This randomized clinical trial compares the effect of transperineal vs transrectal prostate biopsy on infection rates after biopsy.

PURPOSE:Implicit, unconscious biases in medicine are personal attitudes about race, ethnicity, gender, and other characteristics that may lead to discriminatory patterns of care. However, there is no consensus on whether implicit bias represents a true predictor of differential care given an absence of real-world studies. We conducted the first real-world pilot study of provider implicit bias by evaluating treatment parity in prostate cancer using unstructured data-the most common way providers document granular details of the patient encounter. METHODS AND FINDINGS:Patients ≥18 years with a diagnosis of very-low to favorable intermediate-risk prostate cancer followed by 3 urologic oncologists from 2010 through 2021. The race Implicit Association Test was administered to all providers. Natural language processing screened human annotation using validated regex ontologies evaluated each provider's care on four prostate cancer quality indicators: (1) active surveillance utilization; (2) molecular biomarker discussion; (3) urinary function evaluation; and (4) sexual function evaluation. The chi-squared test and phi coefficient were utilized to respectively measure the statistical significance and the strength of association between race and four quality indicators. 1,094 patients were included. While Providers A and B demonstrated no preference on the race Implicit Association Test, Provider C showed preference for White patients. Provider C recommended active surveillance (p<0.01, φ = 0.175) and considered biomarkers (p = 0.047, φ = 0.127) more often in White men than expected, suggestive of treatment imparity. Provider A considered biomarkers (p<0.01, φ = 0.179) more often in White men than expected. Provider B demonstrated treatment parity in all evaluated quality indicators (p>0.05). CONCLUSIONS:In this pilot study, providers' practice patterns were associated with both patient race and implicit racial preferences in prostate cancer. Alerting providers of existing implicit bias may restore parity, however future assessments are needed to validate this concept.

261 Background: Transrectal prostate biopsy is the predominant approach to prostate cancer detection in the U.S. and worldwide. The transperineal approach is traditionally preformed under general anesthesia. Recent advances enable prostate biopsy to be performed through the skin of the perineum (transperineal) under local anesthesia. There are potential advantages to this clean, percutaneous approach over the inherently contaminated transrectal approach. However, comparative evidence is limited. Methods: In a multicenter, randomized trial, we used two-stage consent and assigned participants with suspicion for prostate cancer to undergo transperineal biopsy without antibiotic prophylaxis vs. transrectal biopsy with targeted prophylaxis. The primary outcome was post-biopsy infection, with secondary outcomes of urinary retention, significant bleeding, cancer detection, and a numerical rating scale (0-10) for biopsy-related pain and discomfort during 7-days post-biopsy. Results: Six-hundred fifty-eight participants underwent randomization, and 567 (86%) of participants were included in the intent to treat analysis. Seventy-nine men declined to participate. There were zero transperineal versus 4 (1.4%) transrectal biopsy infections (adjusted difference -1.4%; 95% confidence interval -3.2, 0.3; P=0.059). Rates of other complications were very low and similar by approach. Importantly, detection of clinically significant cancer was similar (53% transperineal vs. 50% transrectal, adjusted difference 2.0%; 95% CI -6.0, 10; p=0.6). Participants undergoing transperineal biopsy experienced worse periprocedural pain (0.6 adjusted difference [0-10 scale] 95% CI 0.2, 0.9; P=0.002), but the effect was small and resolved by 7-days. Conclusions: Office-based transperineal biopsy is tolerable, does not compromise cancer detection and likely reduces the risk of infection without antibiotic prophylaxis, thereby improving antibiotic stewardship. Altogether, our findings support office based transperineal prostate biopsy without antibiotic prophylaxis as the new standard of care for prostate cancer detection with per patient and population-based antibiotic stewardship and healthcare cost benefits. Finally, two-stage consent facilitates accrual for surgical randomized trials, as evidenced by the relatively low rate of participants declining and withdrawing from the trial. Clinical trial information: NCT04815876 .

