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Bladder paragangliomas are rare tumors, with no prospective studies or guidelines on the management of this disease. We present a case series of 6 patients managed with bladder preservation over a median follow-up period of 124 months. We also present a review of the recent literature on bladder paragangliomas. We aim to provide a timely synthesis of the recent evidence on bladder paragangliomas as changing paradigms necessitate individualized treatment.

Objective To investigate survival outcomes of patients with muscle-invasive bladder cancer (MIBC) that demonstrate complete clinical response (cT0) to neoadjuvant chemotherapy (NAC) and then reject subsequent radical cystectomy (RC). Methods A retrospective chart review identified patients with MIBC who were cT0 after platinum-based NAC. cT0 was defined as negative cytology, cystoscopy with transurethral resection of bladder tumor, and imaging. cT0 patients refusing for RC were followed up with cytology, cystoscopy with biopsy, and cross-sectional imaging. Results Forty-eight patients were identified with MIBC that were cT0 after NAC. Seven patients underwent immediate RC, whereas 41 elected bladder preservation with close surveillance. Of those remaining 41 patients, mean age was 68 ± 11 years with median follow-up of 35 months. NAC regimens were 46% methotrexate/vinblastine/doxorubicin/cisplatin, 39% gemcitabine/cisplatin, and 15% other platinum-based therapies. Five-year cancer-specific survival was 87%, disease-free survival was 58%, and cystectomy-free survival was 79%. A total of 19 patients (46%) relapsed with 5.4-month median recurrence time. Conclusion Bladder preservation may be a reasonable option in a highly select subset of patients with MIBC who are complete clinical responders after NAC. For those patients that were cT0 after NAC and refused or were ineligible for RC, 5-year disease-free survival was nearly 60% and cancer-specific survival was nearly 90%. Future studies should focus on identifying clinical and molecular factors associated with a durable pathologic complete response after NAC.

Objective To compare postoperative infectious outcomes of bladder biopsies performed in the office without antibiotic prophylaxis vs those done with preoperative antibiotic prophylaxis in the operating room (OR). Materials and Methods Our institutional review board-approved database was retrospectively reviewed for patients who underwent bladder biopsy in the office or in the OR between July 2014 and August 2015. All patients with bladder biopsies performed in the OR and none in the office received preoperative antibiotic prophylaxis. Patient characteristics and post-procedural outcomes including bacteriuria, urinary tract infection (UTI), and febrile UTI were recorded. The rates of these outcomes were compared between the 2 groups using the chi-square test. Patients were excluded from analysis if they experienced a UTI or were prescribed antibiotics within 30 days before their procedure. Results In all, 216 biopsies were identified (106 in the office and 110 in the OR). No difference was noted in the rate of UTI (0.94% vs 0.91%, P = .98), or febrile UTI (0% vs 0.91%, P = .33) between those undergoing bladder biopsy in the office and those in the OR. There was no difference in the incidence of new urinary symptoms (2.8% vs 5.5%, P = .33) or post-procedural bacteriuria (3.8% vs 3.6%, P = .96). Conclusion Since the introduction of the mandated use of antibiotics for routine procedures such as bladder biopsy, antibiotic use has markedly increased. Our data suggest that the preoperative antibiotic prophylaxis that is recommended may not confer benefit to select patients. At a time when antibiotic stewardship is of utmost importance, guidelines regarding its use should be reconsidered.

Objective To identify the effect of the 2012 United States Preventive Services Task Force (USPSTF) prostate-specific antigen (PSA) recommendation statement on primary care referral patterns and urologists' decision making. Methods Men referred to our institution for newly elevated PSA level from June 2011 to June 2013 were identified. Patients with a prior history of prostate cancer or biopsy were excluded. Clinical and management parameters were compared between those presenting in the year before vs the year after the USPSTF statement. Factors predictive of receiving a prostate biopsy were identified using multivariate regression analysis. Results A total of 201 men were identified in the pre-USPSTF period and 212 men, thereafter. The groups were comparable in age, race, prostate cancer family history, PSA values, and digital rectal examination findings. At the initial evaluation, patients presenting after the statement were more likely to undergo PCA3 testing (27% vs 11%; P P = .02) and less likely to undergo immediate biopsy (16% vs 24%; P = .03). The proportion of patients ultimately receiving a biopsy was equivalent. The groups were similar in the percentage of positive biopsies, Gleason distribution, and D'Amico risk. African American race and family history were predictors for receiving a biopsy in the post-USPSTF group but not in the pre-USPSTF group. Conclusion The 2012 USPSTF recommendation statement has not affected the number or clinical characteristics of patients referred to a tertiary center for elevated PSA level. After recommendation, urologists ordered significantly more PCA3 and repeat PSA tests and recommended fewer biopsies at the initial visit. The fraction of patients ultimately receiving a biopsy remained the same.

