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We assessed survival after radical prostatectomy, intensity modulated radiation therapy or conformal radiation therapy vs no local therapy for metastatic prostate cancer adjusting for patient comorbidity, androgen deprivation therapy and other factors.We identified men 66 years old or older with metastatic prostate cancer treated with radical prostatectomy, intensity modulated radiation therapy, conformal radiation therapy or no local therapy in the SEER-Medicare linked database from 2004 to 2009. Multivariable Cox proportional hazards models before and after inverse propensity score weighting were used to assess all cause and prostate cancer specific mortality. Competing risk regression analysis was done to assess prostate cancer specific mortality.Of 4,069 men with metastatic prostate cancer radical prostatectomy in 47, intensity modulated radiation therapy in 88 and conformal radiation therapy in 107 were selected as local therapy vs no local therapy in 3,827. Radical prostatectomy was associated with a 52% decrease (HR 0.48, 95% CI 0.27-0.85) in the risk of prostate cancer specific mortality after adjusting for sociodemographics, primary tumor characteristics, comorbidity, androgen deprivation therapy and bone radiation within 6 months of diagnosis. Intensity modulated radiation therapy was associated with a 62% decrease (HR 0.38, 95% CI 0.24-0.61) in the risk of prostate specific cancer specific mortality. Conformal radiation therapy was not associated with improved survival compared to no local therapy. Propensity score weighting yielded comparable results. Competing risk analysis revealed a 42% and 57% decrease (SHR 0.58, 95% CI 0.35-0.95 and SHR 0.43, 95% CI 0.27-0.68, respectively) in the risk of prostate cancer specific mortality for radical prostatectomy and intensity modulated radiation therapy.Local therapy with radical prostatectomy and intensity modulated radiation therapy but not with conformal radiation therapy was associated with a survival benefit in men with metastatic prostate cancer. This finding warrants prospective evaluation in clinical trials.

Metformin has recently been shown to have potential to reduce prostate cancer risk. We conducted a randomized, double-blind, placebo-controlled trial to determine the modulating effects of metformin on tissue and systemic biomarkers of drug activity and its distribution into the prostate tissue. Twenty patients with prostate cancer scheduled to undergo prostatectomy were randomly assigned to receive either extended-release metformin or placebo for a median of 34 days before surgery. Prostatectomy and serum samples were analyzed for metformin concentrations, serum biomarkers of drug activity (prostate-specific antigen, insulin, insulin-like growth factor-1, insulin-like growth factor binding protein 3, sex hormone-binding globulin, and testosterone) and tissue biomarkers of proliferation, apoptosis, cell cycle regulation, and mTOR inhibition. For participants in the metformin arm, the prostate tissue and serum metformin concentrations ranged from 0.88 to 51.2 μg/g tissue and from not detectable to 3.6 μg/ml, respectively. There were no differences between the two groups in either the postintervention tissue biomarker expression in the prostatectomy tissue or pre to postintervention changes in serum biomarkers. We conclude that metformin distributes to human prostate tissue, suggesting that metformin could exert its effects directly on tissue targets. However, there was no difference in tissue and systemic drug effect biomarkers between the two treatment arms. Future studies with longer intervention duration and larger sample size should be considered in order to evaluate the potential of metformin for prostate cancer prevention.

To evaluate the utility of using Internet search trends data to estimate kidney stone occurrence and understand the priorities of patients with kidney stones. Internet search trends data represent a unique resource for monitoring population self-reported illness and health information-seeking behavior.The Google Insights for Search analysis tool was used to study searches related to kidney stones, with each search term returning a search volume index (SVI) according to the search frequency relative to the total search volume. SVIs for the term, "kidney stones," were compiled by location and time parameters and compared with the published weather and stone prevalence data. Linear regression analysis was performed to determine the association of the search interest score with known epidemiologic variations in kidney stone disease, including latitude, temperature, season, and state. The frequency of the related search terms was categorized by theme and qualitatively analyzed.The SVI correlated significantly with established kidney stone epidemiologic predictors. The SVI correlated with the state latitude (R-squared=0.25; P.001), the state mean annual temperature (R-squared=0.24; P.001), and state combined sex prevalence (R-squared=0.25; P.001). Female prevalence correlated more strongly than did male prevalence (R-squared=0.37; P.001, and R-squared=0.17; P=.003, respectively). The national SVI correlated strongly with the average U.S. temperature by month (R-squared=0.54; P=.007). The search term ranking suggested that Internet users are most interested in the diagnosis, followed by etiology, infections, and treatment.Geographic and temporal variability in kidney stone disease appear to be accurately reflected in Internet search trends data. Internet search trends data might have broader applications for epidemiologic and urologic research.