Hormones may play a role in bladder cancer. We evaluated the impact of a novel marker, the enzyme aromatase, on characteristics of bladder cancer in 40 patients. We found that expression of this enzyme was associated with higher tumor stage as well as survival outcomes. Our preliminary results should encourage further investigations into the role of hormones in bladder cancer. Background: Hormonal factors may play a role in bladder cancer (BCa). We investigated the expression of aromatase and estrogen receptor (ER)beta and its association with pathological variables and survival outcomes. Patients and Methods: BCa specimens from 40 patients were evaluated. Immunohistochemistry was performed for aromatase and ER beta. Descriptive statistics and univariate analyses assessed the association of these markers with pathologic variables and survival outcomes. Results: Aromatase expression was significantly associated with tumor stage; muscle invasive disease was found in 15 of 19 (79%) patients with positive staining and in 7 of 18 (39%) patients with negative staining (P =.02). Node-positive disease was found in 8 of 19 (42%) patients with positive staining and 1 of 18 (6%) patients with negative staining (P =.01). After a median follow-up of 112 months, Cox regression analysis demonstrated that aromatase expression was associated with a more than 2-fold risk of cancer recurrence (hazard ratio, 2.37; confidence interval, 0.92-6.08; P =.07) and an almost 4-fold higher risk of cancer-specific death (hazard ratio, 3.66; 95% confidence interval, 1.19-12.06; P =.02). Muscle-invasive disease was found in 15 of 18 (83%) ER13positive specimens and 4 of 12 (33%) ER beta-negative specimens (P =.0009). Hierarchical clustering analysis demonstrated a 4-fold up-regulation of ER beta gene expression in tumor versus adjacent, non-tumor urothelium (P <.05). However, no significant association with survival outcomes was found. Conclusion: Aromatase expression in BCa may be associated with advanced tumor stage and poorer survival outcomes. ER beta is upregulated in malignant tissue, and its expression is associated with muscle-invasive disease. These findings provide further evidence for the hormonal paradigm in BCa.

You have accessJournal of UrologyKidney Cancer: Evaluation and Staging I1 Apr 2010519 IDENTIFICATION OF NEPHROMETRIC VARIABLES PREDICTIVE OF RENAL IMPAIRMENT FOLLOWING PARTIAL NEPHRECTOMY Eugene Cha, Bryan Jeun, Casey Ng, Michael Herman, James Wysock, James DiPietro, Danielle Shehorn, George Shih, Gerald Wang, and Douglas Scherr Eugene ChaEugene Cha More articles by this author , Bryan JeunBryan Jeun More articles by this author , Casey NgCasey Ng More articles by this author , Michael HermanMichael Herman More articles by this author , James WysockJames Wysock More articles by this author , James DiPietroJames DiPietro More articles by this author , Danielle ShehornDanielle Shehorn More articles by this author , George ShihGeorge Shih More articles by this author , Gerald WangGerald Wang More articles by this author , and Douglas ScherrDouglas Scherr More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.595AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We used objective nephrometric criteria on preoperative CT scans to identify variables associated with postoperative renal impairment following partial nephrectomy for renal cortical tumors. METHODS We investigated all patients who underwent a partial nephrectomy for renal cortical tumors at our institution from years 2006 to the present. Of 187 patients during that time span, 58 patients had preoperative CT scans available for evaluation. We calculated the preoperative and postoperative glomerular filtration rates (GFR) as determined by the 4 variable MDRD equation. Renal impairment was defined as a 20% or greater reduction from the preoperative GFR after partial nephrectomy. We subsequently examined 11 distinct criteria on preoperative CT scans to attempt to predict the degree of postoperative renal impairment. Some of these criteria include tumor volume as determined by an ellipsoid formula, endophytic or exophytic distance of tumor relative to renal parenchyma, tumor proximity to collecting system and to renal vessels, tumor laterality, and interlobar location. We also analyzed renal artery clamp times and surgical technique with respect to changes in GFR as well as common risk factors including smoking history, hypertension, diabetes mellitus, or previous history of renal insufficiency. RESULTS Of the 58 