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Introduction: The benefit of lymph node dissection (LND) in renal cell carcinoma (RCC) remains poorly defined. Despite this uncertainty, the American Urological Association (AUA) guideline on localized renal cancer recommends that LND be performed for staging purposes when there is suspicion of regional lymphadenopathy on imaging. Using the National Cancer Database (NCDB), we sought to determine how much of a departure the new AUA guideline is from current practice. We hypothesized that practice patterns would reflect the "Expert Opinion" recommendation and that patients who are clinical lymph node (cLN) positive would receive a LND more often than those who are cLN negative. Additionally, we sought to determine factors that would trigger a LND as well the accuracy of clinical staging by examining the relationship between cLN and pathologic lymph node (pLN) status of patients who received a LND., Materials and Methods: The NCDB was queried for patients with nonmetastatic RCC who underwent partial nephrectomy or nephrectomy from 2010 to 2014. Patient sociodemographic and clinical characteristics were extracted. Frequency distributions were calculated for patients with both cLN and pLN status available. Of patients who received a LND, sensitivity, specificity, and positive/negative predictive values (PPV/NPV) of cLN status for pLN positivity were calculated. Logistic regression models were used to examine association between clinical and socioeconomic factors and receipt of LND. Propensity score matching was used in sensitivity analyses to examine potential for reporting bias in NCDB data., Results: We identified 110,963 patients who underwent surgery for RCC, of whom 11,867 (11%) had LND performed at the time of surgery. cLN and pLN information were available in 11,300 patients, of which 1,725 were preoperatively staged as having positive cLN. More LNDs were performed per year for patients who were cLN negative than cLN positive. Of patients who received a LND, the majority of patients were cLN negative across all clinical T (cT) stages. Multivariable analysis showed that all patients who had care at an academic/research institution (odds ratio [OR]: 1.58, 95% confidence interval [CI]: 1.43-1.74) and had to travel >12.5 to 31.0 miles and >31.0 miles to a treatment center (OR: 1.08, 95%CI: 1.01-1.15 and OR: 1.28, 95%CI: 1.20-1.36, respectively) were more likely to get a LND. As cT stage increased from cT2-4, the risk of LND increased (OR range: 4.7-7.90, respectively). Patients who were cLN positive were more likely to receive a LND at the time of surgery (OR: 18.68, 95%CI: 16.62-21.00). Of the patients who received a LND, clinical staging was more specific than sensitive., Conclusion: More patients received a LND who were cLN negative compared to patients who were cLN positive. Patients who were cLN positive were more likely to receive a LND. Treatment center type, distance to treatment center, cT stage, and cLN positivity were factors associated with LND receipt., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Alvimopan use has reduced the length of hospital stay in patients undergoing major abdominal surgeries and radical cystectomy. Retroperitoneal lymph node dissection for testicular cancer may be associated with delayed gastrointestinal recovery prolonging hospital length of stay. We evaluate whether alvimopan is associated with enhanced gastrointestinal recovery and shorter hospital length of stay in men undergoing retroperitoneal lymph node dissection for testicular cancer., Materials and Methods: From 2010 to 2016, 29 patients underwent open, transperitoneal bilateral template retroperitoneal lymph node dissection. Data for patients who received alvimopan were prospectively collected and compared to a historical cohort of patients who did not receive alvimopan. Primary outcome measures were length of stay and recovery of gastrointestinal function. Descriptive statistics were reported. Time-to-event outcomes were evaluated using cumulative incidence curves and log rank test. Factors associated with length of stay were analyzed for correlation using multiple linear regression., Results: Of 29 men undergoing retroperitoneal lymph node dissection, eight received alvimopan and 21 did not. The two cohorts were well matched, with no significant differences. In the alvimopan cohort compared with those who did not receive alvimopan median time to return of flatus was 2 versus 4 days ( p =0.0002), and median time to first bowel movement was 2.5 versus 5 days ( p =0.046), respectively. Median length of stay in the alvimopan cohort was 4 days versus 6 days in those who did not receive alvimopan ( p =0.074). In adjusted analyses, receipt of alvimopan did not influence length of stay., Conclusion: Alvimopan may facilitate gastrointestinal recovery after retroperitoneal lymph node dissection for testicular cancer. Whether this translates into reduced length of stay needs to be determined by randomized controlled trials using larger cohorts., Level of Evidence: 3b., Competing Interests: Conflicting interests The authors declare that there is no conflict of interest.

Purpose: Lymph node (LN) involvement in renal cell carcinoma (RCC) is associated with a poor prognosis. While lymph node dissection (LND) may provide diagnostic information, its therapeutic benefit remains controversial. Thus, the aim of our study is to analyze survival outcomes after LND for nonmetastatic RCC and to characterize contemporary practice patterns., Materials and Methods: The National Cancer Database was queried for patients with nonmetastatic RCC who underwent either partial or radical nephrectomy from 2010 to 2014. A total of 11,867 underwent surgery and LND. Chi-square tests were used to examine differences in patient demographics. To minimize selection bias, propensity score matching (PSM) was used to select one control for each LND case (n = 19,500). Cox regression analyses were conducted to examine overall survival (OS) in patients who received LND compared to those who did not., Results: Of all patients undergoing LND for RCC (n = 11,867), 5%, 23%, 31%, 47% were performed for tumors of clinical T stage 1, 2, 3, and 4, respectively. Proportions of LND have not significantly changed from 2010 to 2014. No significant improvement in median OS for patients undergoing LND compared to no LND was shown (34.7 vs. 34.9 months, respectively; P = 0.98). Similarly, no significant improvement in median OS was found for clinically LN positive patients undergoing LND compared to no LND (P = 0.90). On Cox regression analysis, LND dissection was not associated with an OS benefit (hazard ratio: 1.00; 95% confidence interval 0.97 to 1.04)., Conclusions: Among all RCC patients, LNDs are often performed for low stage disease, suggesting a potential overutilization of LND. No OS benefit was seen in any subgroup of patients undergoing LND. Further investigation is needed to determine which patient populations may benefit most from LND., (Copyright © 2018. Published by Elsevier Inc.)