Study Type – Diagnostic (exploratory cohort) Level of Evidence 2b What’s known on the subject? and What does the study add? Optical coherence tomography has been used for the diagnosis of retinal disease and has been used experimentally for imaging of vascular plaques, gastrointestinal pathology, bladder cancer, prostate cancer, and recently to examine benign kidney microanatomy. It has not been previously used to image kidney cancer. This study presents the first data on the utility of OCT in the imaging for renal neoplasms. It found that OCT was most successful in distinguishing AML and TCC from normal parenchyma. OCT had more limited success at differentiating oncocytoma. Clear cell tumors and other renal cancer subtypes had a more heterogenous appearance, precluding reliable identification using OCT. The study shows that higher resolution versions of OCT, such as OCM, will be needed to allow optical coherence imaging to reach clinical utility in the assessment of renal neoplasms. OBJECTIVEs • To determine the appearance of normal and neoplastic renal tissue when imaged with optical coherence tomography (OCT). • To preliminarily assess the feasibility of using OCT to differentiate normal and neoplastic renal tissue. PATIENTS AND METHODS • After radical or partial nephrectomy in 20 subjects, normal renal parenchyma and neoplastic tissue samples were obtained. • The tissue was evaluated with light microscopy and using a bench-top laboratory OCT system with a lateral resolution of 10 µm. • OCT images were compared with histological slides to evaluate the ability of OCT to differentiate renal neoplasms. RESULTS • Pathological subtypes included eight clear-cell, three papillary and two chromophobe renal carcinomas; two oncocytomas; one angiomyolipoma (AML); two transitional cell carcinomas (TCCs); and one haematoma. • Using OCT, benign renal parenchyma showed recognizable glomeruli and tubules. • TCC had a distinctive appearance on OCT whereas AML showed a unique identifiable signature because of its fat content. Oncocytomas had a lobulated appearance, which appeared subtly different from renal carcinoma. • Renal carcinoma lacked recognizable anatomical elements and had a heterogeneous appearance making differentiation from normal parenchyma at times difficult. • Subtypes of renal cancer appeared to vary on OCT imaging although discrimination was unreliable. CONCLUSIONS • OCT imaging for renal neoplasms was most successful in distinguishing AML and TCC from normal parenchyma and malignant tumours. Oncocytoma differed subtly from renal carcinoma, making distinction more challenging. • Clear-cell tumours and other renal carcinoma subtypes had a heterogeneous appearance on OCT, which precluded reliable differentiation from normal parenchyma and between renal carcinoma subtypes. • Higher resolution versions of optical coherence imaging, such as optical coherence microscopy, will be necessary to achieve clinical utility.

Objectives To determine whether gender variations in imaging and healthcare access are contributing to observed differences in renal cancer, we examine the initial events in the diagnosis of renal masses in a cohort of patients and correlate it with detailed data on imaging patterns over the same period. Methods A total of 308 patients diagnosed with a renal mass over 11 years were reviewed. Information on symptoms, imaging, diagnosing physician, demographics, and pathology was gathered. Data on imaging for 1 862 485 patients at our institution over the same period were also collected. The data were analyzed for temporal trends, gender variations, and differences between incidental and nonincidental masses. Results Females presented with smaller masses (4.8 vs 6.0 cm, P = .0064), and were less likely to have clear cell tumors (58.7% vs 63.4%, P = .049). A total of 66.9% of female and 61.1% of male cases were incidental (not significant). In both males and females, primary care physicians were the most common diagnosing physicians (47.4% and 49.6%, respectively). Gynecologic complaints were an uncommon cause of diagnosis for women (5.3%). Computerized tomography was the most common diagnosing modality for both males and females (69.1% and 63.2%, respectively). Ultrasound as the diagnosing modality did not reach statistical significance between males and females (23.4% and 28.6%, respectively). During the 11- year period, women underwent more imaging studies overall than men (19.7% difference), but the difference was lower when only considering studies that can diagnose renal masses (6.4% difference). Conclusions Gender variations in imaging rates and presentation for obstetrics/gynecology concerns by females did not lead to a significant difference in incidental diagnosis and do not appear adequate to explain gender differences in renal cancer presentation.

Purpose of review The approach to treatment of renal cancer has shifted dramatically from radical surgery to a current emphasis on nephron-sparing treatment. We review the changes in renal cancer presentation and our understanding of its clinical behavior that have driven this shift in treatment philosophy. Recent findings Renal cancer incidence has increased progressively in the USA. In Europe, incidence trends have been variable. Renal cancers are increasingly being diagnosed incidentally. Increasing utilization of abdominal imaging will likely continue this trend. Renal cancer size at presentation has decreased. Fewer cases are presenting with metastasis. Mean age at diagnosis has increased slightly. Experience with active surveillance suggests that a significant percentage of small renal masses are indolent and possess a low metastatic risk. Summary The presentation of renal cancer has evolved. There has been an increase in the incidence of cases in the USA and several European countries and at the same time a shift to incidentally diagnosed, smaller, localized tumors in a slightly older population. This new landscape of renal cancer patients can be offered an expanded list of treatment options, including focal therapies, with an increased treatment priority on preservation of renal function and minimization of treatment morbidity.