patients in our cohort, 16 met our criteria for renal impairment (27.1%). Tumor diameter and endophytic distance were significantly associated with postoperative renal impairment > 20% (p=0.03 and 0.04, respectively). Renal impairment was also associated with interlobar location and tumor volume, though not statistically significant (p=0.08 and p=0.09, respectively). With regard to known risk factors for renal insufficiency, we found no correlation between postoperative renal impairment and history of diabetes, hypertension, smoking and preoperative renal insufficiency. When subdivided by open versus laparoscopic approaches, the cohorts appeared to be well matched in terms of tumor volume (57.2 vs. 27.1 mL, p= 0.35), renal artery clamp time (31.1 vs 34.8 min, p=0.86) and percent reduction in GFR (35.7 vs 32.5, p =0.85). CONCLUSIONS Using an objective nephrometric system based on preoperative CT criteria, tumor diameter and endophytic distance were associated with postoperative renal impairment > 20% after partial nephrectomy. The inclusion of these indices in radiology reports may assist the urologist in the expectant management of renal function during the postoperative period. New York, NY© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e205 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Eugene Cha More articles by this author Bryan Jeun More articles by this author Casey Ng More articles by this author Michael Herman More articles by this author James Wysock More articles by this author James DiPietro More articles by this author Danielle Shehorn More articles by this author George Shih More articles by this author Gerald Wang More articles by this author Douglas Scherr More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyTransplantation, Urolithiasis & Hydronephrosis1 Apr 2010V1993 LAPAROENDOSCOPIC SINGLE SITE DONOR NEPHRECTOMY: AN ILLUSTRATION OF TECHNIQUE James Wysock, Elena Gimenez, Casey Ng, Eric Kaufman, Gerald Wang, Abhishek Srivastava, David Leeser, Sandip Kapur, and Joseph J. Del Pizzo James WysockJames Wysock More articles by this author , Elena GimenezElena Gimenez More articles by this author , Casey NgCasey Ng More articles by this author , Eric KaufmanEric Kaufman More articles by this author , Gerald WangGerald Wang More articles by this author , Abhishek SrivastavaAbhishek Srivastava More articles by this author , David LeeserDavid Leeser More articles by this author , Sandip KapurSandip Kapur More articles by this author , and Joseph J. Del PizzoJoseph J. Del Pizzo More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.2005AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The purpose of this video is to provide a stepwise illustration and explanation of our approach to laparoendoscopic single site donor nephrectomy (LESS DN) using a Gel Point™ device. METHODS A single access Gel Point™ device (Applied Medical, Rancho Santa Margarita, CA) was inserted into the abdomen through a 5 cm periumbilical incision. Apart from standard laparascopic instruments, a bariatric camera with a right angle attachment for the light cord was used to maximize triangulation. Data was collected prospectively for 20 consecutive patients undergoing the described procedure. Parameters analyzed were warm ischemia time, operative time, EBL, pain scores, time to recipient creatinine less than 3mg/dL, and recipient creatinine at discharge. RESULTS Complete LESS DN was successful in 19 cases. One case was converted to hand assisted laparascopy for failure to maintain pneumoperitoneum. Patient characteristics are noted in Table 1. Table 2 describes the operative parameters analyzed. Visual analog pain scores were 0/10 in all cases at two weeks post-operatively. One patient developed a wound infection treated with antibiotics. Table 1. Patient Characteristics Male: Female 7:13 Age (years) 44.85(range21-64) BMI kg/m2 27.77(range19.5–37) Preoperative Cr mg/dL 0.77(range0.4–1) Renal Artery Single: Double 12:6 Table 2. Parameters analyzed for laparaendoscopic single port donor nephrectomy Mean operative time 96.68min(range62–187) EBL 114.47ml(range25–450) Warm Ischemia Time 4.49min(+/-2.33) Mean time to recipient Cr <3.0 mg/dL 31.74hrs(range8-72) Mean recipient Cr at discharge 1.41mg/dL(+/-0.34) Mean incision length 5.13cm(+/-0.48) Hospital LOS 1.82days(+/-0.48) CONCLUSIONS This video demonstrates a stepwise technique for performing LESS DN. Our early prospective data for this approach is encouraging and supports additional work to validate LESS DN as a