Background: Men with locally advanced prostate cancer (LAPCa) or regionally advanced prostate cancer (RAPCa) are at high risk for death from their disease. Clinical guidelines support multimodal approaches, which include radical prostatectomy (RP) followed by radiotherapy (XRT) and XRT plus androgen deprivation therapy (ADT). However, there are limited data comparing these substantially different treatment approaches. Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, this study compared survival outcomes and adverse effects associated with RP plus XRT versus XRT plus ADT in these men., Methods: SEER-Medicare data were queried for men with cT3-T4N0M0 (LAPCa) or cT3-T4N1M0 (RAPCa) prostate cancer. Propensity score methods were used to balance cohort characteristics between the treatment arms. Survival analyses were analyzed with the Kaplan-Meier method and Cox proportional hazards models., Results: From 1992 to 2009, 13,856 men (≥65 years old) were diagnosed with LAPCa or RAPCa: 6.1% received RP plus XRT, and 23.6% received XRT plus ADT. At a median follow-up of 14.6 years, there were 2189 deaths in the cohort, of which 702 were secondary to prostate cancer. Regardless of the tumor stage or the Gleason score, the adjusted 10-year prostate cancer-specific survival and 10-year overall survival favored men who underwent RP plus XRT over men who underwent XRT plus ADT. However, RP plus XRT versus XRT plus ADT was associated with higher rates of erectile dysfunction (28% vs 20%; P = .0212) and urinary incontinence (49% vs 19%; P < .001)., Conclusions: Men with LAPCa or RAPCa treated initially with RP plus XRT had a lower risk of prostate cancer-specific death and improved overall survival in comparison with those men treated with XRT plus ADT, but they experienced higher rates of erectile dysfunction and urinary incontinence., (© 2018 American Cancer Society.)

A 41-year-old female patient presented with left-sided flank pain and gross hematuria temporally unrelated to her menstrual cycle. Abdominal computed tomography scan showed a large left-sided solid, enhancing kidney mass radiographically consistent with renal cell carcinoma. Following surgical resection, histopathological examination revealed polypoid endometriosis. Polypoid endometriosis is rare and mimics a neoplasm clinically, radiographically, and on gross examination. Patients with polypoid endometriosis often present with symptoms related to mass effect rather than classic endometriosis hallmark symptoms such as dyspareunia, dysmenorrhea, and cyclic abdominal pain. Treatment includes surgical resection., (Copyright © 2018. Published by Elsevier Inc.)

Background: Radical cystectomy (RC) with ileal conduit (IC) or continent diversion (CD) is standard treatment for high-risk non-invasive and muscle-invasive bladder cancer., Objective: Our aim is to study contemporary trends in the utilization of ICs and CDs in patients undergoing RC., Methods: Using the National Inpatient Sample 2001-2012, we identified all patients diagnosed with a malignant bladder neoplasm who underwent RC followed by IC or CD. Patient demographics, comorbidities, length of stay (LOS), and in-hospital complications, mortality, and costs were compared. Multivariable logistic regression analysis, Chi square, and t -tests were used for analysis., Results: Between 2001-2012, approximately 69,049 ICs and 6,991 CDs were performed. CDs increased from 2001 to 2008, but declined after 2008 ( p  < 0.0001). Patients of all ages received ICs at a higher rate than CDs (40-59 years: 79.5% vs. 20.5%; 60-69 years: 88.0% vs. 12.0%; p  < 0.0001). There was a difference in males vs. females (10.2% vs. 4.0%; OR 2.36) and Caucasians vs. African Americans (9.0% vs. 6.7%; OR 1.49) when comparing CD rates. CD rates were highest in the West, urban teaching centers, and large hospitals ( p  < 0.001). ICs were associated with higher rates of overall postoperative complications ( p  = 0.0185) including infection ( p  = 0.002) and mortality ( p  < 0.0001). In-hospital costs were greater for the CD group., Conclusions: The number of CDs has declined recently. Patients of all ages are more likely to receive ICs than CDs. Gender, racial, and geographic disparities exist among those receiving CDs. CDs are associated with lower rates of in-hospital complications and mortality, but higher in-hospital costs.

Introduction: Physician-industry relationships are common in the U.S. and a source of considerable public scrutiny. The Open Payments program is a public database of all physician-industry financial interactions in the U.S. administered by the Centers for Medicare & Medicaid Services. In this study we describe payments received by urologists for research and nonresearch purposes., Methods: The number and value of payments to urologists were determined using Open Payments program data. The nature of each payment and identity of industry partners were analyzed. Descriptive statistics were calculated separately for research and nonresearch payment data. The total number of practicing physicians per specialty was obtained from the Association of American Medical Colleges Physician Specialty Data Book for 2014., Results: In 2014, 8,620 urologists had nonresearch financial relationships with industry for a total value of $32.4 million, with 2,698 urologists receiving more than $1,000 in total nonresearch payments. Urologists as a whole had the 8th highest total value received of all specialties. A total of $22.4 million was spent by industry for urology directed research funding, representing a small proportion of the more than $3 billion spent by industry on medical research in 2014. The majority (93.1%) of urology directed research funding was provided to nonteaching institutions., Conclusions: The Open Payments program database is an important public database of financial transactions between industry and physicians. A large proportion of urologists received nonresearch related transfers of value from industry sources. Industry supported research funding is primarily awarded to nonteaching institutions.

The past decade has seen a rapid proliferation in the number and types of systemic therapies available for renal cell carcinoma. However, surgery remains an integral component of the therapeutic armamentarium for advanced and metastatic kidney cancer. Cytoreductive surgery followed by adjuvant cytokine-based immunotherapy (predominantly high-dose interleukin 2) has largely given way to systemic-targeted therapies. Metastasectomy also has a role in carefully selected patients. Additionally, neoadjuvant systemic therapy may increase the feasibility of resecting the primary tumor, which may be beneficial for patients with locally advanced or metastatic disease. Several prospective trials examining the role of adjuvant therapy are underway. Lastly, the first immune checkpoint inhibitor was approved for metastatic renal cell carcinoma (mRCC) in 2015, providing a new treatment mechanism and new opportunities for combining systemic therapy with surgery. This review discusses current and historical literature regarding the surgical management of patients with advanced and mRCC and explores approaches for optimizing patient selection.