To evaluate gender differences in initial presentation, pathology, and outcomes with renal cell carcinoma (RCC).The 1973-2004 Surveillance Epidemiology and End Results (SEER) 17-registries database was analyzed for renal tumors from 1988 to 2004 coded as primary site "kidney and renal pelvis." After various exclusions, a final study group of 35,336 cases with complete data was obtained. Demographic variables analyzed included age, sex, and race. Tumor variables included size, stage at diagnosis, grade, and histology. Primary outcome variables included overall and cancer-specific survival.Of the patients, 22,288 were male (63%). Females presented with smaller tumors (5.9 vs. 6.1cm, p0.0001) of lower grade (p0.0001). Males had a higher incidence of regional or metastatic spread of renal carcinoma (p0.0001). Median overall survival from time of diagnosis was 130 mo for females versus 110 mo for males (p0.0001). In comparisons of males and females, 5-yr cancer-specific survival was 78% versus 81%, and 5-yr overall survival was 65% versus 69% (p0.0001). On multivariate analysis, cancer-specific survival was similar (HR, 1.00, p=0.960), whereas overall survival was significantly longer for females (HR, 0.92, p0.0001). Older age at diagnosis, larger tumor size, higher grade, higher SEER historic stage, and sarcomatoid, collecting duct, or "other" histology were related to worse cancer-specific and overall survival.Men present with larger, higher stage, higher grade RCC than women. Overall survival is better in women, whereas cancer-specific survival is not significantly different.

OBJECTIVES To evaluate the relative merits of robotically assisted partial nephrectomy (RPN), using a matched-pair analysis, with laparoscopic PN (LPN). PATIENTS AND METHODS Between July 2006 and August 2007, 12 patients had RPN for tumour; the outcomes were compared retrospectively with 12 matched patients who had LPN. Patients were matched for age, gender, body mass index, American Society of Anesthesiologists score, tumour side, size and location, and the specific technique used (early vs conventional unclamping). Operative measures evaluated included operative time, estimated blood loss, warm ischaemia time (WIT), and number of ports used. Outcomes measured included serum creatinine and estimated glomerular filtration rate before and after surgery, length of hospital stay, transfusion rate, operative and 30-day complication rate, and surgical margin status. RESULTS Overall there were no differences in perioperative variables (WIT, estimated blood loss, surgery time, length of stay) between the groups. Fewer ports were used during LPN. Renal functional outcomes, transfusion rate and complication rates were comparable. Two RPN cases required conversion to standard LPN. A subset analysis of six patients in each group who had early unclamping showed a 7-min shorter WIT with LPN (14 vs 21 min, P = 0.05), despite larger tumours being treated with LPN (3 vs 2.4 cm, P

Coexisting renal calculus disease may pose technical challenges in the surgical management of ureteropelvic junction obstruction. We report our experience with laparoscopic pyelolithotomy at the time of laparoscopic pyeloplasty and compare outcome data with a cohort of patients undergoing laparoscopic pyeloplasty without coexistent stone disease.We reviewed data on 117 patients undergoing laparoscopic pyeloplasty in the last 3 years at our institution. Fifteen (10.6%) patients underwent concomitant ipsilateral pyelolithotomy at the time of laparoscopic pyeloplasty. Laparoscopic graspers alone were used in 11 (73.3%) patients, flexible nephroscopy in 2 (13.3%) patients, and laparoscopic irrigation in 2 (13.3%) patients for renal stone removal. Patients in the group undergoing pyelolithotomy were compared with 15 matched patients undergoing laparoscopic pyeloplasty without concomitant calculus disease. Preoperative, intraoperative, and postoperative parameters were compared between the groups.Overall stone-free rate after laparoscopic pyelolithotomy was 80%. Mean operative time was 174 minutes nu 170 minutes for the pyelolithotomy nu control group, respectively (P = 0.81).Laparoscopic pyelolithotomy, primarily using laparoscopic graspers, is an efficient procedure with associated high stone-free rates without significant increase in operative time or morbidity. Intraoperative flexible nephroscopy may be necessary only occasionally for stone retrieval.