potential method for improving cosmetic and post-operative pain outcomes for living donor nephrectomies. New York, NY© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e774 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information James Wysock More articles by this author Elena Gimenez More articles by this author Casey Ng More articles by this author Eric Kaufman More articles by this author Gerald Wang More articles by this author Abhishek Srivastava More articles by this author David Leeser More articles by this author Sandip Kapur More articles by this author Joseph J. Del Pizzo More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation, Vascular Surgery II1 Apr 20102169 LAPAROENDOSCOPIC SINGLE SITE (LESS) VERSUS CONVENTIONAL LAPAROSCOPIC DONOR NEPHRECTOMY: PROSPECTIVE COMPARISON OF PERIOPERATIVE AND EARLY GRAFT OUTCOMES Gerald Wang, Elena Gimenez, James Wysock, Casey Ng, David Leeser, Sandip Kapur, and Joseph Del Pizzo Gerald WangGerald Wang More articles by this author , Elena GimenezElena Gimenez More articles by this author , James WysockJames Wysock More articles by this author , Casey NgCasey Ng More articles by this author , David LeeserDavid Leeser More articles by this author , Sandip KapurSandip Kapur More articles by this author , and Joseph Del PizzoJoseph Del Pizzo More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.2272AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Laparoendoscopic single site (LESS) surgery is a recent advance in minimally invasive surgery that may have particular relevance to living donor nephrectomy (DN). While the benefits of laparoscopic DN (LDN) are well established and may have reduced some barriers to graft donation, kidney donors remain in short supply. Therefore, LESS-DN represents an important development with the potential to further reduce barriers to kidney donation. Here, we present a matched comparison of LESS-DN versus conventional LDN using a new single-port access system. METHODS From August to October 2009, we performed 20 consecutive cases of LESS-DN using the new GelPoint™ system (Applied Medical, Rancho Santa Margarita, CA). A transumbilical approach was used through a 4-5 cm incision and no extra-umbilical incisions or punctures were made. Data was collected prospectively and compared to a matched cohort of 20 LDN performed by the same surgeons (JJD, DBL). RESULTS LESS-DN was performed successfully in all 20 patients and each allograft demonstrated immediate function. There was no difference between the cohorts with regard to age, gender, BMI, anatomic complexity and surgical date. There was one conversion from LESS to conventional hand-assisted LDN for inability to maintain pneumoperitoneum. Operative time was longer in the LESS cohort (92 vs 78 min, p=0.8) and mean blood loss was lower in the LESS group (111 vs 122 mL, p=0.7) but neither was statistically significant. Warm ischemia time was longer in the LESS cohort (4 vs 3 min, p=0.3). There was a trend towards decreased visual analogue pain score in the LESS group but this was not statistically significant (1.4 vs 3.4, p=0.1). Length of stay was similar between the 2 groups (LESS 1.5 vs 1.8 days, p=0.2). There was one postoperative complication in the LESS cohort (wound infection). There was no difference in graft function between the 2 groups. Mean time to recipient creatinine < 3.0 mg/dL was 31 hrs for LESS-DN and 33 hrs for LDN (p=0.9). At time of discharge, recipient creatinine was 1.40 mg/dL for LESS-DN and 1.35 mg/dL for LDN (p=0.9). CONCLUSIONS LESS-DN was performed successfully in 20 patients without additional extra-umbilical port sites and with one conversion to hand-assisted LDN. While the benefits of LESS-DN may be limited to decreased postoperative pain and improved cosmesis, this approach using the new GelPoint™ system demonstrates equivalent graft function and may nevertheless prove beneficial to further reduce barriers to kidney donation. New York, NY© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e844 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gerald Wang More articles by this author Elena Gimenez More articles by this author James Wysock More articles by this author Casey Ng More articles by this author David Leeser More articles by this author Sandip Kapur More articles by this author Joseph Del Pizzo More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyOncology, Bladder Oncology1 Apr 2010V1699 EARLY ONCOLOGIC OUTCOMES AND POSTOPERATIVE COMPLICATIONS FOLLOWING ROBOTIC RADICAL