This article aimed to assess the burden of scheduling major urologic oncology procedures if all cases were performed robotically and to determine whether this would increase the time a patient would have to wait for surgery. We retrospectively determined the number of prostatectomies, radical nephrectomies, partial nephrectomies, and cystectomies at a single institution for one calendar year. A hypothetical situation was then constructed where all procedures were performed robotically. Using the allotted number of days that each surgeon was able to schedule robotic procedures, we analyzed the amount of time it would take to schedule and complete all cases. Five fellowship-trained surgeons were included in the study and accounted for 317 surgical cases. Three of the surgeons had dedicated robotic surgery (RS) time (block time), while two surgeons scheduled when there was non-dedicated RS time (open time) available. If all cases were performed robotically an additional 32 days would be needed, which could significantly increase the wait time to surgery. The limited number of robotic systems available in most hospitals creates a bottleneck effect; whereby increasing the number of cases would considerably lengthen the waiting time patients have for surgery. As RS becomes increasingly more commonplace in urology and other surgical fields, this could create a significant problem for health care systems., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Introduction: To investigate the trends in the performance of radical cystectomy (RC) versus partial cystectomy (PC) in the United States over the past 10 years and compare postoperative outcomes between two procedures., Materials and Methods: The data was captured from the Nationwide Inpatient Sample (NIS) 2001-2010 using the appropriate ICD-9-CM diagnosis and procedure codes. Patient sociodemographics, comorbidities and in-hospital complications after PC and RC were compared, taking into account some hospital characteristics. A chi-square analysis including a Cochran-Armitage trend test and a multivariable logistic regression analysis were employed., Results: RC rate increased from 84.8% in 2001 to 90.3% in 2010, while PC decreased from 15.2% to 9.7% (p < 0.0001). PC patients were older than their RC counterparts (72.1 ± 11.3 versus 68.6 ± 10.1 years; p < 0.0001), had higher prevalence of major comorbidities, but decreased rate of postoperative complications overall (21.3% versus 38.6%; p < 0.001). The greatest rates of PC utilization were found in the Northeast and South (12.8% and 12.7%). The frequency of PC was 18.9% in non-teaching hospitals compared to 9.0% in teaching hospitals (p < 0.0001). In multivariate analysis, females, octogenarians, patients with hypertension and obesity, and patients in non-teaching and rural hospitals were more likely to receive PC., Conclusions: Despite the potential advantages in cancer control offered by RC, PC is being performed more frequently on the elderly, female patients, patients with hypertension and obesity, in non-teaching and rural hospitals, and in certain United States geographic regions, which can be partially explained by disparities in access to high volume cancer centers.

Background: Few studies have analyzed factors that influence longitudinal changes in patient-perceived satisfaction during the recovery period following robot-assisted radical prostatectomy (RARP) for prostate cancer. We investigated variables that were associated with patient-perceived satisfaction after RARP using the expanded prostate cancer index composite (EPIC) survey., Methods: Of 175 men who underwent RARP between 2010 and 2011, 140 men completed the EPIC questionnaire preoperatively and 3, 6 and 12 months postoperatively. On the basis of the EPIC question no. 32 (item number 80), patients were divided into four groups according to the pattern of satisfaction change at postoperative 3 and 12 months: satisfied to satisfied (group 1); satisfied to dissatisfied (group 2); dissatisfied to satisfied (group 3); and dissatisfied to dissatisfied (group 4). Longitudinal changes in EPIC scores over time in each group and differences in EPIC scores of each domain subscale between groups at each follow-up were analyzed. A linear mixed model with generalized estimating equation approach was used to identify independent factors that influence overall satisfaction among repeated measures from same patients., Results: On the basis of the pattern of satisfaction change, groups 1, 2, 3 and 4 had 103 (74.3%), 21 (15.0%), 11 (7.9%) and 5 (2.9%) patients, respectively. The factor that was associated with overall satisfaction was urinary bother (UB) (β=0.283, 95% confidence interval (0.024, 0.543 ); P=0.033) adjusted for other factors under consideration., Conclusions: UB was the independent factor influencing patient-perceived satisfaction after RARP. During post-RARP follow-up, physician should have the optimal management for the patient's UB.

Unlabelled: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Receipt of androgen deprivation therapy (ADT) has been associated with an increased risk of skeletal-associated complications, such as a decrease in bone mineral density and an increase in fracture risk. Many men with pre-existing health conditions receive ADT as their primary treatment because they are considered to be inappropriate candidates for attempted curative treatments. However, several chronic health conditions, such as diabetes, rheumatoid disease and chronic liver disease, are strong predictors for osteoporosis and fractures. We undertook the present study aiming to quantify the impact of treating men with ADT who carry known risk factors for skeletal complications. Among these high-risk men, more than 58% develop at least one fracture after ADT within the 12 years of follow-up. Men who sustained a fracture within 48 months experienced an almost 40% higher risk of mortality than those who did not. Our findings suggest that treating men with a high fracture risk at baseline with long-term ADT may have serious adverse consequences., Objective: To quantify the impact of androgen deprivation therapy (ADT) in men with a high baseline risk of skeletal complications and evaluate the risk of mortality after a fracture., Patients and Methods: We studied 75994 men, aged ≥ 66 years, with localized prostate cancer from the Surveillance, Epidemiology and End Results-Medicare linked data. Cox proportional hazard models were employed to evaluate the risk., Results: Men with a high baseline risk of skeletal complications have a higher probability of receiving ADT than those with a low risk (52.1% vs 38.2%, P < 0.001). During the 12-year follow-up, more than 58% of men with a high risk and 38% of men with a low risk developed at least one fracture after ADT. The dose effect of ADT is stronger among men who received ADT only compared to those who received ADT with other treatments. In the high-risk group, the fracture rate increased by 19.9 per 1000 person-years (from 52.9 to 73.0 person-years) for men who did not receive ADT compared to those who received 18 or more doses of gonadotropin-releasing hormone agonist among men who received ADT only, and by 14.2 per 1000 person-years (from 45.2 to 59.4 person-years) among men who received ADT and other treatments. Men experiencing a fracture had a 1.38-fold higher overall mortality risk than those who did not (95% CI, 1.34-1.43)., Conclusions: Men with a high baseline risk of skeletal complications developed more fractures after ADT. The mortality risk is 40% higher after experiencing a fracture. Consideration of patient risk before prescribing ADT for long-term use may reduce both fracture risk and fracture-associated mortality., (© 2013 BJU International.)

The aim of this study was to assess the treatment patterns and 3-12-month complication rates associated with receiving prostate cryotherapy in a population-based study. Men >65 years diagnosed with incident localized prostate cancer in Surveillance Epidemiology End Results (SEER)-Medicare-linked database from 2004 to 2005 were identified. A total of 21,344 men were included in the study, of which 380 were treated initially with cryotherapy. Recipients of cryotherapy versus aggressive forms of prostate therapy (ie, radical prostatectomy or radiation therapy) were more likely to be older, have one co-morbidity, low income, live in the South and be diagnosed with indolent cancer. Complication rates increased from 3 to 12 months following cryotherapy. By the twelfth month, the rates for urinary incontinence, lower urinary tract obstruction, erectile dysfunction and bowel bleeding reached 9.8, 28.7, 20.1 and 3.3%, respectively. Diagnoses of hydronephrosis, urinary fistula or bowel fistula were not evident. The rates of corrective invasive procedures for lower urinary tract obstruction and erectile dysfunction were both <2.9% by the twelfth month. Overall, complications post-cryotherapy were modest; however, diagnoses for lower urinary tract obstruction and erectile dysfunction were common.