Objectives To detail the technique and evaluate in a preliminary study the effectiveness of posterior reconstruction of Denonvilliers' musculofascial plate (PRDMP) in enhancing early continence after robotic and laparoscopic radical prostatectomy (RP). Patients and methods Thirty-two consecutive patients having robotic or laparoscopic RP with PRDMP (group 1). Thirty previous patients not having PRDMP were compared as historical controls (group 2). Continence, as measured by patient self-reporting of the number of pads used/24 h, was assessed at 3 days and 6 weeks after catheter removal, by telephone interview. 'Continent' was defined as the use of none or one pads, 'moderate incontinence' as two pads, and 'severe incontinence' as more than two pads. Intraoperative transrectal ultrasonography (TRUS) was used to measure the membranous urethral length before and after PRDMP. Results At 3 days after catheter removal, more patients in group 1 were continent than in group 2 (34% vs 3%, P = 0.007). At 6 weeks continence was again better in group 1 (56% vs 17%, P = 0.006). The mean length of the membranous urethra on TRUS measured before RP, after RP but before the musculofascial suture, and afterward, was 15.6, 12 and 14 mm, respectively. Thus, reconstruction restored the length of the transected membranous urethra by a mean of 2 mm. Conclusions PRDMP during robotic and laparoscopic RP leads to improved maintenance of membranous urethral length and significantly higher early continence rates.

OBJECTIVES To report our experience with laparoscopic radical prostatectomy for the treatment of localized prostate carcinoma in 3 renal transplant recipients. METHODS We retrospectively identified all patients who had undergone laparoscopic prostatectomy for clinically localized prostate cancer between 1999 and 2006 at our institution (n = 1067). Of these patients, 3 were renal transplant recipients (dual cadaveric renal transplant, simultaneous pancreas kidney transplant, and a cadaveric renal transplant that had failed owing to chronic rejection by the time of surgery). We reviewed all available clinicopathological data. RESULTS All three patients underwent successful laparoscopic radical prostatectomy without major complications. The average operative time was 237 minutes (range, 180 to 290 minutes) with a mean estimated blood loss of 425 mL (range, 75 to 1000 mL). No changes in renal graft function, measured by serum creatinine, were noted. Pathological outcomes revealed negative surgical margins with organ-confined disease in each case. All three patients tolerated the procedure well and had an average hospital stay of 3.3 days (range, 2 to 5 days). CONCLUSIONS The data from our 3 patients suggest that laparoscopic radical prostatectomy is a technically feasible and safe treatment of localized prostate cancer in renal transplant recipients.

The incidence of renal cancer is increasing, while cases series suggest that tumor size is decreasing. This has important implications for treatment planning. We evaluated national trends in renal cancer size and observed survival in patients diagnosed in the 3 periods 1988 to 1992, 1993 to 1997 and 1998 to 2002.From the Surveillance, Epidemiology, and End Results database we identified 29,053 patients diagnosed with primary renal cancer. Patients were stratified into size categories and 5-year time cohorts. Size distribution was compared across cohorts. Kaplan-Meier survival curves and Cox proportional hazards modeling were used to examine trends in overall and stage specific survival.From 1988 through 2002 renal tumor size decreased from 66.8 to 58.6 mm, while the age adjusted incidence of renal cancer increased from 8.6 to 11.2 cases per 100,000 individuals. Kaplan-Meier analysis showed steadily deteriorating survival with increased cancer size above 4 cm with a median survival of 105 months for 4 to 7 cm vs 46 months for more than 7 cm. Cox modeling demonstrated significantly improved survival in patients diagnosed in the latter cohorts. With adjustment for size the latter cohorts remained significantly improved compared to the earliest cohort, although the 1998 to 2002 cohort was no longer significantly different than the 1993 to 1997 cohort.Nationally renal tumor size at presentation has steadily and consistently decreased. Patients more recently diagnosed had improved survival, which could be attributable to decreased tumor size in the latter cohorts. Patients more recently diagnosed also demonstrated a relative survival advantage independent of size compared to the earliest patients studied.

Objectives To examine the racial differences in testicular cancer incidence, pathologic grade, stage, and survival with specific reference to Asian and white Americans and to evaluate the impact of disparities in stage at presentation, if present, on survival. Methods Using the Surveillance, Epidemiology, and End Results (SEER) database, we extracted all testicular cancer cases among white and Asian-American males for the years 1973 to 2000. Baseline demographic data included age at diagnosis, year of diagnosis, stage at diagnosis, and histologic features. Survival was examined using the Kaplan-Meier method and Cox proportional hazards modeling. Results The incidence of testicular cancer is lower among Asian Americans than among whites. However, Asian-American males presented with higher stage disease at diagnosis. Significant differences were noted in the histologic features between the two groups, with Asian Americans presenting with greater rates of seminoma. Asians also demonstrated survival differences, with poorer unadjusted survival compared with whites. However, when the variables of stage at diagnosis and histologic features were included in the analysis, the survival curves became similar. Conclusions Asians appeared to present with higher stage disease than do whites. Observed differences in survival for the Asian group relative to whites appeared to be primarily a result of delayed presentation. Cultural perceptions of malignancy and the understanding of cancer screening may be important determinants of later presentation. Healthcare access and education issues, rather than inherent biologic differences, are more likely the primary underlying factors for the observed survival differences in Asian males.