Objective To assess functional outcomes and complications of ureteroneocystotomies (UNCs) with or without psoas hitch or Boari flap in the reconstruction and repair of the ureter. Methods We reviewed a consecutive series of patients that underwent open ureteral reconstruction for ureteral obstruction or injury. Underlying ureteral disorder, preoperative and postoperative estimated glomerular filtration rate (eGFR), and imaging studies regarding resolution of hydronephrosis were assessed. Results A total of 100 ureteral reimplantations performed at our institution from November 1986 to August 2012 were identified: 24 primary ureteroneocystotomies, 58 with psoas hitch, and 18 with Boari flap. Median follow-up was 48.7 months (range 12.3-253 months). The most common underlying disorder was ureteral transitional cell cancer (TCC). Men were found to have more frequent underlying chronic ureteral disorders with chronic renal failure when compared to women. Ureteral stents were placed in 81% and were removed after a median of 33 days (range 2-161 days). Resolution of hydronephrosis was noted in 81% of the patients. The eGFR deteriorated significantly over time only in male patients ( P = .001). Postoperative complications included stent-related dysuria, urinary tract infection, and contrast-extravasation on cystogram necessitating prolonged urethral and ureteral catheter drainage. Conclusion Excellent functional outcome without significant morbidity associated with ureteral reimplantation/reconstruction was achieved. Despite resolution of hydronephrosis in the vast majority of patients, those with chronic underlying ureteral disorder and renal failure did not show improvement of their eGFR.

Objective To investigate the role of early feeding on recovery after radical cystectomy and urinary diversion. Enhanced recovery protocols have helped to standardize postoperative recovery. This is the first study to directly review the impact of early feeding on recovery in a randomized multi-institutional protocol. Methods From 2011 to 2014, patients at 2 large hospitals were randomized after radical cystectomy to receive access to liquids and then a regular diet on postoperative days 1 and 2 or conventional care with introduction of a liquid diet after return of bowel activity, typically days 3-5. Early ambulation, use of metoclopramide, and no nasogastric tube were standard for all patients. The study was powered to detect a 50% decrease in 90-day complication rate with secondary end points of length of stay, time to bowel activity, and time to diet tolerance. The study was terminated early due to slow accrual (102 of 328). Results Overall complications for the early vs standard groups were similar (34 vs 31, P = .86). Immediate inpatient and postdischarge complication rates were also similar ( P = .63 and P = .44). Length of stay was not different (8.74 days vs 9.69 days, P = .43). Rates of ileus (27% vs 41%, P = .21) and return of bowel function (4.67 days vs 4.09 days, P = .62) were the same in arms. Conclusion Although this prospective randomized study did not meet the accrual target, early introduction of diet was well tolerated and did not show a negative or positive difference in any outcomes. Enhanced recovery protocols standardize postoperative care and early feeding is a well-tolerated addition.