Active surveillance is an acceptable treatment option in men with a low-risk prostate cancer. In the present study, we have retrospectively reviewed the outcomes of 509 men who fit the criteria for active surveillance but selected radical prostatectomy. Then, the impact of varying prostate-specific antigen (PSA) levels on the risk of upstaging and upgrading in these patients was assessed. Pathological characteristics of patients who fulfilled the inclusion criteria under three active surveillance criteria--those of the University of California-San Francisco, the National Cancer Institute and the European Association of Urology--were examined. The proportion of men who were deemed candidates for active surveillance but were subsequently upstaged or upgraded was determined. Of 509 patients, 186 (36.5%), 132 (25.9%) and 88 (17.3%) men fulfilled the active surveillance criteria, respectively. Upgrading (Gleason scores 7-10) ranged from 32.8% to 38.6%, while upstaging (≥pT3) ranged from 10.2% to 12.5%, depending on the three active surveillance criteria. After a median follow-up of 24 months, three patients developed a biochemical recurrence. When the impact of varying PSA levels was examined using a test for trend analysis in the context of PSA for each protocol, rates of upstaging were lower in men with PSA <4 ng ml(-1). However, there was no impact of varying PSA levels on upgrading. In conclusion, commonly used active surveillance protocols carry the risks of upgrading and upstaging. More reliable and accurate markers are needed to better stratify the risks of men who are appropriate candidates for active surveillance.

Prostate cancer is the most common non-skin-related cancer in men. With advances in technology, the care and treatment for men with this disease continues to become more complex. Large databases offer researchers a unique opportunity to conduct prostate cancer research in various areas, and provide important information that helps patients and providers determine prognosis after treatment. Furthermore, the studies using these databases may provide information on how side effects from various treatments can affect one's quality of life. Finally, information from these datasets can help to identify factors that determine why patients receive the treatments they do. Despite this, these databases are not without limitations. In this review, we discuss various available, national, multicenter, and institutional databases in the context of prostate cancer research, citing numerous important studies that have impacted on our understanding of prostate cancer outcomes.

Background: DNA methyltransferase (DNMT) is one of the major factors mediating the methylation of cancer related genes such as TGF-β receptors (TβRs). This in turn may result in a loss of sensitivity to physiologic levels of TGF-β in aggressive prostate cancer (CaP). The specific mechanisms of DNMT's role in CaP remain undetermined. In this study, we describe the mechanism of TGF-β-mediated DNMT in CaP and its association with clinical outcomes following radical prostatectomy., Methodology/principal Findings: We used human CaP cell lines with varying degrees of invasive capability to describe how TGF-β mediates the expression of DNMT in CaP, and its effects on methylation status of TGF-β receptors and the invasive capability of CaP in vitro and in vivo. Furthermore, we determined the association between DNMT expression and clinical outcome after radical prostatectomy. We found that more aggressive CaP cells had significantly higher TGF-β levels, increased expression of DNMT, but reduced TβRs when compared to benign prostate cells and less aggressive prostate cancer cells. Blockade of TGF-β signaling or ERK activation (p-ERK) was associated with a dramatic decrease in the expression of DNMT, which results in a coincident increase in the expression of TβRs. Blockade of either TGF-β signaling or DNMT dramatically decreased the invasive capabilities of CaP. Inhibition of TGF-β in an TRAMP-C2 CaP model in C57BL/6 mice using 1D11 was associated with downregulation of DNMTs and p-ERK and impairment in tumor growth. Finally, independent of Gleason grade, increased DNMT1 expression was associated with biochemical recurrence following surgical treatment for prostate cancer., Conclusions and Significance: Our findings demonstrate that CaP derived TGF-β may induce the expression of DNMTs in CaP which is associated with methylation of its receptors and the aggressive potential of CaP. In addition, DNMTs is an independent predictor for disease recurrence after prostatectomy, and may have clinical implications for CaP prognostication and therapy.

Objective: To examine our institutional experience in patients treated with partial nephrectomy (PN) for renal cortical tumours (RCTs) of ≥ 7 cm, as PN is an accepted surgical approach for appropriate RCTs of < 7 cm but there are limited data on the use of PN for larger tumours., Patients and Methods: After Institutional Review Board approval, we examined our prospectively collected surgical database for patients treated with PN for RCTs of ≥ 7 cm between 1989 and 2008. Pertinent demographic, clinical, surgical and pathological data were reviewed., Results: In all, 34 patients (37 renal units) were identified for analysis with a median (interquartile range, IQR) age of 63 (52-71) years, median (IQR) tumour size of 7.5 (7.2-9.0) cm with the largest tumour being 19 cm. In 31 renal units (28 patients, 84%) carcinoma was evident, with 16 renal units (43%) having conventional clear cell carcinoma, followed by papillary in eight renal units (21%). Currently, 20 of these 28 patients (71%) are disease free, three are alive with metastatic disease (two had known preoperative metastatic disease), three died from disease and two died from other causes. The median (IQR) preoperative estimated glomerular filtration rate was 65 (55-73) mL/min/1.73 m(2) , compared with 55 (47-74) mL/min/1.73 m(2) after PN (P= 0.003, paired Student's t-test)., Conclusions: Our findings suggest that PN for RCTs of ≥ 7 cm can be safely performed and provide effective tumour control for selected patients. PN should be considered for patients with appropriate tumours, solitary kidneys or pre-existing renal insufficiency., (© 2010 THE AUTHORS. JOURNAL COMPILATION © 2010 BJU INTERNATIONAL.)

Purpose: Enthusiasm for laparoscopic surgical approaches to prostate cancer treatment has grown despite limited evidence of improved outcomes compared with open radical prostatectomy. We compared laparoscopic prostatectomy with or without robotic assistance vs open radical prostatectomy in terms of postoperative outcomes and subsequent cancer directed therapy., Materials and Methods: Using a population based cancer registry linked with Medicare claims we identified men 66 years old or older with localized prostate cancer who underwent radical prostatectomy from 2003 to 2005. Outcome measures were general medical/surgical complications and mortality within 90 days after surgery, genitourinary/bowel complications within 365 days, radiation therapy and/or androgen deprivation therapy within 365 days and length of hospital stay., Results: Of the 5,923 men 18% underwent laparoscopic radical prostatectomy. Adjusting for patient and tumor characteristics, there were no differences in the rate of general medical/surgical complications (OR 0.93 95% CI 0.77-1.14) or genitourinary/bowel complications (OR 0.96 95% CI 0.76-1.22), or in postoperative radiation and/or androgen deprivation (OR 0.80 95% CI 0.60-1.08). Laparoscopic prostatectomy was associated with a 35% shorter hospital stay (p <0.0001) and a lower bladder neck/urethral obstruction rate (OR 0.74, 95% CI 0.58-0.94). In laparoscopic cases surgeon volume was inversely associated with hospital stay and the odds of any genitourinary/bowel complication., Conclusions: Laparoscopic prostatectomy and open radical prostatectomy have similar rates of postoperative morbidity and additional treatment. Men considering prostate cancer surgery should understand the expected benefits and risks of each technique to facilitate decision making and set realistic expectations., (Copyright (c) 2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background: The 2 primary therapeutic interventions for localized prostate cancer are delivered by different types of physicians, urologists, and radiation oncologists. We evaluated how visits to specialists and primary care physicians (PCPs) by men with localized prostate cancer are related to treatment choice., Methods: Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database, we identified 85 088 men with clinically localized prostate cancer diagnosed at age 65 years or older, between 1994 and 2002. Men were categorized by primary treatment received within 9 months of diagnosis: radical prostatectomy (n = 18 201 [21%]), radiotherapy (n = 35 925 [42%]), androgen deprivation (n = 14 021 [17%]), or expectant management (n = 16 941 [20%]). Visits to specialists and PCPs were analyzed by patient characteristics and primary therapies received and were identified using Medicare claims and the American Medical Association Physician Masterfile., Results: Overall, 42 309 men (50%) were seen exclusively by urologists, 37 540 (44%) by urologists and radiation oncologists, 2329 (3%) by urologists and medical oncologists, and 2910 (3%) by all 3 specialists. There was a strong association between the type of specialist seen and primary therapy received. Visits to PCPs were infrequent between diagnosis and receipt of therapy (22% of patients visited any PCP and 17% visited an established PCP) and were not associated with a greater likelihood of specialist visits. Irrespective of age, comorbidity status, or specialist visits, men seen by PCPs were more likely to be treated expectantly., Conclusions: Specialist visits relate strongly to prostate cancer treatment choices. In light of these findings, prior evidence that specialists prefer the modality they themselves deliver and the lack of conclusive comparative studies demonstrating superiority of one modality over another, it is essential to ensure that men have access to balanced information before choosing a particular therapy for prostate cancer.