Ureteral stent removal is a source of patient morbidity. We surveyed 599 patients to evaluate their experiences and identify the preferred method of stent removal.Visitors to a kidney stone website were invited to participate. Respondents were asked how their ureteral stent was removed? Pain during and after the procedure, patient experiences, and preferences regarding stent removal were queried. Chi-square and ANOVA tests were used to identify significant differences among removal methods.Five hundred seventy-one respondents were included in the study. The majority of stents (44%) were removed by office cystoscopy while 39% had their stents removed by string. Mean pain during stent removal was 4.8 out of 10 with 57% reporting moderate-to-severe pain levels of 4 or more. Removal by office cystoscopy resulted in the highest experienced pain (5.3). Thirty-two percent reported delayed severe pain after stent removal, including 9% who returned for emergency care. Removal by string resulted in more emergency room visits when compared to cystoscopy. Willingness to undergo the same removal technique was lowest for those who underwent office cystoscopy and highest for operating room cystoscopy. Being informed of why a stent was placed and the removal process was of high priority for respondents.The majority of patients report moderate-to-severe pain with stent removal and a third report delayed significant pain after stent removal. Variations exist in the patient experience with stent removal based on the method used. More research is needed to identify effective ways to prevent or manage stent-removal-related adverse events.

Objectives. To review the pediatric renal trauma cases during the past 10 years to determine the appropriate indications for imaging and operative intervention. Methods. We searched the medical records from 1989 to 1999 and identified 61 patients aged up to 18 years old with objective data on renal trauma grade by either computed tomography or operative exploration and analyzed the data. Results. Of the 61 cases, 46 were blunt and 15 were penetrating injuries. Thirty-two (70%) of 46 patients with blunt injuries and all 15 patients (100%) with penetrating injuries sustained significant grade 2-5 injuries. The 14 grade 1 blunt injuries included 4 (29%) with gross hematuria, 7 (50%) with microscopic hematuria, and 3 (21%) with normal urinalyses. The 32 grade 2-5 blunt injuries included 20 (63%) with gross hematuria, 8 (25%) with microscopic hematuria, and 4 (13%) with normal urinalyses. The 15 grade 2-5 penetrating injuries included 9 (60%) with gross hematuria, 2 (13%) with microscopic hematuria, and 4 (27%) with normal urinalyses. Five of the blunt (11%) and 13 of the penetrating (87%) injuries were managed with renal operative intervention, including 12 repairs of lacerations or vessel injuries and 6 nephrectomies. Conclusions. Renal injuries of significant grade were encountered that presented with microscopic hematuria, as well as with normal urinalysis findings. Therefore, the decision for renal imaging for the diagnosis and grading of renal injuries should not be based on urinalysis alone in isolation from clinical status, history, and mechanism of injury. Although the vast majority of renal injuries do not require surgical intervention, their accurate grading prompts treatment with surveillance, bed rest, and close in-hospital monitoring.

Background Sequential compression devices (SCDs) are commonly used for thromboprophylaxis in postoperative patients but compliance is often poor. We investigated causes for noncompliance, examining both hospital and patient related factors. Methods 100 patients undergoing inpatient urologic surgery were enrolled. All patient had SCD sleeves placed preoperatively. Postoperative observations determined SCD compliance and reasons for non-compliance. Patient demographics, length of stay, inpatient unit type, and surgery type were recorded. At discharge, a patient survey gauged knowledge and attitudes regarding SCDs and bother with SCDs. Statistical analysis was performed to correlate SCD compliance with patient demographics; patient knowledge and attitudes regarding SCDs; and patient self-reported bother with SCDs. Results Observed overall compliance was 78.6%. The most commonly observed reasons for non-compliance were SCD machines not being initially available on the ward (71% of non-compliant observations on post-operative day 1) and SCD use not being restarted promptly after return to bed (50% of non-compliant observations for entire hospital stay). Mean self-reported bother scores related to SCDs were low, ranging from 1–3 out of 10 for all 12 categories of bother assessed. Patient demographics, knowledge, attitudes and bother with SCD devices were not significantly associated with non-compliance. Conclusions Patient self-reported bother with SCD devices was low. Hospital factors, including SCD machine availability and timely restarting of devices by nursing staff when a patient returns to bed, played a greater role in SCD non-compliance than patient factors. Identifying and addressing hospital related causes for poor SCD compliance may improve postoperative urologic patient safety.

