Native nephrectomies for patients with autosomal dominant polycystic kidney disease (ADPKD) have traditionally been performed via an open approach. We have previously described our experience with robotic synchronous bilateral nephrectomies. However, little data is available comparing open nephrectomy (ONx) to robotic nephrectomy (RNx). Here we compare outcomes of ONx and RNx in patients with ADPKD undergoing synchronous bilateral nephrectomy. We performed a retrospective review of patients with ADPKD undergoing open or robotic synchronous bilateral nephrectomy from January 2015 to November 2023 at a single institution. Patient characteristics, perioperative factors, kidney size, and complication rates were compared. Overall, seventeen patients underwent RNx and fifteen patients underwent ONx. There was no significant difference in gender, preoperative BMI, or kidney volume. Patients undergoing ONx had significantly higher estimated blood loss (EBL), length of stay (LOS), and higher rates of non-autologous blood transfusion and complications overall. Complications in the ONx group included 10 patients who required blood transfusions and 2 patients who sustained visceral injuries. Time from nephrectomy to transplant was significantly shorter in the RNx arm. Robotic synchronous bilateral nephrectomies for ADPKD may have advantages over the traditional open approach, including lower EBL, shorter LOS, decreased overall complication rates, less severe complications and potentially faster time from nephrectomy to transplant.

Abstract Objective This study aims to describe our technique and review our experience with synchronous robotic bilateral nephrectomy for large kidneys in ADPKD with the da Vinci XI and da Vinci Single Port platforms (Intuitive Surgical, Sunnyvale, CA). Materials and Methods We performed a retrospective review of all robotic bilateral nephrectomy cases from January 2020 to present at a high‐volume robotic single centre. Demographic data and perioperative details including preoperative CT scans, indication for nephrectomy and renal function were collected. We also collected post‐op course data and final specimen data details. Results Fourteen cases were included. Patient demographics, indications for surgery and specimen data are outlined in Table 1. The largest kidney removed has a measurement of 32 cm in the largest dimension on preoperative imaging. Median operating time from incision to closure was 299 min (IQR 260, 339). Median estimated blood loss was 75 cc (IQR 50, 187.5). Two patients were transfused intraoperatively. Median pre‐ and post‐operative Hgb was 11.0 and 9.6, respectively. Median length of stay was 3 days (IQR 2, 3.5). There were no intraoperative complications and no open conversions. Post‐operative complications included one incisional hematoma and one superficial wound infection. One patient was admitted to the surgical ICU post operatively for ventilatory support. Two patients were readmitted within 30 days of surgery. Conclusion The robotic approach to bilateral native nephrectomy for ADPKD should be considered when native nephrectomies are indicated. The operative times and outcomes are favourable compared with prior series, and this technique works even for very large kidneys.