To assess the role of confirmatory prostate biopsy in the accurate risk assessment of patients with low risk prostate cancer eligible for active surveillance.Patients electing active surveillance of their low grade, low volume prostate cancer with prostate-specific antigen20 ng/mL,cT2 disease who underwent confirmatory rebiopsy were included. Biopsy progression was defined as2 core involvement or Gleason 7 disease on subsequent biopsies. Prostate-specific antigen, total number of cores on initial and rebiopsy, the presence of high-grade prostatic intraepithelial neoplasia, and prostate-specific antigen density, when available, were assessed as predictors of biopsy progression.Sixty patients were included. Median time to rebiopsy was 2 months. Nineteen patients (31.7%) had findings that excluded them from active surveillance. Despite rebiopsy findings, 7 patients elected for active surveillance, all of which eventually underwent treatment for continued biopsy progression. Of the 41 patients eligible for active surveillance after rebiopsy, 8% elected treatment, 74% remained on active surveillance, and 13% experienced biopsy progression. No cancer on rebiopsy was associated with a reduced risk of progression to treatment on active surveillance (odds ratio 0.14, P = .011). A microfocus of Gleason 4 pattern (odds ratio 16.0, P = .04) and high-grade prostatic intraepithelial neoplasia (odds ratio 7.29, P = .03) on initial biopsy were independent predictors of immediate rebiopsy progression. Prostate-specific antigen, prostate-specific antigen density, and the total number of cores were not significant.Confirmatory rebiopsy aids in the accurate identification of low-risk patients for active surveillance as one-third are initially undergraded. Patients with high-grade prostatic intraepithelial neoplasia and any Gleason pattern 4 on initial biopsy are at highest risk and should be counseled regarding the risks of progression on active surveillance accordingly.

Objective To compare robotic surgery skill acquisition of residents trained with Mimic dVTrainer (MdVT) and da Vinci Surgical System (dVSS) console. No standardized curriculum currently exists for robotic surgical education. The MdVT is a compact hardware platform that closely reproduces the experience of the dVSS. Methods Sixteen urology trainees were randomized into 3 groups. A baseline evaluation using dVSS was performed and consisted of 2 exercises requiring endowrist manipulation (EM), camera movement and clutching (CC), needle control (NC), and knot-tying (KT). Groups 1 and 2 completed a standardized training curriculum on MdVT and dVSS, respectively. Group 3 received no additional training. After completion of the training phase, all trainees completed a secondary evaluation on dVSS consisting of the same exercises performed during baseline evaluation. Results There was no difference in baseline performance scores across the 3 groups. Although Group 3 showed no significant improvement in EM/CC domain (P = .15), Groups 1 and 2 had statistically significant improvement in EM/CC domain (P = .039 and P = .007, respectively). The difference in improvement between Groups 1 and group 2 was not statistically different (P = .21). Only Group 2 trainees showed significant improvement in the NC and KT domains during secondary evaluation (P = .02). Conclusion Curriculum-based training with MdVT or dVSS significantly improves robotic surgery aptitude. Similar improvements are seen for exercise domains shared between MdVT and dVSS groups. Follow-up studies are necessary to assess the efficacy of MdVT over a wider spectrum of domains.

Objectives To report our experience with patients undergoing active surveillance (AS) with Stage T1bN0M0 and T2N0M0 tumors. AS is a reasonable option for selected patients with renal cortical neoplasms (RCNs). Most patients undergoing AS are high-risk surgical candidates with Stage T1a lesions. The natural history of larger (Stage cT1bN0M0 and cT2N0M0) RCNs remains undefined. Methods Our institution's institutional review board-approved urologic oncology database was reviewed and identified 229 patients undergoing AS for RCNs. Of this cohort, 36 patients with 42 RCNs ≥4 cm were monitored at regular intervals with imaging. Patients with metastatic disease were excluded. The patient demographics, presentation, comorbidity level (Charlson comorbidity index), tumor size, tumor growth rate, and survival data were recorded. A failure of AS was defined as a progression to metastasis or a change from AS to a delayed surgical intervention. Results The mean Charlson comorbidity index was 2.83, with 52.8% of patients having an index of ≥3, indicating a high surgical risk. The mean tumor size on the initial computed tomography scan was 7.13 cm (range 4-13.7), and the mean growth rate was 0.57 cm/y (range 0-5.9). With a mean follow-up of 36 months (range 6-96), 5 patients (13.8%) had failure. Three lesions were treated with laparoscopic radical nephrectomy and found to be pT2N0M0 on final pathologic examination. Two patients (5.6%) in this cohort developed metastatic disease, and no cancer-specific deaths occurred. Conclusions Patients with Stage T1bN0M0 and T2N0M0 RCNs, monitored for a mean follow-up of 3 years, demonstrated a growth rate of 0.57 cm/y, with only 5.6% of patients progressing to metastatic disease.