Background Digital rectal examination (DRE) may play an important role as a secondary method of prostate cancer detection if prostate-specific antigen (PSA) screening decreases. Current practice patterns in the use of DRE are not well defined, and potential variations in its use among different subgroups of men are unclear. Materials and Methods The Behavioral Risk Factor Surveillance System was examined for the year 2010. All men aged 40 years old or older were asked if they ever had a rectal examination to check their prostate and the date of their last examination. Men who reported having had a DRE within the past 12 months were considered up to date. The proportion of men who reported having had a DRE and independent demographic and socioeconomic predictors for having had a DRE were determined. Results A total of 110,661 respondents were included: 72.2% of respondents reported ever having had a DRE; 36.8% had had a DRE within the past year, and 49.7% within the past 2 years. On multivariate analysis for reporting having an up-to-date DRE, older men, those with higher body mass index, and those of black race were more likely to have an up-to-date DRE. Asian or Hispanic race, divorced or widowed marital status, lower education, lower income, and lack of health insurance were independently associated with being less likely to have an up-to-date DRE. Conclusions Of American men, 36.8% reported having an up-to-date DRE within the past year and 49.7% of men within the past 2 years. Demographic and socioeconomic characteristics were strongly associated with the likelihood of having an up-to-date DRE.

Compelling preclinical and pilot clinical data support the role of green tea polyphenols in prostate cancer prevention. We conducted a randomized, double-blind, placebo-controlled trial of polyphenon E (enriched green tea polyphenol extract) in men with prostate cancer scheduled to undergo radical prostatectomy. The study aimed to determine the bioavailability of green tea polyphenols in prostate tissue and to measure its effects on systemic and tissue biomarkers of prostate cancer carcinogenesis. Participants received either polyphenon E (containing 800 mg epigallocatechin gallate) or placebo daily for 3 to 6 weeks before surgery. Following the intervention, green tea polyphenol levels in the prostatectomy tissue were low to undetectable. Polyphenon E intervention resulted in favorable but not statistically significant changes in serum prostate-specific antigen, serum insulin-like growth factor axis, and oxidative DNA damage in blood leukocytes. Tissue biomarkers of cell proliferation, apoptosis, and angiogenesis in the prostatectomy tissue did not differ between the treatment arms. The proportion of subjects who had a decrease in Gleason score between biopsy and surgical specimens was greater in those on polyphenon E but was not statistically significant. The study's findings of low bioavailability and/or bioaccumulation of green tea polyphenols in prostate tissue and statistically insignificant changes in systemic and tissue biomarkers from 3 to 6 weeks of administration suggests that prostate cancer preventive activity of green tea polyphenols, if occurring, may be through indirect means and/or that the activity may need to be evaluated with longer intervention durations, repeated dosing, or in patients at earlier stages of the disease. Cancer Prev Res; 5(2); 290–8. ©2011 AACR.

We determined factors influencing the behavior of patients with kidney stones in the prevention of recurrent stones.Patients with stones from an academic and a community practice were recruited for key informant interviews and focus groups. Groups were guided based on the framework of the health belief model. Content analysis was done on transcriptions using qualitative data analysis software.Key informant interviews were completed with 16 patients and with a total of 29 subjects in 5 focus groups. Content analysis revealed that patients were highly motivated to prevent stones. The minimum level of perceived benefit for adopting the behavior change varied among patients and the behaviors proposed. An important strategy to increase fluid intake was insuring availability with containers. Patients were more consistently confident in the ability to increase fluid, in contrast to ingesting medicine or changing the diet. While barriers to increasing fluid were multifactorial among individuals, the barriers aligned into 3 progressive stages that were associated with distinct patient characteristics. Stage 1 barriers included not knowing the benefits of fluid or not remembering to drink. Stage 2 barriers included disliking the taste of water, lack of thirst and lack of availability. Stage 3 barriers included the need to void frequently and related workplace disruptions.Patients with kidney stones are highly motivated to prevent recurrence and were more amenable to fluid intake change than to another dietary or pharmaceutical intervention. Barriers preventing fluid intake success aligned into 3 progressive stages. Tailoring fluid intake counseling based on patient stage may improve fluid intake behavior.

To evaluate patient preferences, understanding, and satisfaction regarding visual review of radiographic images during counseling.101 urologic patients who presented for counseling where images impacted decision making were randomized into group A, shown their images, and group B, shown a diagram. Both completed a satisfaction survey blinded to the study's purpose. A second unblinded survey evaluated patient comprehension of and preferences regarding images. Comparison of intervention and control groups for differences in satisfaction and analysis of patient self-reported preferences and understanding regarding radiographic images was performed.Group A had higher satisfaction scores but did not reach statistical significance. Both groups reported comprehension of images (100%, 97.9%), improvement in understanding of their condition and treatment because of viewing images (98%, 95.8%), and felt images should be shown to all patients (92%, 89.6%). Multivariate analysis identified female sex to independently predict greater understanding of images and belief that all patients should be shown their images.Almost all patients reported comprehension of images, improvement in understanding because of review of images, and preference for being shown images. Female patients expressed greater understanding and preference for all patients to be shown their images. Review of radiographic images represents a potentially useful additional modality for patient counseling whose usefulness for improving satisfaction will need to be confirmed in further studies.