You have accessJournal of UrologyCME1 Apr 2023V09-06 SINGLE-PORT ROBOT-ASSISTED TUBULARIZED URACHUS-PERITONEAL HINGE-FLAP SALVAGE GENDER-AFFIRMING VAGINOPLASTY Maurice Garcia, Shannon Smith, Jenna Stelmar, Nance Yuan, Amit Gupta, Samhita Mallavarapu, and Hyung Kim Maurice GarciaMaurice Garcia More articles by this author , Shannon SmithShannon Smith More articles by this author , Jenna StelmarJenna Stelmar More articles by this author , Nance YuanNance Yuan More articles by this author , Amit GuptaAmit Gupta More articles by this author , Samhita MallavarapuSamhita Mallavarapu More articles by this author , and Hyung KimHyung Kim More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003317.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: A morbid complication of gender affirming vaginoplasty surgery is loss neovaginal canal depth. Options to restore depth are limited. Some surgeons describe increasing depth by opening the fore-shortened vaginal canal into the pelvis and then gathering peritoneum adherent to the bladder and rectum together to enclose the vaginal canal opening into pelvis. Two principal disadvantages of this technique are that: 1. The rectum is, by necessity, incorporated as a wall of the vaginal canal; and 2. The gathering sutures remain to tension, especially during rectal filling. We describe a novel alternative technique that utilizes peritoneum from the urachus and anterior bladder dome to restore vaginal length, and show that it can be easily performed via a dual approach using a single-port robot-assisted and trans-vaginal technique. We also highlight technical innovations we developed. METHODS: From a view optimized by the Lap SP camera, we identify the location of the remnant vaginal canal vault, and incise the peritoneum horizontally over a dilator in the canal space. Anterior vaginal canal is anastomosed to peritoneum anterior to the incision, and the peri-umbilical end of our flap (Figure 1a) is anastomosed to the posterior edge. Our flap completely anteriorly based (uses a 3-layer flap of peritoneum, urachus and Transversalis fascia, from the umbilicus to the anterior bladder dome), and completely excludes the rectum. Our tubularized flap suture-lines are subject to tension only during filling of the vaginal canal, and has no sutures at the vault-end. RESULTS: (See video) Our novel technical innovations not described in the literature for peritoneal vaginoplasty include: 1. Design of a novel hollow vaginal dilator for intra-op (lighted transillumination) and post-op use (dilation/douching) (b-d); 2. Vaginal insertion of our lighted dilator to confirm location of the remnant vaginal-vault (e); 3. Excision of the Seminal vesicles to un-obstruct the canal space (f); and 4. A spatulated/offset anterior/posterior vaginal-peritoneal anastomosis (g). CONCLUSIONS: Our flap is based on anatomy quite familiar to the urologic surgeon: the urachus. It is technically simple to perform, and our innovations render it safer with better outcomes. Clinical outcomes presented in: Smith, Garcia, et al, Sex. Med., 2022. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e838 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Maurice Garcia More articles by this author Shannon Smith More articles by this author Jenna Stelmar More articles by this author Nance Yuan More articles by this author Amit Gupta More articles by this author Samhita Mallavarapu More articles by this author Hyung Kim More articles by this author Expand All Advertisement PDF downloadLoading ...

BACKGROUND: Intravesical Bacillus Calmette-Guerin (BCG), a live attenuated tuberculosis vaccine that acts as a non-specific immune system stimulant, is the most effective adjuvant treatment for patients with intermediate or high-risk non-muscle-invasive bladder cancer (NMIBC). However, to date, there are no reliable tests that are predictive of BCG treatment response. In this study, we evaluated the performance of OncuriaTM, a bladder cancer detection test, to predict response to intravesical BCG. METHODS: OncuriaTM data was evaluated in voided urine samples obtained from a prospectively collected cohort of 64 subjects with intermediate or high risk NMIBC prior to treatment with intravesical BCG. The OncuriaTM test, which measures 10 cancer-associated biomarkers was performed in an independent clinical laboratory. The ability of the test to identify those patients in whom BCG is ineffective against tumor recurrence was tested. Predictive models were derived using supervised learning and cross-validation analyses. Model performance was assessed using ROC curves. RESULTS: Pre-treatment urinary concentrations of MMP9, VEGFA, CA9, SDC1, PAI1, APOE, A1AT, ANG and MMP10 were increased in patients who developed disease recurrence. A combinatorial predictive model of treatment outcome achieved an AUROC 0.89 [95% CI: 0.80–0.99], outperforming any single biomarker, with a test sensitivity of 81.8% and a specificity of 84.9%. Hazard ratio analysis revealed that patients with higher urinary levels of ANG, CA9 and MMP10 had a significantly higher risk of disease recurrence. CONCLUSIONS: Monitoring the urinary levels of a cancer-associated biomarker panel enabled the discrimination of patients who did not respond to intravesical BCG therapy. With further study, the multiplex OncuriaTM test may be applicable for the clinical evaluation of bladder cancer patients considering intravesical BCG treatment.