CYSTECTOMY Gerald Wang, Eric Kauffman, Casey Ng, James Wysock, Lee Richstone, Ashutosh Tewari, Philip Li, and Douglas Scherr Gerald WangGerald Wang New York, NY More articles by this author , Eric KauffmanEric Kauffman New York, NY More articles by this author , Casey NgCasey Ng New York, NY More articles by this author , James WysockJames Wysock New York, NY More articles by this author , Lee RichstoneLee Richstone New Hyde Park, NY More articles by this author , Ashutosh TewariAshutosh Tewari New York, NY More articles by this author , Philip LiPhilip Li New York, NY More articles by this author , and Douglas ScherrDouglas Scherr New York, NY More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1545AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To date, there have been several robotic cystectomy case series demonstrating not only feasibility but also potential perioperative advantages compared to the open approach. However, whether robotic cystectomy is an appropriate treatment for bladder cancer depends on long-term oncologic outcomes, which at this point are not yet available. Here, we report early oncologic and clinical outcomes at a median follow-up of 18 months in our cohort of robotic cystectomies. METHODS From 2002 to 2008, 85 consecutive patients underwent robotic-assisted radical cystectomy by a single surgeon at our institution. Urinary diversion was performed extracorporeally. Perioperative and pathologic outcomes, as well as complications at 30 and 90 days were collected prospectively. Kaplan-Meier analysis was performed to calculate disease-free, cancer-specific and overall survival rates at 1 and 2 years. Cox proportional hazards model was used to identify predictors of survival. RESULTS Mean operative time was 6 hrs and estimated blood loss was 400mL. On final pathology, 49% of patients had organ-confined disease, 37% had extravesical disease, and 15% had node-positive disease. There were 5 cases of positive surgical margins (6%), all in patients with significant extravesical and node-positive disease. Mean number of lymph nodes removed was 19.1. Overall complication rates at 30 and 90 days were 40% and 44%, respectively. At a median follow-up of 18 months, 60 patients (71%) were alive without evidence of disease, 7 (8%) were alive with recurrent disease, 13 (15%) were dead of disease, and 5 (6%) were dead of other causes. Kaplan-Meier analysis demonstrated that at 1 and 2 years, respectively, disease-free survival for the entire cohort was 79% and 73%, cancer-specific survival was 88% and 84%, and overall survival was 83% and 79%. When stratified by stage, patients with extravesical disease at 1 year demonstrated significantly worse disease-free survival (52% vs 94% organ-confined), cancer-specific survival (70% vs 98%), and overall survival (62% vs 94%, p < 0.0001 for each). Similarly, patients with lymph node positive disease had significantly worse disease-free and overall survival at 1 year. Using a Cox proportional hazards model, tumor stage was the strongest predictor of both disease-free and overall survival. CONCLUSIONS At an early median follow-up of 18 months, robotic cystectomy appears to demonstrate favorable disease-free, cancer-specific and overall survival rates. However, longer follow-up is required. © 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e656 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.Metrics Author Information Gerald Wang New York, NY More articles by this author Eric Kauffman New York, NY More articles by this author Casey Ng New York, NY More articles by this author James Wysock New York, NY More articles by this author Lee Richstone New Hyde Park, NY More articles by this author Ashutosh Tewari New York, NY More articles by this author Philip Li New York, NY More articles by this author Douglas Scherr New York, NY More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE To determine oncological outcomes including early survival rates among unselected bladder urothelial carcinoma (BUC) patients treated with robotic‐assisted radical cystectomy (RRC). PATIENTS AND METHODS Clinicopathologic and survival data were prospectively gathered for 85 consecutive BUC patients treated with RRC. The decision to undergo a robotic rather than open approach was made without regard to tumor volume or surgical candidacy. Kaplan–Meier survival rates were determined and stratified by tumor stage and LN positivity, and multivariate analysis was performed to identify independent predictors of survival. RESULTS