To report a weakness in the April 2006 release of the Surveillance, Epidemiology, and End Results (SEER) dataset, in which the primary tumor size of small (1.8 cm) metastatic renal cancers was often incorrectly coded into the dataset from the measurement as listed in the patient's chart.In the SEER dataset, 167 patients with tumor sizeor = 2.5 cm had metastatic disease at presentation in 1998-2003. Each patient's chart was individually re-examined by SEER registries to determine the correct primary tumor size. This confirmed data were compared with the coded tumor size in the SEER dataset.Of the 167 re-examined cases, 2 had incorrect histology and 6 could not be verified. Of the remaining 159 cases, 87 (55%) were correctly coded for primary tumor size while 72 (45%) were incorrect. The error rate decreased with increasing size; for tumorsor = 1 cm,1-2 cm, and2-2.5 cm, error rates were 88%, 53%, and 6.8%, respectively (P.001). A breakpoint in error rate occurred between tumor sizes1.8 cm (78%) andor = 1.8 cm (10%) (P.001). Most errors (72%) were miscoded by a factor of 10. Analysis of the latest April 2009 release suggests that most corrections have been incorporated into the public access dataset.Coded primary tumor sizes in the April 2006 release SEER dataset for metastatic renal tumors1.8 cm from 1998 to 2003 were often inaccurate. Verification of tumor size in this subset was essential to insure data accuracy and quality of research. Researchers should recognize potential limitations of population-based cancer registries.

Ureteral replacement with interposition of a bowel segment has traditionally required a large incision with substantial associated morbidity and prolonged time to convalescence. During the last 7 years a technique for laparoscopic assisted ileal interposition has evolved that mimics our open approach. We present a comparative analysis of functional and perioperative outcomes between patients undergoing laparoscopic or open ileal ureter replacement at our institution.A search of all procedures from 1980 to the present revealed 7 patients undergoing laparoscopic and 7 undergoing open ileal interposition. Functional and perioperative data from these patients are compared, and a detailed description of technique for the laparoscopic procedure is presented.Narcotic analgesic use in morphine equivalents (median 38.9 vs 322.2 mg, p = 0.035) and time to convalescence (median 4 vs 5.5 weeks, p = 0.03) were significantly less in the laparoscopic group. A trend toward shorter hospital stay (median 5 vs 8 days, p = 0.101) was also noted in patients in the laparoscopic group. There was no evidence of anastomotic stricture for patients in either group at last followup.Despite the small number of subjects involved a significant advantage was noted for postoperative recovery after laparoscopic compared to open ileal interposition. A detailed understanding of this complicated procedure can help prevent inherent pitfalls.

We determined the relationship between the prevalence of metastasis at presentation and cancer specific mortality with tumor size in renal cancer cases using a large cancer database.The Surveillance, Epidemiology and End Results data set was analyzed for renal tumors diagnosed from 1998 to 2003. A total of 24,253 patients were included. The prevalence of metastasis and cancer specific survival as a function of tumor size were evaluated using linear and nonlinear curve fitting methods. Metastatic cases with tumors 2.5 cm or less were individually reconfirmed case by case for accuracy.Increasing tumor size correlated with a higher prevalence of metastasis at diagnosis (range 1.4% for tumors 1 cm or less to 50.9% for tumors greater than 15 cm). Five-year cancer specific mortality in treated patients was also closely related to tumor size (range 3.5% for tumors 1 cm or less to 50.9% for tumors greater than 15 cm). In each instance the relationship was sigmoidal rather than linear and it was best modeled using a quadratic function. The most rapid increase in the prevalence of metastasis and mortality was noted for tumors 4 to 12 cm. In treated patients with tumors 1 cm or less, 1.1 to 2, 2.1 to 3 and 3.1 to 4 the prevalence of metastasis at diagnosis was 1.4%, 2.5%, 4.7% and 7.4%, and the 5-year cancer specific mortality rate was 3.5%, 3.8%, 4.1% and 5.3%, respectively.In cases of renal cancer the prevalence of metastasis at presentation and 5-year cancer specific mortality increase in a nonlinear sigmoidal relationship with tumor size.

Laparoscopic adrenalectomy for malignant adrenal masses has been controversial because of initial reports of high rates of local recurrence and carcinomatosis. With additional experience, improved outcomes have been reported. We evaluate the contemporary role of laparoscopy in treating adrenal malignancies.Several contemporary reports now demonstrate that laparoscopic adrenalectomy for primary adrenal malignancy can provide oncologic outcomes equivalent to open surgery without an increased risk of carcinomatosis or port site recurrence. Although long-term survival of 47 months with no recurrence has been reported, the underlying aggressiveness of this tumor has contributed to a 39.6% rate of recurrence for the 48 contemporary cases reviewed in this article. This compares favorably to open series that report a similar or higher recurrence rate. When utilized for the treatment of solitary metastases to the adrenal gland, laparoscopic adrenalectomy provides equivalent oncologic outcomes to open adrenalectomy.Laparoscopic adrenalectomy for malignancy can be performed in appropriately selected cases with equal oncologic outcomes to open approaches while providing advantages in patient morbidity. Caution must be taken to avoid tumor entry or spillage because of the potential for local recurrence, port site recurrence, and carcinomatosis that can occur with these aggressive tumors.

