experience with diagnosing and treating tape related complications following the TVT procedure.During the last 4 years 12 patients underwent and 1 is scheduled for additional surgery for complications resulting from the TVT. Another patient is only being observed. Their records were reviewed to retrieve data on presenting symptoms and signs, diagnostic tests, surgical procedures and outcomes.One patient had tape erosion into the bladder, 5 had vaginal tape erosion (concomitant urethral obstruction in 1) and another 8 had an obstructed urethra. The more common presenting symptoms were persistent urethral pain, recurrent urinary tract infection, urgency, urge incontinence and vaginal discharge. A total of 12 patients required partial tape removal or tape incision, which was done transvaginally in 11. The remaining patient underwent cystotomy and excision of the intravesical part of an eroded tape. One patient is awaiting corrective surgery and 1 with asymptomatic vaginal erosion is only being observed. No formal urethrolysis was performed in any case. Mean followup after corrective surgery in 12 patients was 4.8 months (range 1 to 30), during which 10 remained continent and all 12 were symptom-free.Urologists should be aware of the nature and symptoms of tape related complications associated with a TVT procedure for prompt diagnosis and appropriate postoperative management.

We evaluated the effect of simultaneous transurethral resection of bladder tumor (TURBT) and benign prostatic hyperplasia (TURP) on recurrences at the bladder neck and prostatic urethra.During the 10-year study period 51 patients fulfilled the entry criteria of past simultaneous TURBT and TURP, histologically confirmed transitional cell carcinoma of the bladder and benign prostatic hyperplasia, a preserved bladder and a minimal followup of 12 months. Their records were analyzed retrospectively. Patients were divided into 28 with single (group 1) and 23 with multiple (group 2) bladder tumors.During the 12 to 120 months of followup (mean 37.3) the average tumor recurrence rate was 68.6%, that is 53.6% in group 1 and 86.9% in group 2. Recurrences appeared within an average of 14.9 months, that is within 18 (range 4 to 36) in group 1 and 13.5 (range 3 to 36) in group 2. Tumor recurrence was at the bladder neck and/or prostatic urethra in 11 of the 51 cases (21.5%). Average time to recurrence at the prostatic fossa was 23.8 months, that is 27 (range 13 to 46) in group 1 and 21.6 (range 4 to 60) in group 2. Only 1 patient had a single recurrence in the prostatic fossa, while the others also had synchronous and metachronous recurrences at other bladder sites. Tumor progression to invasiveness was diagnosed in 3 of the 51 patients (5.9%).Our data indicate that simultaneous TURBT and TURP do not negatively affect tumor recurrence at the bladder neck and prostatic urethra.

A 56-year-old woman presented 2 years after diagnosis of a right renal mass consistent with angiomyolipoma. The patient had a history of breast cancer treated by surgery and radiotherapy 10 years previously. She had no personal or family history of neurological disease or phakomatoses. Nine years before presentation, as part of breast cancer followup, abdominal computerized tomography (CT) showed absence of renal lesion. Two years before presentation the patient complained of right flank pain and CT reveale da3c mfatty tumor. The diagnosis of angiomyolipoma was established. Because of the small tumor size and the spontaneous improvement of symptoms, watchful waiting was planned with alternate ultrasound and CT annually or every other year. Two years later the patient had pain recurrence and CT demonstrated a 4.5 cm fatty mass of the right renal sinus with a tumor thrombus extending into the right renal vein and IVC. Physical examination was unremarkable and routine laboratory data were normal. Magnetic resonance imaging confirmed a sinusal right renal mass extending into the right renal vein and IVC 2 cm under the hepatic veins (fig. 1). Right nephrectomy and thrombectomy with a short cavotomy were performed. Pathological analysis showed renal angiomyolipoma with an 8 cm fatty thrombus (fig. 2). The patient was discharged home on postoperative day 9. She remained asymptomatic without evidence of recurrent disease at 1 year postoperatively.