You have accessJournal of UrologyCME1 May 2022MP36-17 ROBOTIC BILATERAL NEPHRECTOMY FOR LARGE KIDNEYS WITH ADULT POLYCYSTIC KIDNEY DISEASE WITH DA VINCI XI AND DA VINCI SP Hanson Zhao, Lior Taich, John M. Masterson, Aurash Naser-Tavakolian, Hayley Johnson, Reiad Najjar, Irene Kim, and Amit Gupta Hanson ZhaoHanson Zhao More articles by this author , Lior TaichLior Taich More articles by this author , John M. MastersonJohn M. Masterson More articles by this author , Aurash Naser-TavakolianAurash Naser-Tavakolian More articles by this author , Hayley JohnsonHayley Johnson More articles by this author , Reiad NajjarReiad Najjar More articles by this author , Irene KimIrene Kim More articles by this author , and Amit GuptaAmit Gupta More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002590.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary kidney disorder. Approximately 50% of patients with ADPKD have end stage renal disease (ESRD) by age 60. Native nephrectomy in ADPKD is historically an open procedure with complication and mortality rates of 38% and 5% respectively. In this study, we discuss our technique and review our experience with synchronous robotic bilateral nephrectomy for large kidneys in ADPKD with the Da Vinci XI and Da Vinci Single Port platforms (Intuitive Surgical, Sunnyvale, CA). METHODS: We performed a retrospective review of all robotic bilateral nephrectomy cases from January 2020 to October 2021. Demographic data and peri-operative details including preoperative CT scans, indication for nephrectomy, and renal function were collected. We also collected post-op course data and final specimen data details. RESULTS: Eleven cases were identified as synchronous robotic bilateral nephrectomies during the study period. Patient demographics, indications for surgery, and specimen data are outlined in Table 1. The largest kidney removed measured 30 cm in largest dimension on preoperative imaging. Median operating time from incision to closure was 299 minutes (IQR 260, 339). Median estimated blood loss was 100 cc (IQR 50, 175). Two patients were transfused intra-operatively, one with autologous blood, and one whose preoperative hemoglobin was 8.8 g/dl; median pre- and post-operative hemoglobin was 11.3 and 9.7 respectively. The median length of stay was 3 days (IQR 2, 3.5). There were no intra-operative complications. Post-operative complications included one incisional hematoma, and one superficial wound infection. One patient was admitted to the surgical ICU post operatively for ventilatory support. Two patients were readmitted within 30 days of surgery – one for a superficial wound infection and one for delirium. Four patients successfully underwent kidney transplantation with a median 95 days (IQR 81 to 108) after bilateral nephrectomy. CONCLUSIONS: The robotic approach to bilateral native nephrectomy for ADPKD should be considered when native nephrectomies are indicated. The operative times and outcomes compare favorably to prior series and this technique works even for very large kidneys. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e604 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hanson Zhao More articles by this author Lior Taich More articles by this author John M. Masterson More articles by this author Aurash Naser-Tavakolian More articles by this author Hayley Johnson More articles by this author Reiad Najjar More articles by this author Irene Kim More articles by this author Amit Gupta More articles by this author Expand All Advertisement PDF DownloadLoading ...

Abstract Objective Headache is the predominant disabler in idiopathic intracranial hypertension (IIH). The aim was to characterise headache and investigate the association with intracranial pressure. Methods IIH:WT was a randomised controlled parallel group multicentre trial in the United Kingdom investigating weight management methods in IIH. Participants with active IIH (evidenced by papilloedema) and a body mass index (BMI) ≥35 kg/m2 were recruited. At baseline, 12 months and 24 months headache characteristics and quality of life outcome measures were collected and lumbar puncture measurements were performed. Results Sixty-six women with active IIH were included with a mean age of 32.0 years (SD ± 7.8), and mean body mass index of 43.9 ± 7.0 kg/m2. The headache phenotype was migraine-like in 90%. Headache severity correlated with ICP at baseline (r = 0.285; p = 0.024); change in headache severity and monthly headache days correlated with change in ICP at 12 months (r = 0.454, p = 0.001 and r = 0.419, p = 0.002 respectively). Cutaneous allodynia was significantly correlated with ICP at 12 months. (r = 0.479, p < 0.001). Boot strap analysis noted a positive association between ICP at 12 and 24 months and enabled prediction of both change in headache severity and monthly headache days. ICP was associated with significant improvements in quality of life (SF-36). Conclusions We demonstrate a positive relationship between ICP and headache and cutaneous allodynia, which has not been previously reported in IIH. Those with the greatest reduction in ICP over 12 months had the greatest reduction in headache frequency and severity; this was associated with improvement of quality of life measures. Trial registration This work provides Class IIa evidence of the association of raised intracranial pressure and headache. ClinicalTrials.gov number, NCT02124486 .