Laparoscopic partial nephrectomy has demonstrated renal functional and 5-year oncological outcomes equivalent to those of open partial nephrectomy. A remaining critique of laparoscopic partial nephrectomy is its 10-minute longer ischemia time compared to open surgery. We present an early unclamping laparoscopic partial nephrectomy technique that decreases ischemia time by more than 50%.During standard laparoscopic partial nephrectomy renal reconstruction is completely performed under ischemic conditions. In our early unclamping technique only the initial parenchymal suturing is performed under ischemia with the remainder of bolstered renorrhaphy performed in the revascularized kidney. Of 100 consecutive nonrandomized patients the initial 50 underwent standard laparoscopic partial nephrectomy (group 1) and the subsequent 50 underwent early unclamping laparoscopic partial nephrectomy (group 2).Baseline demographics (body mass index, mean tumor size and central/hilar tumor location) and intraoperative parameters (need for pelvicaliceal repair, blood loss and operative time) were similar in the groups. However, warm ischemia time was significantly lower in group 2 (31.1 vs 13.9 minutes, p0.0001). In groups 1 and 2 ischemia time was 30 minutes or greater in 60% vs 0% of patients (p0.0001). Compared to group 1 overall complications (22% vs 16%), postoperative renal hemorrhage (4% vs 2%) and the re-intervention rate (16% vs 6%) trended lower in group 2 (p = not significant). No patient had a positive cancer margin, required open conversion or showed renal dysfunction.This early unclamping laparoscopic partial nephrectomy technique significantly decreases ischemia time by more than 50% and also trends toward decreased complications. Our current mean ischemia time of less than 14 minutes is lower than or equivalent to that in contemporary open partial nephrectomy series.

We report an unusual case of testicular cancer metastasized solely in the brain and spleen without retroperitoneal disease or other widespread metastasis. The patient initially presented with seizures and underwent craniotomy for presumed primary brain tumor, with a delayed diagnosis of testicular cancer as the true primary. This pattern of spread is highly unusual, and, to our knowledge, we report the first case of splenectomy performed for involvement by testicular cancer. At last follow-up, the patient was doing well, with no evidence of disease after 2 years.

Iatrogenic injuries to the extrahepatic biliary tract are rare during urologic laparoscopy. A few cases of gallbladder injury have been reported; however, to our knowledge, no instance of common bile duct (CBD) injury during urologic laparoscopy has hitherto been described. Out of 2866 transperitoneal laparoscopic urologic procedures between 1997 and 2007, we present two patients who sustained iatrogenic CBD injury, one during laparoscopic anterior pelvic exenteration and Indiana pouch diversion, and the other during laparoscopic partial nephrectomy. Etiology, management, and preventive strategies are summarized.

OBJECTIVE To identify differences in operative outcome between methods of controlling the dorsal vein complex during laparoscopic prostatectomy, i.e. suture ligature or stapling with an endoscopic stapler (Endopath ETS Flex 45 linear stapler; Ethicon, Cincinnati, OH, USA). PATIENTS AND METHODS In all, 120 patients who had a laparoscopic prostatectomy between January 2005 and October 2006 were assessed; 60 had suture ligature and 60 were treated with the stapler. In a multivariate analysis accounting for baseline patient and disease characteristics, the primary outcome variables evaluated included estimated blood loss (EBL), operative duration and positive margin rates. RESULTS The baseline demographics were similar between the sutured and stapled groups for age (59.6 vs 60.1 years, P = 0.674), body mass index (29.2 vs 28.5 kg/m2, P = 0.237), preoperative prostate-specific antigen level (5.3 vs 5.7 ng/mL, P = 0.5), Gleason score (6.4 vs 6.3, P = 0.294), clinical stage (77% vs 88% T1c, P = 0.052) and preoperative Sexual Health Inventory for Men score (19.4 vs 19.6, P = 0.813). Operative measures were not significantly different between the groups for EBL (287 vs 343 mL, P = 0.156) or operative duration (234 vs 223 min, P = 0.324). Apical margin involvement was also not significantly different (12% vs 7%, P = 0.121). The overall positive margin rate (30% vs 18%, P = 0.020) and disease volume (22% vs 13%‘extensive’, P = 0.021) were higher among the sutured group, but on multivariate analysis the overall margin rate was not significantly different. CONCLUSIONS There was no difference between sutured and stapled control of the dorsal vein complex during laparoscopic prostatectomy in EBL, operative duration or positive margin rate.