Purpose: Transforming growth factor-beta (TGF-beta)-mediated epithelial-to-mesenchymal transition (EMT) has been shown to occur in some cancers; however, the pathway remains controversial and varies with different cancers. In addition, the mechanisms by which TGF-beta and the EMT contribute to prostate cancer recurrence are largely unknown. In this study, we elucidated TGF-beta-mediated EMT as a predictor of disease recurrence after therapy for prostate cancer, which has not been reported before., Experimental Design: We analyzed TGF-beta-induced EMT using nuclear factor-kappaB (NF-kappaB) as an intermediate mediator in prostate cancer cell lines. A total of 287 radical prostatectomy specimens were evaluated using immunohistochemistry in a high-throughput tissue microarray analysis. Levels of TGF-beta signaling components and EMT-related factors were analyzed using specific antibodies. Results were expressed as the percentage of cancer cells that stained positive for a given antibody and were correlated with disease recurrence rates at a mean of 7 years following radical prostatectomy., Results: In prostate cancer cell lines, TGF-beta-induced EMT was mediated by NF-kappaB signaling. Blockade of NF-kappaB or TGF-beta signaling resulted in abrogation of vimentin expression and inhibition of the invasive capability of these cells. There was high risk of biochemical recurrence associated with tumors that displayed high levels of expression of TGF-beta1, vimentin, and NF-kappaB and low level of cytokeratin 18. This was particularly true for vimentin, which is independent of patients' Gleason score., Conclusions: The detection of NF-kappaB-mediated TGF-beta-induced EMT in primary tumors predicts disease recurrence in prostate cancer patients following radical prostatectomy. The changes in TGF-beta signaling and EMT-related factors provide novel molecular markers that may predict prostate cancer outcomes following treatment.

Purpose: Compared with partial nephrectomy, radical nephrectomy increases the risk of chronic kidney disease, which is a significant risk factor for cardiovascular events and death. Given equivalent oncological efficacy in patients with small renal tumors, radical nephrectomy may result in overtreatment. We analyzed a population based cohort of patients to determine whether radical nephrectomy is associated with an increase in cardiovascular events and mortality compared with partial nephrectomy., Materials and Methods: Using Surveillance, Epidemiology and End Results cancer registry data linked with Medicare claims we identified 2,991 patients older than 66 years who were treated with radical or partial nephrectomy for renal tumors 4 cm or less between 1995 and 2002. The primary end points of cardiovascular events and overall survival were assessed using Kaplan-Meier survival estimation, Cox proportional hazards regression and negative binomial regression., Results: A total of 2,547 patients (81%) underwent radical nephrectomy and 556 (19%) underwent partial nephrectomy. During a median followup of 4 years 609 patients experienced a cardiovascular event and 892 died. When adjusting for preoperative demographic and comorbid variables, radical nephrectomy was associated with an increased risk of overall mortality (HR 1.38, p <0.01) and a 1.4 times greater number of cardiovascular events after surgery (p <0.05). However, radical nephrectomy was not significantly associated with time to first cardiovascular event (HR 1.21, p = 0.10) or with cardiovascular death (HR 0.95, p = 0.84)., Conclusions: Radical nephrectomy, which is currently the most common treatment for small renal tumors, may be associated with significant, adverse treatment effects compared with partial nephrectomy. Partial nephrectomy should be considered in most patients with small renal tumors.

Objective: To examine the effect of radical nephrectomy (RN) with adjacent organ and structure resection on survival, as invasion of adjacent organs in patients with renal cell carcinoma (RCC) is rare., Patients and Methods: After institutional review board approval, we reviewed our database and statistically analysed of patients with pathological stage T3 or T4 RCC who had RN and resection of a contiguous organ or structure., Results: We identified 38 patients of 2464 (1.5%) who had RN with adjacent organ or structure resection. The median (interquartile range) size of the mass was 11 (8-14) cm, and the follow-up 13 (5-33) months. Most patients (68%) were pT4 stage and had conventional clear cell carcinoma (95%). Fourteen patients (37%) had positive surgical margins. The liver (10) was the most commonly resected adjacent organ or structure. Only one patient remains alive with no evidence of disease at 5 years, while three are currently alive with disease. Overall, 34 of 38 patients (90%) ultimately died from disease at a median (range) of 11.7 (5.4-29.2) months after surgical resection. The surgical margin status was the only statistically significant factor for recurrence and death (P = 0.006)., Conclusions: The prognosis for patients with advanced RCC and adjacent organ or structure involvement is extremely poor and similar to that of patients with metastatic disease. These patients should be thoroughly counselled about the impact of surgical management and considered for entry into neoadjuvant or adjuvant clinical trials with new targeted systemic agents.