OBJECTIVES To determine whether the decreased short-term morbidity associated with minimally invasive surgery (MIS) has resulted in an alteration in the disease-specific risk profile of prostatectomy patients. MIS in many fields has resulted in an expansion in the pool of patients willing to undergo surgery. METHODS The Columbia Urologic Oncology Database was queried, and 1751 patients undergoing radical prostatectomy between 2000 and 2007 were identified. The cohort was divided into 2 groups: patients who received surgery before or after the initiation of robotic-assisted laparoscopic radical prostatectomy (RALRP) at our institution (from 2003 onward). Age at surgery, Kattan Nomogram (KN) score, prostate-specific antigen (PSA), Gleason score sum, and tumor stage were compared using unpaired t tests with Welch correction and Mann-Whitney tests. RESULTS A total of 663 patients underwent prostatectomy from 2000 to 2002 ("pre-MIS era"), and 1088 patients had surgery in 2003 or later ("MIS era"), of which 519 and 569 underwent RALRP and open prostatectomy, respectively. There was no significant difference between the 2 eras regarding age, Kattan Nomogram score, or tumor stage. However, there was a significant difference in preoperative PSA (P = .01) and Gleason sum (P = .0002). In a comparison of the pre-MIS era with RALRP patients, only PSA differed significantly (P = .0002). CONCLUSIONS The advent of MIS for prostate cancer did not significantly alter the characteristics of patients undergoing prostatectomy at our institution. Although advancements in surgical techniques may improve clinical outcomes, this study does not suggest a consequential effect on the risk stratification of patients choosing surgery for prostate cancer.

To determine whether the detection of benign renal tumors is increasing and to identity the predictors of benign histologic features. The detection of renal cortical tumors has increased with the increased use of abdominal imaging. Current imaging and biopsy techniques cannot predict the renal tumor histologic features with complete accuracy, and many patients undergo surgery for benign lesions.The Columbia Urologic Oncology Database was reviewed, and 1244 patients who had undergone partial or radical nephrectomy from 1988 to 2007 were identified. A cohort of 775 patients with a tumor diameter ofor.0 cm, nonmetastatic disease, and nonfamilial disease was selected. Univariate and multivariate logarithmic regression analyses were used to determine the parameters to predict for benign histologic features.The proportion of renal surgery for benign tumors ofor.0 cm in diameter has increased annually. When patients were stratified by the year of surgery, the proportion of benign tumors was 5.0% before 1998, 15.2% from 1998 to 2003, and 21.2% from 2004 to 2007. The mean diameter of benign and malignant tumors was 3.0 and 3.5 cm, respectively, and the mean tumor diameter significantly decreased during the study period (P = .006). Using multivariate analysis, the year of surgery, tumor diameter, and female sex were independent predictors of benign histologic features (P.05). Age, incidental diagnosis, body mass index, and race were not significant predictors (P.05).Even when controlling for tumor diameter and sex, the incidence of benign tumors detected at renal surgery at our institution has increased significantly in the past 2 decades.

The presence of positive surgical margins (PSMs) after prostatectomy for prostate cancer has long been an indicator of poor survival outcomes. However, with the downstaging of cancer occurring in the prostate-specific antigen testing era, we sought to determine whether the risk associated with PSMs retains the same effect on prognosis as before the prostate-specific antigen testing era.Of the 3460 patients in the Columbia University Urologic Oncology database, 2215 (64%) were identified who had undergone radical prostatectomy from 1991 to 2005 and had sufficient pathologic data to be analyzed andor=1 year of follow-up. Three epochs were chosen: 1991-1995, 1996-2000, and 2001-2005.The median age, preoperative prostate-specific antigen, and Gleason score was 61.6 years, 6 ng/mL, and 7, respectively, and50% of patients had pathologic Stage T2 disease. On multivariate analysis, PSMs were a risk factor for biochemical failure for each epoch (P.01). The Wald's test indicated that the significance of PSMs had not changed over time (P = .8). The contribution of PSMs to the accuracy of predicting biochemical failure in a multivariate model was found only for the earliest epoch, because it improved the model by 0.15 (95% confidence interval 0.03-0.27). In the second epoch, it was 0.13 (95% confidence interval -0.01 to 0.27), and it was 0.13 for the third (95% confidence interval -0.06 to 0.32).The results of this study suggest that the predictive contribution of PSMs to the accuracy of a multivariate model or nomogram used to predict the outcomes after prostatectomy has decreased during the past 15 years.