Background Due to insufficient accuracy, urine-based assays currently have a limited role in the management of patients with bladder cancer. The identification of multiplex molecular signatures associated with disease has the potential to address this deficiency and to assist with accurate, non-invasive diagnosis and monitoring. Methods To evaluate the performance of Oncuria™, a multiplex immunoassay for bladder detection in voided urine samples. The test was evaluated in a multi-institutional cohort of 362 prospectively collected subjects presenting for bladder cancer evaluation. The parallel measurement of 10 biomarkers (A1AT, APOE, ANG, CA9, IL8, MMP9, MMP10, PAI1, SDC1 and VEGFA) was performed in an independent clinical laboratory. The ability of the test to identify patients harboring bladder cancer was assessed. Bladder cancer status was confirmed by cystoscopy and tissue biopsy. The association of biomarkers and demographic factors was evaluated using linear discriminant analysis (LDA) and predictive models were derived using supervised learning and cross-validation analyses. Diagnostic performance was assessed using ROC curves. Results The combination of the 10 biomarkers provided an AUROC 0.93 [95% CI 0.87–0.98], outperforming any single biomarker. The addition of demographic data (age, sex, and race) into a hybrid signature improved the diagnostic performance AUROC 0.95 [95% CI 0.90–1.00]. The hybrid signature achieved an overall sensitivity of 0.93, specificity of 0.93, PPV of 0.65 and NPV of 0.99 for bladder cancer classification. Sensitivity values of the diagnostic panel for high-grade bladder cancer, low-grade bladder cancer, MIBC and NMIBC were 0.94, 0.89, 0.97 and 0.93, respectively. Conclusions Urinary levels of a biomarker panel enabled the accurate discrimination of bladder cancer patients and controls. The multiplex Oncuria™ test can achieve the efficient and accurate detection and monitoring of bladder cancer in a non-invasive patient setting.

Purpose: While the majority of the musculoskeletal manifestations of tuberculosis (TB) affect the spine and their imaging findings are well known to radiologists, extra-spinal musculoskeletal manifestations are less frequently encountered. The authors' institution sees a particularly high number of TB cases mainly due to the large surrounding ethnic minority population. The challenge of making such a diagnosis is its non-specific presentation as well as the lack of awareness by radiologists in the varied imaging findings. We present this pictorial review with the aim of raising awareness of such manifestations and the importance of raising its possible diagnosis based on the clinical history and imaging findings.

Purpose: Current knowledge regarding risk of renal-cell carcinoma (RCC) is based on meta-analyses of case control studies. The Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial and National Lung Screening Trial (NLST) provide robust prospective databases with clinical information and rates of cancer development. PLCO and NLST were used to identify risk factors for RCC.Methods: Data were extracted from PLCO and NLST to stratify risk of RCC by sex, race, age at inclusion, obesity, and smoking status. Incidence rates between groups were compared using the chi-square test. We excluded urothelial carcinomas.Results: Overall, 701/154,118 and 190/53,242 RCCs were detected in PLCO and NLST, respectively. Incidence rates were higher in men (PLCO: 0.56 vs. 0.28/1000 person y, NLST: 0.73 vs. 0.35/1000 person y; both with P < 0.0001). In the PLCO, male sex, age > 60 years, obesity, and intensity of smoking were associated with higher risk of developing RCC. In the NLST, sex and morbid obesity increased the risk for RCC but age, ethnicity, and smoking intensity were not predictors. There was no effect of screening for other cancers on detection of RCC. High-grade (grades > 3) RCCs were diagnosed in 145 (20.7%) and 60 (31.6%) in the PLCO and NLST. In PLCO, age (60-64 y), male sex, obesity, and current smokers with > 50 pack years were at increased risk for high-grade RCC. In NLST, only male sex was an independent predictor of high-grade RCC.Conclusions: Age over 60 years, male sex, smoking intensity, and obesity affect the risk of RCC. Identification of a high-risk population may allow a pilot study of rational screening for RCC. (C) 2016 Elsevier Inc. All rights reserved.