Objective: To evaluate the effect of baseline renal function and comorbidity index on survival in patients with renal tumors., Patients and Methods: We retrieved demographic, clinicopathologic, body mass index (BMI), and comorbidity data (assessed by Charlson-Romano index and hypertension) for 1479 patients who underwent partial or radical nephrectomy between January 4, 1995, and June 9, 2005, for localized renal tumors. We used the abbreviated Modified Diet and Renal Disease equation to estimate glomerular filtration rate (eGFR) using the last preoperative serum creatinine measurement. Body mass index and eGFR time trends were analyzed with linear regression. The effect of BMI, comorbidity, and baseline eGFR on disease-free and overall survival was studied using Cox regression controlling for pathologic stage, nodal status, and metastasis., Results: Over a 10-year interval, median BMI increased from 27 (interquartile range [IQR], 24-31) to 28 (IQR, 25-31; P=.004), and median baseline eGFR decreased from 70 (IQR, 58-80) to 63 mL/min per 1.73 m(2) (IQR, 57-78; P<.001). Multivariate regression demonstrated an association between year of surgery and baseline eGFR (P<.001) even after adjusting for age, sex, comorbidity, BMI, and tumor size. We repeated the analysis for patients aged 18 to 70 years, and this association persisted (P<.001). Baseline eGFR, BMI, and comorbidity were not associated with disease-free survival after controlling for stage. However, moderately reduced baseline eGFR (45-60 mL/min per 1.73 m(2)) and severely reduced eGFR (<45 mL/min per 1.73 m(2)) were significantly associated with overall survival (hazard ratio, 1.5; P<.003; and hazard ratio, 2.8; P<.001; respectively)., Conclusion: Baseline eGFR has declined over the past decade. Nephron-sparing techniques should be considered for patients with severely diminished baseline eGFR.

Background: Mortality rates from kidney cancer have continued to rise despite increases in the detection of smaller renal tumors and rates of renal surgery. To explore the factors associated with this treatment-outcome discrepancy, the authors evaluated how changes in tumor size have affected disease progression in patients after nephrectomy for localized kidney cancer, and they sought to identify the factors associated with disease progression and overall patient survival after resection for localized kidney cancer., Methods: In total, 1618 patients with localized kidney cancer were identified who underwent nephrectomy at Memorial Sloan-Kettering Cancer Center from 1989 to 2004. Patients were categorized by year of surgery: from 1989 to 1992, from 1993 to 1996, from 1997 to 2000, and from 2001 to 2004. Tumor size was classified according to the following strata: <2 cm, from 2 cm to 4 cm, from 4 cm to 7 cm, and >7 cm. Disease progression was defined as the development of local recurrence or distant metastases. Five-year progression-free survival (PFS) was calculated for patients in each tumor size strata according to the year of operation using the Kaplan-Meier method. The patient-, tumor-, and surgery-related characteristics associated with PFS and overall survival (OS) were explored using univariate analysis, and all significant variables were retained in a multivariate Cox regression analysis., Results: Overall, the number of nephrectomies increased for all tumor size categories from 1989 to 2004. A tumor size migration was evident during this period, because the proportion of patients with tumors <2 cm and with tumors from 2 cm to 4 cm increased, whereas the proportion of patients with tumors >7 cm decreased. One hundred seventy-nine patients (11%) developed disease progression after nephrectomy. Sixteen patients (1%) developed local recurrences, and 163 patients (10%) developed distant metastases. When 5-year PFS was calculated for each tumor size strata according to 4-year cohorts, trends in PFS did not improve or differ significantly over time. Compared with historic cohorts, patients in more contemporary cohorts were more likely to undergo partial nephrectomy rather than radical nephrectomy and were less likely to undergo concomitant lymph node dissection and adrenalectomy. Multivariate analysis demonstrated that pathologic stage and tumor grade were associated with disease progression, whereas patient age and tumor stage were associated with overall patient survival., Conclusions: Despite an increasing number of nephrectomies and a size migration toward smaller tumors, trends in 5-year PFS and OS did not improve or differ significantly over time. These findings require further research to identify causative mechanisms, and they argue for the consideration of active surveillance for patients who have select renal tumors and a re-evaluation of the current treatment paradigm of surgically removing solid renal masses on initial detection., ((Copyright) 2008 American Cancer Society.)

Purpose: To characterize the variation in adherence to quality measures of external beam radiotherapy (EBRT) for localized prostate cancer and its relation to patient and provider characteristics in a population-based, representative sample of U.S. men., Methods and Materials: We evaluated EBRT quality measures proposed by a RAND expert panel of physicians among men aged >or=65 years diagnosed between 2000 and 2002 with localized prostate cancer and treated with primary EBRT using data from the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare program. We assessed the adherence to five EBRT quality measures that were amenable to analysis using SEER-Medicare data: (1) use of conformal RT planning; (2) use of high-energy (>10-MV) photons; (3) use of custom immobilization; (4) completion of two follow-up visits with a radiation oncologist in the year after therapy; and (5) radiation oncologist board certification., Results: Of the 11,674 patients, 85% had received conformal RT planning, 75% had received high-energy photons, and 97% had received custom immobilization. One-third of patients had completed two follow-up visits with a radiation oncologist, although 91% had at least one visit with a urologist or radiation oncologist. Most patients (85%) had been treated by a board-certified radiation oncologist., Conclusions: The overall high adherence to EBRT quality measures masked substantial variation in geography, socioeconomic status in the area of residence, and teaching affiliation of the RT facility. Future research should examine the reasons for the variations in these measures and whether the variation is associated with important clinical outcomes.

The management of low risk prostate cancer, defined as Gleason's sum

Objective: To investigate the role of the leader sequence (which during clusterin biosynthesis facilitates its proper post-translational processing and secretion) in the functional activities of clusterin, a ubiquitous secretory glycoprotein with many biological functions, reported to be pro-apoptotic and anti-apoptotic in target cells, but for which the dual mechanism remains unclear., Materials and Methods: We designed an expression vector starting from the second in-frame ATG on the full-length human clusterin cDNA that was capable of driving the expression of both the full-length and the truncated isoforms of clusterin. We established stable expression clones of the androgen-dependent prostate cancer line LNCaP expressing clusterin with and without the leader sequence. This induced expression provided an opportunity to evaluate both the in vivo and in vitro actions of clusterin expression., Results: The LNCaP cells expressing clusterin with the leader sequence resisted apoptosis induced by tumour necrosis factor (TNF)-alpha, but clones with no leader sequence were highly susceptible to TNF-alpha-induced apoptosis. Furthermore, in the absence of the leader sequence, the expressed clusterin had a molecular weight consistent with that of the predicted holoprotein (40 kDa), suggesting a compromised post-translational processing with diffuse distribution throughout the cytoplasm. However, cells transfected with the full-length vector expressed clusterin of 60 and 35 kDa variants, and located exclusively in the Golgi apparatus. In vivo, only the overexpression of the full-length clusterin is anti-apoptotic and stimulates the proliferation of tumour., Conclusion: The leader sequence is important in determining the functions of clusterin, which include anti-apoptotic and anti-necrotic properties. The lack of the leader sequence allowed the incompletely processed clusterin to induce apoptosis in target cells; without the leader sequence, clusterin functions differently. Thus, the leader sequence is a trigger for many functions of clusterin in the progression of human prostate cancer cells.