OBJECTIVES To determine whether present subclassifications for pathologic T2 (pT2) prostate cancer are predictive for recurrence-free survival (RFS) after radical prostatectomy. METHODS The study sample included 906 patients who underwent radical prostatectomy between 1990 and 2004 and were subsequently staged as having pT2 disease. The estimated 5- and 10-year RFS for patients with pT2a, pT2b, and pT2c was calculated by using the Kaplan-Meier method. Multivariate analysis was performed by using Cox Proportional Hazards models to determine differences in RFS among the 3 groups, and their association with preoperative variables, including prostate-specific antigen (PSA) and biopsy Gleason score. RESULTS Preoperative PSA and Gleason score were strongly predictive for RFS (P

One in three American men is obese (body mass index [BMI]or=30 kg/m(2)); however, the relationship between obesity and prostate cancer is highly debated. We examined BMI trends in patients undergoing radical prostatectomy (RP) and evaluated the role of obesity in predicting biochemical failure (BCF) after RP.From 1988 to 2006, 964 patients underwent RP and had BMI data available. The patients who had received neoadjuvant therapy or were followed up for1 year were excluded, yielding 702 patients who were grouped by BMI and stratified by year of surgery. The postoperative Kattan nomogram was used to assess BCF risk after RP. Obese and nonobese patients' BCF rates were compared using the Kaplan-Meier method, and Cox proportional hazard models were used to assess the effect of obesity on BCF.The mean BMI (P = .02) and proportion of patients undergoing RP who are obese (P = .02) have increased, parallel to, but less than, national trends. Our obese patients had higher grade cancer and showed a trend toward having a more advanced pathologic stage. Obese patients also had a lower predicted free from BCF survival at 7 years (74.3% vs 80.1%). However, no difference was found in the obese and nonobese patients' actual observed BCF rates (P = .48), nor was obesity an independent predictor of BCF in univariate or multivariate models (P = .46).The growing proportion of obesity at RP parallels, but is less than, national trends. Our data have shown that, despite the increased recurrence risk and advanced tumor parameters, obesity does not contribute to predicting BCF for a given tumor stage, grade, or prostate-specific antigen level on multivariate analysis.

Objectives With the advent of prostate-specific antigen (PSA) screening, the number of lymph node metastases found after radical prostatectomy (RP) has been decreasing. Although it has been shown in this population that immediate adjuvant androgen deprivation therapy (ADT) improves survival compared with initiating ADT at clinical recurrence, the effect of starting ADT at biochemical recurrence is unknown. We examined a series of patients with Stage D1 (T2-T4N1-N2M0) prostate cancer discovered after RP, most of whom started ADT at biochemical recurrence. Methods A total of 2121 patients underwent RP and bilateral pelvic lymph node dissection from January 1990 and December 2000. Of these men, 28 had lymph node metastases (1.3%), 24 of whom had adequate follow-up data for analysis. Results No perioperative or long-term complications, such as pelvic recurrence, gross hematuria, urinary retention, or hydronephrosis, developed. With a median follow-up of 74 months, the estimated 5-year survival rate was 94%, similar to the average life expectancy of age-matched men in the United States. The 5-year biochemical disease-free survival rate was 15%. A total of 18 patients who did not start immediate ADT had an estimated 100% overall survival rate at 5 years. Conclusions The results of our study have shown that survival for patients with Stage D1 prostate cancer after RP is excellent and equivalent to that of age-matched controls. Long-term pelvic morbidity due to primary tumor progression was prevented by RP. By waiting until PSA failure to initiate ADT, we found that a small percentage of patients (15% at 5 years) were rendered disease free with surgery alone and could avoid the side effects of ADT, with excellent overall survival maintained for those starting ADT at biochemical progression.