BACKGROUND:Although the natural history of urothelial carcinoma of the bladder (UCB) from radical cystectomy (RC) to disease recurrence (DR) has been investigated intensively, the course of patients who have experienced DR after RC for UCB remains poorly understood.OBJECTIVE:To evaluate the prognostic value of the Bajorin criteria that consists of two risk factors: Karnofsky performance status (KPS) and the presence of visceral metastases (VMs) in patients with DR after RC for UCB. Furthermore, to identify additional factors associated with cancer-specific mortality (CSM) and thus build a multivariable model to predict survival after DR.DESIGN, SETTING, AND PARTICIPANTS:We identified 967 patients with UCB who underwent RC at 17 centers between 1979 and 2012 and experienced DR. Of these, 372 patients had complete data we used for analysis.OUTCOMES MEASUREMENTS AND STATISTICAL ANALYSIS:Univariable Cox regressions analysis was performed. We used a forward stepwise selection process for our final multivariable model.RESULTS AND LIMITATIONS:Within a median follow-up of 18 mo, 266 patients died of disease. Cancer-specific survival at 1 yr was 79%, 76%, and 47% for patients with no (n=105), one (n=180), and two (n=87) risk factors (p<0.001; c-index: 0.604). On multivariable analyses, we found that KPS <80%, higher American Society of Anesthesiologists score, anemia, leukocytosis, and shorter time to DR (all p values <0.034) were independently associated with increased CSM. The combination of time to DR and KPS resulted in improved discrimination (c-index: 0.694).CONCLUSIONS:We confirmed the prognostic value of KPS and VMs in patients with DR following RC for UCB. We also found several other clinical variables to be associated with worse CSM. We developed a model for predicting survival after DR inclusive of time to DR and KPS assessed at DR. If validated, this model could help clinical trial design.PATIENT SUMMARY:We developed a model to predict survival following disease recurrence after radical cystectomy for urothelial carcinoma of the bladder, based on time to disease recurrence and Karnofsky performance status.

An increasing body of evidence suggests gender differences in the presentation and prognosis of bladder cancer. We aimed to assess the impact of gender on outcomes in patients with primary T1 high-grade (HG) urothelial carcinoma of the bladder (UCB).

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Of patients treated with an indwelling ureteric stent 80–90% experience lower urinary tract symptoms that are a hindrance to health‐related quality of life. The prevalence of the extraction/retrieval string after ureteroscopy for stone disease and stent placement varies significantly between surgeons and published series, but the benefits of eliminating the need for a secondary procedure such as cystoscopy and stent removal, as well as the decrease in cost to the patient are well established. Published reports have not addressed the prevalence of post‐procedure related events (PREs) in patients who have received an indwelling ureteric stent with the extraction/retrieval string still intact after ureteroscopy for stone disease. By analysing PREs (Emergency Room visits, unscheduled clinic visits, and telephone calls) related to their stent or procedure for patients with and without an extraction/retrieval string, the feasibility of the extraction string can be validated and the misconceptions about their use can be alleviated. OBJECTIVE To review a retrospective ureteric stent cohort with and without extraction string to compare post‐procedure related events (PRE), as ureteric stent placement after endoscopic management of urolithiasis is common, but data regarding the potential benefits or disadvantages of ureteric stent placement with extraction string are sparse. PATIENTS AND METHODS Between June 2009 and June 2010, 293 patients underwent ureteroscopy with or without lithotripsy for stone disease. In all, 181 patients had a unilateral procedure and underwent stent placement postoperatively. Records were retrospectively reviewed for operative data and PRE occurring within the first 6 weeks after surgery, defined as unscheduled clinic or Emergency Room visits, or adverse event telephone calls. RESULTS Of 181 patients who underwent ureteric stent placement, 43 (23.8%) included an extraction string. In all, 34.3% of all patients had a PRE, including 37.2% and 33.3% of patients with and without extraction string, respectively ( P = 0.64). PRE occurred in men with or without an extraction string (27.8 vs 32.4%, respectively; P = 0.71) and women with or without an extraction string (44.0 vs 34.3%, respectively, P = 0.39). PRE occurred with relatively equal frequency between men and women ( P = 0.28). Only two women (4.7%) reported removing their stent prematurely, on postoperative days 2 and 6. CONCLUSIONS Ureteric stent placement with extraction string after ureteroscopy for stone disease does not seem to result in more PRE, regardless of gender. Prospective randomised trials are needed to determine the benefits and disadvantages of ureteric stents with extraction string.