Background: TGF-beta is a potent immunosuppressant. High levels of TGF-beta produced by cancer cells have a negative inhibition effect on surrounding host immune cells and leads to evasion of the host immune surveillance and tumor progression. In the present study, we report a distinct ability of tumor reactive, TGF-beta-insensitive CD8+ T cells to infiltrate into established tumors, secrete relevant cytokines, and induce apoptosis of tumor cells., Methods: CD8+ T cells were isolated from the spleens of C57BL/6 mice, which were primed with irradiated mouse prostate cancer cells, the TRAMP-C2 cells. After ex vivo expansion, these tumor reactive CD8+ cells were rendered TGF-beta-insensitive by infection with a retroviral (MSCV)-mediated dominant negative TGF-beta type II receptor (TbetaRIIDN). Control CD8+ cells consist of those transfected with the GFP-only empty vector and naïve CD8+ T cells. Recipient mice were challenged with a single injection of TRAMP-C2 cells 21 days before adoptive transfer of CD8+ T cells was performed. Forty days after the adoptive transfer, all animals were sacrificed. The presence of pulmonary metastases was evaluated pathologically. Serial slides of malignant tissues were used for immunofluorescent staining for different kinds of immune cell infiltration, cytokines, and apoptosis analysis., Results: Pulmonary metastases were either eliminated or significantly reduced in the group receiving adoptive transfer of tumor-reactive TGF-beta-insensitive CD8+ T cells (3 out of 12) when compared to GFP controls (9 out of 12), and naïve CD8+ T cells (12 out of 12). Results of immunofluorescent studies demonstrated that only tumor-reactive TGF-beta-insensitive CD8+ T cells were able to infiltrate into the tumor and mediate apoptosis when compared to CD4+ T cells, NK cells, and B cells. A large amount of cytokines such as perforin, nitric oxide, IFN-gamma, IL-2, TNF-alpha were secreted in tumor tissue treated with tumor-reactive TGF-beta-insensitive CD8+ T cells. No immune cells infiltration and cytokine secretion were detected in tumor tissues treated with naïve T cells and GFP controls., Conclusions: Our results demonstrate the mechanism of anti-tumor effect of tumor-reactive TGF-beta-insensitive CD8+ T cells that adoptive transfer of these CD8+ T cells resulted in infiltration of these immune cells into the tumor parenchyma, secretion of relevant cytokines, and induction of apoptosis in tumor cells. These results support the concept that tumor-reactive TGF-beta-insensitive CD8+ T cells may prove beneficial in the treatment of advanced cancer patients., (Copyright (c) 2005 Wiley-Liss, Inc.)

Objectives: To describe the changes in pathologic outcomes and progression-free survival (PFS) rates after radical retropubic prostatectomy for clinically localized prostate cancer in men whose cancers were detected in a 12-year longitudinal prostate cancer screening study., Methods: Between 1989 and 2001, more than 36,000 men participated in a digital rectal examination-based and prostate-specific antigen (PSA)-based screening program. In 1995, the PSA cutoff for biopsy recommendation was lowered from 4.0 ng/mL to 2.6 ng/mL, and the biopsy protocol was changed from four to at least six-sector biopsies. From the screening study, 2952 men were diagnosed with cancer and 2241 of these men underwent radical retropubic prostatectomy. We analyzed the differences in clinical and pathologic stage and PFS after surgery, according to the greater PSA cutoff era (1989 to 1995) and lower PSA cutoff era (1996 to 2001)., Results: A significant downward clinical and pathological stage migration was found toward T1c and organ-confined disease, respectively, in men whose cancer was detected in the lower PSA cutoff era. Furthermore, men with cancer diagnosed in the lower PSA cutoff era had improved PFS rates 5 and 8 years after radical retropubic prostatectomy (P = 0.007). These changes occurred without a significant increase in the proportion of unimportant tumors (organ confined, smaller than 0.5 cm3 without a Gleason pattern of 4 or 5)., Conclusions: These findings support the enhanced detection of favorable cancer and improved PFS rates with lower PSA cutoffs and more intensive biopsy regimens, although the follow-up and lead-time and length-time biases, as well as improvements in surgical technique, might also have affected these results.

Introduction: We report a novel surgical technique used to repair a rectourethral fistula associated with two short-segment urethral strictures located in the anterior and posterior segments of the urethra in a patient with prior unsuccessful repairs., Technical Considerations: The anterior urethral stricture was reconstructed with a ventral onlay of buccal mucosa in the exaggerated lithotomy position. In a modified prone position, the rectourethral fistula was repaired using the transrectal transsphincteric (York-Mason) technique and the posterior urethral stricture with a radial forearm fasciocutaneous free flap which was anastomosed to the inferior gluteal artery and vein. The coexistence of a rectourethral fistula and distal urethral stricture requires simultaneous repair, because the urethral pressure from the distal obstruction may compromise fistula closure. Reconstructive efforts should be tailored to minimize disruption of the urethral blood supply in patients with previous pelvic trauma. Rectal and urethral repairs should be separated by well-vascularized tissue to prevent fistula recurrence., Conclusions: The radial fasciocutaneous flap may offer the reconstructive surgeon another surgical option for complex urethral stricture and rectourethral fistula reconstruction when the local blood supply is in question. Longer follow-up and more cases are needed to further evaluate the continued use of this technique.

Objectives: To compare postoperative intraoral morbidity after mucosal graft harvesting from the lower lip and inner cheek in men undergoing substitution urethroplasty., Methods: From 2000 to 2004, 40 patients underwent oral mucosal graft harvesting for urethral reconstruction. Of the 40 patients, 17 underwent harvest from the lower lip (group 1), 19 from the inner cheek (group 2), and 4 from both sites (group 3). We analyzed the postoperative differences in discomfort levels, neurosensory deficits, salivary flow, complications, and overall quality of life according to harvest site. Outcomes were assessed using analog scales and a questionnaire., Results: At longer term follow-up, the proportion of men with persistent postoperative discomfort, neurosensory deficits, and changes in salivary flow was greater in men whose grafts were harvested from the lower lip than in those whose grafts were harvested from the cheek. Contractures were noted in 1 (5.9%) of 17 and 5 (26.3%) of 19 men in groups 1 and 2, respectively. At the last follow-up visit, overall quality of life (measured by an analog scale of 0 [delighted] to 6 [terrible]) was not significantly different in patients with lower lip versus inner cheek harvest (1.35 versus 0.66, respectively, P = 0.079)., Conclusions: Persistent postoperative discomfort, neurosensory deficits, and salivary flow changes were more common in men whose grafts were harvested from the lower lip. However, the overall quality of life in this group was not significantly different compared with men whose grafts were harvested from the inner cheek. From a morbidity standpoint, the inner cheek appears to be the preferable site of graft harvest.