To more clearly elucidate the relationship between prostate volume (PV) and prostate cancer parameters.The Urologic Oncology Database was reviewed. A total of 3460 patients had undergone radical prostatectomy from 1988 to 2006. Of these, 2600 with complete data were included in the study and were stratified by the PV: normal (0 to 40 cm(3)), moderate (40 to 80 cm(3)), or large (greater than 80 cm(3)). The prostate cancer variables were evaluated using analysis of variance. Regression models were used to determine the role of PV in Gleason sum discordance (greater than 1 unit) controlling for prostate-specific antigen level and clinical and pathologic stage.Of the 2600 patients, 1453 (55.2%) had a normal, 1035 (39.8%) a moderate, and 130 (5.0%) a large PV. Patients with a normal PV were more likely to have a Gleason sum greater than 6 at biopsy (46.2%) and radical retropubic prostatectomy (68.4%) compared with patients with a moderate (39.0% and 58.9%, respectively) or a large (41.5% and 57.7%, respectively) PV (P = 0.005 and P = 0.001, respectively). Patients with a normal PV had greater rates of extraprostatic extension (32.3%) and positive margins (28.2%) compared with those with a moderate (25.5% and 22.4%, respectively) or a large (23.3% and 20.3%, respectively) PV (P = 0.002 and P = 0.005, respectively). Of all 2600 patients, 55.9% had no change between the biopsy and pathologic Gleason sum, 255 (9.8%) were downgraded, and 890 (34.3%) were upgraded. Patients with a large PV had a greater rate of downgrading (16.2%) than those with a normal (8.7%) or moderate (10.5%) PV (P = 0.01). Patients upgraded had the greatest rate of pathologically advanced disease (35.3% with Stage T3 or greater, P0.001). On multivariate regression analysis, PV (odds ratio 0.99, P = 0.005), prostate-specific antigen level (odds ratio 1.03, P0.001), and age (odds ratio 1.03, P0.001) were predictors of Gleason discordance +/-2.The results of our study have shown that patients with a large PV (greater than 80 cm(3)) are more likely to have a lower Gleason sum, locally confined and less-aggressive pathologic disease, and were more often downgraded.

OBJECTIVES To assess the likelihood of biochemical disease-free survival, urinary continence, and sexual potency after radical retropubic prostatectomy (RRP) as an aggregate outcome, the "trifecta" analysis. METHODS From the Columbia University Urologic Oncology Database of 2522 patients from 1988 to 2005, 503 had undergone RRP by a single surgeon. Of these, 87 patients were excluded: 31 with inadequate follow-up, 47 who had undergone additional confounding therapy, and 9 with insufficient data for the trifecta analysis. The final sample of 416 patients was stratified according to preoperative prostate-specific antigen level, Gleason sum, and clinical stage. Biochemical disease-free survival, continence, and potency were defined, respectively, as a prostate-specific antigen level of less than 0.2 ng/mL, not requiring daily pads, and having an erection sufficient for intercourse with or without oral pharmacotherapy. Patients achieving all three positive outcomes, the trifecta, were analyzed using analysis of variance. RESULTS Risk stratification identified 225 low-risk, 144 intermediate-risk and 47 high-risk patients whose biochemical disease-free survival rate was 96.4%, 90.3%, and 78.7% at a median follow-up period of 4.4, 4.8, and 7.1 years, respectively. The corresponding continence rates were 93.8%, 94.4%, and 93.3% and the potency rates were 81.3%, 67.7%, and 69.6% with at least 1 year of follow-up. Of the 314 analyzable patients, 130 (72.6%) of 179 low-risk, 61 (58.1%) of 105 intermediate-risk, and 12 (40.0%) of 30 high-risk patients achieved the trifecta. The trifecta rates were significantly different between the low and intermediate-risk (P = 0.04) and low and high-risk (P = 0.001) groups. CONCLUSIONS Preoperative (RRP) low-risk patients are more likely to remain disease-free, continent, and potent after surgery than are patients of higher risk. Physicians should consider aggregate outcomes when counseling patients regarding the clinical outcomes after RRP.

Objectives The current TNM staging system for renal cortical tumors (RCTs) differentiates between tumors confined to the kidney (T1, T2) and tumors that extend through the renal capsule and invade into the perinephric fat (T3a). We examined the relative survival rates of patients with T1 and T3a tumors to determine the accuracy of the current TNM staging classification. Methods We analyzed the Columbia University Surgical Urological Oncology Database for all patients with clinically localized Stage T1, T2, and T3a RCTs treated surgically from 1988 to 2004. The primary outcomes included local and distant recurrence. Because the T3a classification is not limited by size, we compared T3a tumors with T1 tumors alone and tumors confined within the renal capsule (Stage T1 and T2 tumors combined). Results A total of 819 patients underwent partial or radical nephrectomy for RCTs at Columbia University during the study period. After the exclusion criteria were applied, 131 patients with T1N0M0, 19 patients with T2N0M0, and 82 patients with T3aN0M0 conventional renal cell carcinoma were eligible for analysis. The median follow-up was 37 months. The median tumor diameter was 3.2, 3.8, and 5.0 cm for Stage T1, T1 and T2 combined, and T3a lesions, respectively. The estimated 5-year disease-free survival was 95.2% and 90.6% for T1 and T3a RCTs, respectively ( P = 0.922). Conclusions Patients with Stage T3a tumors experienced similar outcomes as patients with tumors confined to the renal capsule. These data suggest that the T3a classification should be examined more closely to attempt to improve the prognostic validity of the TNM classification.