What's known on the subject? and What does the study add? Lymphovascular invasion (LVI) is an important step in systemic cancer cell dissemination. LVI has been shown to be an independent predictor of disease recurrence and cancer‐specific survival in urothelial carcinoma of the bladder (UCB) for patients with carcinoma invading bladder muscle. Patients with final pathological stage T1N0 UCB who underwent radical cystectomy (RC) have not been separately analysed for influence of LVI on outcomes. Our study shows that LVI predicts disease recurrence and cancer‐specific survival in patients with final stage T1 UCB after RC. Objective To determine the outcomes of patients with final pathological stage T1N0 disease after radical cystectomy (RC) for urothelial carcinoma of the bladder (UCB) and to determine whether lymphovascular invasion (LVI) is an independent predictor of prognosis in these patients. Patients and Methods Records of 958 consecutive patients who underwent RC at three academic centres were reviewed. A total of 101 patients with negative lymph nodes and with final stage (the higher of the pre‐RC clinical/transurethral resection [TUR] and post‐RC pathological stages) T1 UCB were identified. The median (range) follow‐up was 38 (0.4–177) months and the median (range) number of nodes examined was 19 (9–80). Results Overall, 12/101 (11.9%) patients experienced cancer recurrence and 7/101 (6.9%) died from their cancer. The 3‐year recurrence‐free survival probability (SD) was 0.89 (0.04) and 3‐year cancer‐specific survival probability (SD) was 0.96 (0.02). Six of 101 (6%) patients had LVI, of whom four experienced disease recurrence and three died from bladder cancer. All recurrences and deaths occurred in patients who had either LVI and/or concomitant carcinoma in situ. On multivariable analysis, LVI (hazard ratio [HR] 4.9, P = 0.01) and higher pathological stage (HR 8.5, P = 0.04) predicted cancer recurrence and LVI (HR 6.7, P = 0.01) predicted cancer‐specific survival. Conclusions LVI helps identify patients with final pathological T1N0 UCB who are at significantly increased risk of bladder cancer recurrence and death. These patients should be considered for close monitoring after cystectomy.