Prostate cancers often develop insensitivity to TGF-beta to gain a growth advantage. In this study, we explored the status of promoter methylation of TGF-beta receptors (TbetaRs) in a prostate cancer cell line, LNCaP, which is insensitive to TGF-beta. Sensitivity to TGF-beta was restored in cells treated with 5-Aza-2'-deoxycytidine (5-Aza), as indicated by an increase in the expression of phosphorylated Smad-2, type I (TbetaRI), and type II (TbetaRII) TGF-beta receptors, and a reduced rate of proliferation. The same treatment did not significantly affect a benign prostate cell line, RWPE-1, which is sensitive to TGF-beta. Mapping of methylation sites was performed by screening 82 potential CpG methylation sites in the promoter of TbetaRI and 33 sites in TbetaRII using methylation-specific PCR and sequence analysis. There were six methylation sites (-365, -356, -348, -251, -244, -231) in the promoter of TbetaRI. The -244 site was located in an activator protein (AP)-2 box. There were three methylated sites (-140, +27, +32) in the TbetaRII promoter and the -140 site was located in one of the Sp1 boxes. Chromatin immunoprecipitation analysis demonstrated DNA binding activity of AP-2 in the TbetaRI promoter and of Sp1 in the TbetaRII promoter after treatment with 5-Aza. To test whether promoter methylation is present in clinical specimens, we analyzed human prostate specimens that showed negative staining for either TbetaRI or TbetaRII in a tissue microarray system. DNA samples were isolated from the microarray after laser capture microdissection. Methylation-specific PCR was performed for TbetaRI (six sites) and TbetaRII (three sites) promoters as identified in LNCaP cells. A significant number of clinical prostate cancer specimens lacked expression of either TbetaRI and/or TbetaRII, especially those with high Gleason's scores. In those specimens showing a loss of TbetaR expression, a promoter methylation pattern similar to that of LNCaP cells was a frequent event. These results demonstrate that insensitivity to TGF-beta in some prostate cancer cells is due to promoter methylation in TbetaRs.

Purpose: Laparoscopic renal cryoablation is a nephron sparing treatment alternative for selected patients with small renal tumors. The acute tumoricidal effects of cryosurgery on human renal tumors and in experimental models have been reported previously. For cryoablation to be a viable option in the treatment of renal tumors, it must induce not only acute tissue injury but also sustain permanent tissue necrosis and cellular death, in addition to affording an adequate surgical margin free of viable tumor. We report on the longer term effects of in vivo human tumor tissue destruction by cryosurgery and describe the histopathology of a cryoablated renal lesion., Materials and Methods: Three patients in our series who were treated with laparoscopic renal cryosurgery subsequently underwent radical nephrectomy of the cryoablated renal unit., Results: All patients underwent uneventful cryosurgery. Two patients were found to have positive post-cryosurgery biopsies, while a new, metachronous lesion developed in 1 patient. All 3 patients elected to undergo radical nephrectomy. Mean time from cryosurgery to nephrectomy was 275 days. The cryoablated lesions demonstrated coagulative necrosis as evidenced by numerous histiocytes, cholesterol crystals and dystrophic calcification. There was no evidence of viable tumor within the cryoablated field., Conclusions: The longer term tumoricidal effects of laparoscopic renal cryosurgery in human renal tissue have been demonstrated. However, careful patient selection with lesions less than 3.0 cm and vigilant monitoring of the iceball under strict radiographic guidance are imperative to ensure successful oncological outcomes.

Xanthogranulomatous inflammation is an uncommon process that is usually associated with severe renal infection. We report a case of a 64-year-old man with xanthogranulomatous inflammation in the testis who presented with contralateral epididymoorchitis and a painless testicular mass. Only two prior cases of xanthogranulomatous orchitis have been reported. This case highlights the need for a broad differential diagnosis when approaching testicular masses, particularly in the setting of coincident infection.

There is substantiating evidence to support the role of the immune system in the pathogenesis of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Inflammation of the prostate is mediated through the cytokine-induced expression of several factors such as chemokines, inducible nitric oxide synthase, and cyclooxygenase-2. The balance between the effects of proinflammatory and anti-inflammatory cytokines determines the outcome of the inflammatory process. Several proinflammatory and anti-inflammatory cytokines have been identified in CPPS patients, their roles characterized, and their inter-relationships defined. Study of this system will provide further insights into the etiology of CP/CPPS, and lead the way for the development of novel therapeutic approaches for this morbid condition.

Purpose: We describe the successful repair of a 6 cm. ureteral stricture involving the right ureteropelvic junction and proximal ureter using appendix as a ureteral substitute., Materials and Methods: A 37-year-old man involved in a motorcycle accident presented with a retroperitoneal urinoma and a 6 cm. proximal ureteral stricture. At flank exploration we were unable to perform successfully primary pyeloureterostomy through renal descensus with ureteral mobilization. The appendix was selected to bridge the ureteral defect. The right colon and cecum were mobilized to the area of the diseased ureter and the appendix was transected across the base of the cecum. Ureteral scar tissue was resected and the appendix was interposed in an isoperistaltic orientation from renal pelvis to proximal ureter., Results: Convalescence was unremarkable. Retrograde pyelography and flexible ureteroscopy 2 months postoperatively demonstrated a patent anastomosis and viable appendix. The ureteral stent was removed at that time. Excretory urography 3 months postoperatively revealed prompt enhancement of the 2 kidneys and visualization of the 2 ureters. Mercaptoacetyltriglycine-3 renal scan 5 months postoperatively confirmed no scintigraphic evidence of obstruction. The patient was asymptomatic 6 months postoperatively and renal function tests were normal., Conclusions: The appendix can be considered for proximal ureteral defects extending to the right renal pelvis.

Responses to ligation of the left anterior descending coronary artery (blood pressure, heart rate, ECG, arrhythmias, myocardial tissue loss, and mortality) were investigated in chronically prepared rats anesthetized with one of various halogenated hydrocarbon anesthetics. Halothane (inhaled concentrations of 0, 0.25, 0.5, 1.0, and 2.0%) reduced arrhythmias, mortality, and "S-T" segment changes in the ECG in a dose-related manner. The most effective antiarrhythmic concentrations were 0.5 and 1.0%. Other halogenated hydrocarbon anesthetics (chloroform, enflurane, isoflurane, methoxyflurane, and trichlorethylene) were investigated at minimal anesthetic concentrations. Of these, only chloroform and enflurane reduced arrhythmias. However, both increased mortality as a result of nonarrhythmic causes. At one-half anesthetic concentrations, chloroform (0.25%) and enflurane (0.75%) were not antiarrhythmic and mortality resulting from nonarrhythmic causes was not increased. In the chronically prepared rat, halothane at anesthetic and subanesthetic concentrations has antiarrhythmic actions against ligation-induced arrhythmias, reducing mortality. Of the other halogenated hydrocarbons tested, only enflurane and chloroform had antiarrhythmic actions, however, mortality was high with both agents because of accompanying cardiovascular depression.