Objectives To determine the natural history of patients younger than 40 years (young patient [YP] group) who are diagnosed with a sporadic renal cortical tumor (RCT) and to compare the natural history of these patients with the more typical older patient (OP) with RCT. Methods We reviewed our database and identified 34 patients (younger than 40 years old, median age 35) who underwent surgery for a sporadic RCT. The YP group outcomes were compared with 100 patients between 41 and 85 years (median 65). We fit a Cox proportional hazards model to examine the relationship between age at presentation and recurrence risk. Results The median tumor size in the YP group was 3.8 cm (range 0.6 to 19) and in the OP group was 5.0 cm (range 0.9 to 22; P = 0.225). Tumors were discovered incidentally in 51% and 56% of the YP and OP groups, respectively ( P = 0.65). The frequency of partial nephrectomy did not differ between the two groups (35% YP and 30% OP, P = 0.55). The frequency of malignant histologic subtypes did not differ between the groups ( P = 0.439). In the YP group, only larger tumor size (hazard ratio 1.23, 95% confidence interval 1.02 to 1.50, P = 0.034) was associated with a statistically significant increased risk of recurrence. Those in the YP group were not more or less likely to develop recurrence than those in the OP group (hazard ratio 0.79, 95% confidence interval 0.22 to 2.85, P = 0.72). The 5-year disease-free survival rate was 73% and 80% in the YP and OP groups, respectively ( P = 0.23). The 5-year disease-specific survival rate was 85% and 84% in the YP and OP groups, respectively ( P = 0.88). Conclusions The findings of our study indicate that the natural history of RCTs is similar in both younger and older patients. Young patients were neither more nor less likely to develop recurrence compared with their older counterparts.

Objectives To study prospectively the prognostic significance of the reverse transcriptase-polymerase chain reaction (RT-PCR) assay for patients with prostate cancer treated definitively with external beam radiotherapy. The RT-PCR assay for prostate-specific antigen (PSA) has been used to detect circulating prostate cancer cells in the serum of patients with prostate cancer. Methods In prospective fashion, serum RT-PCR testing was performed before and/or after definitive therapy, with the results scored as positive or negative. The results were analyzed for 161 patients, and the RT-PCR result was correlated with the treatment outcome. Results The median follow-up was 29 months. The pretreatment RT-PCR result was not predictive of biochemical relapse-free survival (bRFS) or clinical disease-free survival (DFS). Of 25 patients with T3-T4 tumors, those with a negative pretreatment RT-PCR result had better bRFS and a trend was noted toward better DFS compared with those with a positive result. Among patients with Gleason score 8 to 10 tumor who underwent pretreatment testing (n = 19), those with a negative RT-PCR result had better bRFS and DFS compared with those with a positive result. A trend toward better bRFS was seen for patients with negative versus positive post-treatment RT-PCR results. The DFS was better for patients with negative versus positive post-treatment RT-PCR results. Conclusions RT-PCR, when obtained before radiotherapy, may be predictive of outcome for patients with more advanced stages or higher Gleason scores. Post-treatment testing predicted for clinical relapse. Additional study is needed before RT-PCR is used regularly in clinical practice.

Increasingly, physicians will seeelderly people in their everyday practice.Aging-related health problems, including thegradual decrease in gonadal function in men aftermiddle age (“andropause”), have gained interest inthe medical community. The term “andropause” isphysiologically incorrect, because, unlike women,men do not experience universal absolute gonadalfailure. Some investigators have therefore sug-gested more appropriate names, such as androgendecline in the aging male