UNLABELLED:It is well established that upper tract urothelial carcinoma is a rare cancer with an aggressive course. Currently, radical nephroureterectomy with bladder cuff excision remains the standard of care in the treatment of these tumours. Previous studies demonstrate that stage, grade and lymphovascular invasion have prognostic significance on recurrence and outcome whereas the prognostic impact of tumour location remains unclear. This study provides an accurate analysis of the impact of tumour location and multifocality on prognosis in patients with upper tract urothelial carcinoma following nephroureterectomy with bladder cuff excision. Ureteral tumour location, particularly when associated with multifocal disease in the renal pelvis, is significantly associated with an increased risk of disease recurrence and cancer-specific death after surgery.OBJECTIVE:To examine the significance of ureteral and renal pelvic location of upper tract urothelial carcinoma in a large multi-institutional study.MATERIALS AND METHODS:We collected and pooled a database of 637 patients with upper tract urothelial carcinoma who underwent radical nephroureterectomy and bladder cuff excision in nine international academic centres. Univariate and multivariate models examined the effect of tumour location on recurrence-free survival (RFS) and cancer-specific survival (CSS) rates. Collected variables included age, gender, race, presence of lymphovascular invasion, concomitant carcinoma in situ, pathological stage, lymph node dissection and type of surgery (open vs laparoscopic).RESULTS:Anatomically, 34% of tumours were ureteral, 59% were renal pelvic and 7% were multifocal. Median follow-up for patients alive was 42 months (interquartile range: 19-76). Race, type of surgery, pathological stage and presence of lymphovascular invasion were significantly different across the three subgroups of patients (all P values <0.05). Age, gender, grade, presence of concomitant carcinoma in situ and follow-up duration were similar among the three subgroups. On multivariable Cox regression analyses, ureteral tumour location was an independent predictor of worse RFS (hazard ratio 2.1, P = 0.006) and CSS (hazard ratio 2.0, P = 0.027). When associated with renal pelvic disease, ureteral location was an even stronger independent predictor of worse RFS (hazard ratio 4.6, P < 0.001) and CSS (hazard ratio 4.0, P < 0.001).CONCLUSION:Ureteral tumour location, particularly in association with multifocal disease in the renal pelvis, is an independent prognostic factor for higher disease recurrence and cancer-specific mortality.

OBJECTIVE To examine histologic findings and clinical outcomes of patients who underwent neck dissection for residual neck masses.METHODS From 1987 to 2008, 968 postchemotherapy retroperitoneal lymph node dissections (RPLND) were performed at our institution. We identified 41 of these patients who underwent a postchemotherapy residual neck mass resection.RESULTS Thirty-nine patients presented with primary testis, one with retroperitoneal, and one with mediastinal GCT. Teratoma was present in 54% of patients at diagnosis. During the neck dissection, 23 (56.1%) patients had teratoma, 14 (34.2%) had fibrosis, three (7.3%) had viable GCT, and one had benign lymph nodes. There was histologic discordance between the neck and the RPLND in 22.5% of patients and between the neck and other extraretroperitoneal resection sites in 26.5% of patients. At a median follow-up of 49.5 months from diagnosis, 16 patients had recurrence, and seven had died of testis cancer. No patient had recurrence in the neck. Five of seven patients with residual viable cancer at extraretroperitoneal resection sites died of disease compared with two of 23 with teratoma and none with fibrosis (P = .0005).CONCLUSIONS Resection of residual postchemotherapy neck masses is indicated because of the high incidence of viable tumor or teratoma in the residual mass and the inability to accurately predict the histology of the neck masses. Resection of residual neck masses leads to excellent local control and can contribute to long-term disease control and survival. UROLOGY 77: 655-659, 2011. (C) 2011 Elsevier Inc.

PURPOSE:We assessed the prognostic value of pT3 bladder urothelial carcinoma substaging.MATERIALS AND METHODS:We reviewed the records of 2,605 patients treated with radical cystectomy for bladder urothelial carcinoma at 6 international centers, of whom 808 (31.0%) had pT3 disease. No patient received systemic chemotherapy or radiotherapy preoperatively. Median followup was 45 months in survivors at last followup.RESULTS:Median patient age was 68 years. Stage was pT3a in 310 patients (38.4%) and pT3b in 498 (61.6%). Of the patients 352 (43.6%) had metastasis to regional lymph nodes. Five-year recurrence-free (43.8% and 41.4%) and cancer specific (48.6% and 46.8%) survival estimates were similar in pT3a and pT3b cases (p = 0.277 and 0.625, respectively). Conversely in patients with pathologically negative lymph nodes pT3b substaging was associated with worse 5-year recurrence-free (60.7% vs 47.9%) and cancer specific (64.4% vs 55.0%) survival (p = 0.020 vs 0.048).CONCLUSIONS:Macroscopic perivesical fat extension (pT3b) is associated with a worse outcome than pT3a disease in lymph node negative cases of bladder urothelial carcinoma. Together with other features pT3 substaging may help identify patients with pT3 who could benefit from adjuvant chemotherapy.

Study Type – Economic (cost impact)
Level of Evidence 2b