Patients were relatively old (25% >80 years; median 73.5 years), with frequent comorbidities (46% with ASA class ≥3). Of these patients 28% had undergone previous pelvic radiation or pelvic surgery, and 20% had received neoadjuvant chemotherapy. Extended pelvic lymphadenectomy was performed in 98% of patients, with on average 19.1 LN retrieved. On final pathology, extravesical disease was common (36.5%). Positive surgicalmargins were detected in five (6%) patients, all of whom had extravesical tumors with perineural and/or lymphovascular invasion, and most of whom were >80 years old. At a mean postoperative interval of 18 months, 20 (24%) patients had developed recurrent disease, but only three (4%) patients had recurrence locally. Disease‐free, cancer‐specific and overall survival rates at 2 years were 74%, 85% and 79%, respectively. Patients with low‐stage/LN(−) cancers had significantly better survival than extravesical/LN(−) or any‐stage/LN(+) patients, with stage being the most important predictor on multivariate analysis. CONCLUSION RRC can achieve adequately high LN yields with a low positive margin rate among unselected BUC patients. Early survival outcomes are similar to those reported in contemporary open series, with an encouragingly low incidence of local recurrence, however long‐term follow‐up and head‐to‐head comparison with the open approach are still needed.

You have accessJournal of UrologyKidney Cancer: Localized II1 Apr 20121298 RELATIONSHIP OF METABOLIC SYNDROMES TO CLEAR CELL HISTOLOGY IN RENAL MASSES Christopher Barbieri, Casey Ng, Sagit Goldenberg, James DiPietro, Jennifer Reifsnyder, Benjamin Shin, Kymora Scotland, Gerald Wang, Joseph Del Pizzo, E. Darracott Vaughan, and Douglas Scherr Christopher BarbieriChristopher Barbieri New York, NY More articles by this author , Casey NgCasey Ng New York, NY More articles by this author , Sagit GoldenbergSagit Goldenberg New York, NY More articles by this author , James DiPietroJames DiPietro New York, NY More articles by this author , Jennifer ReifsnyderJennifer Reifsnyder New York, NY More articles by this author , Benjamin ShinBenjamin Shin New York, NY More articles by this author , Kymora ScotlandKymora Scotland New York, NY More articles by this author , Gerald WangGerald Wang New York, NY More articles by this author , Joseph Del PizzoJoseph Del Pizzo New York, NY More articles by this author , E. Darracott VaughanE. Darracott Vaughan New York, NY More articles by this author , and Douglas ScherrDouglas Scherr New York, NY More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1632AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Metabolic syndromes such as obesity and diabetes mellitus are associated with increased risk for a variety of cancers. Recent data suggests a relationship between obesity and the clear cell variety of renal cell carcinoma (RCC). We investigated the association between metabolic disorders (including obesity, diabetes mellitus) and clear cell histology in patients undergoing surgical management of renal masses. METHODS A database of 735 patients undergoing partial or radical nephrectomy was retrospectively analyzed. Univariable and multivariable models tested the association of BMI and diabetes with clear cell histology. RESULTS Increased BMI and diabetes mellitus were associated with a significantly higher odds of clear cell carcinoma. When BMI was analyzed as a continuous variable, the odds ratio for clear cell histology was 1.05 for each point of BMI (95% CI 1.02-1.08, P<0.001). When BMI was considered as a categorical variable, risk of clear cell carcinoma was associated with overweight (odds ratio 1.41, P=0.063), obese (odds ratio 1.96, P=0.003) and morbidly obese (odds ratio 1.86, P=0.037) patients compared to those with BMI<25. Diabetes was also independently associated with clear cell histology, with odds ratio 1.69 (95% CI 1.08-2.64, P=0.022). The association of diabetes with clear cell histology was more pronounced in thin patients (BMI<25) than in overweight or obese patients. In patients with BMI<25, patients without diabetes had clear cell histology in 42% of renal tumors, compared to 72% in patients with diabetes (p=0.0027). In overweight or obese patients, there was no significant difference between the percentage of clear cell tumors in patients with or without diabetes (54% vs. 61%, p=0.1973). CONCLUSIONS In a database of surgically managed renal masses, clear cell RCC histology is associated with increased BMI and diabetes mellitus. The relationship between diabetes and clear cell histology is more pronounced in patients with a BMI<25. Metabolic derangements such as obesity and diabetes may predispose patients to clear cell RCC. Further studies are necessary to determine if this association is causative, and to elucidate the biological mechanisms responsible for this phenomenon. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e526 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Christopher Barbieri New York, NY More articles by this author Casey Ng New York, NY More articles by this author Sagit Goldenberg New York, NY More articles by this author James DiPietro New York, NY More articles by this author Jennifer Reifsnyder New York, NY More articles by this author Benjamin Shin New York, NY More articles by this author Kymora Scotland New York, NY More articles by this author Gerald Wang New York, NY More articles by this author Joseph Del Pizzo New York, NY More articles by this author E. Darracott Vaughan New York, NY More articles by this author Douglas Scherr New York, NY More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

OBJECTIVES Although the ileal conduit is the most well-established urinary diversion, the optimal technique for ureteroileal anastomosis remains controversial. Here, we present a technique for anastomosis of the ureters from within the lumen of the ileal conduit, under direct visualization. We examine the rate of ureteral stricture using this method, and review the literature regarding ureteroenteric anastomotic complications with various techniques.METHODS An intraluminal technique for ureteroenteric anastomsosis was performed by opening the conduit on the antimesenteric border to allow direct visualization of the ureteroileal anastomosis. Using our prospectively collected database, we investigated the prevalence of anastomotic stricture in patients undergoing urinary diversion using this method for anastomosis.RESULTS One-hundred eighteen patients underwent ileal conduit diversion with ureteroileal anastomoses performed as described. Median postoperative follow-up was 15 months. Ureteral strictures were identified in 5/118 patients (4.2%). Of the patients with strictures, one was successfully treated with endoscopic balloon dilatation, three were managed with chronic ureteral stents, and one was managed with a chronic percutaneous nephrostomy. Review of the recent literature reveals stricture rates up to 10% with current techniques.CONCLUSIONS We conclude from these results that during ileal conduit creation, intraluminal anastomosis of the ureters to the ileal segment under direct vision represents a viable alternative to other techniques, with complication rates that compare favorably with other reported series. UROLOGY 76: 1496-1500, 2010. (C) 2010 Elsevier Inc.

You have accessJournal of UrologyBladder Cancer: Invasive/Metastatic Disease III1 Apr 20101819 RISK FACTORS FOR THROMBOEMBOLISM AFTER RADICAL CYSTECTOMY IN BLADDER CANCER PATIENTS Eric Kauffman, Casey Ng, Ming Ming Lee, Brandon Otto, Gerald J. Wang, and Douglas S. Scherr Eric KauffmanEric Kauffman More articles by this author , Casey NgCasey Ng More articles by this author , Ming Ming LeeMing Ming Lee More articles by this author , Brandon OttoBrandon Otto More articles by this author , Gerald J. WangGerald J. Wang More articles by this author , and Douglas S. ScherrDouglas S. Scherr More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1757AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Studies indicate radical cystectomy (RC) carries the highest risk among different cancer surgeries for thromboembolism (TE) events. However, the specific characteristics of radical cystectomy that contribute most to the high TE risk are unclear. The goal of this study was to identify clinicopathologic and operative variables independently predicting TE following RC. METHODS Between 2002-2009, 194 consecutive bladder cancer patients underwent radical cystectomy (88 open, 106 robotic) with or without pelvic lymph node dissection at our institution. Twenty-four clinical, operative and pathologic variables were compared between patients with and without TE occurring within =90 days of surgery. Variables trending towards correlation (p<0.25) with TE on univariate analysis were subjected to a stepwise multivariate regression analysis to identify independent predictors. RESULTS Of the 194 RC patients, 19 (9.8%) experienced postoperative TE. All but 3 of these patients had extravesical disease or prior neoadjuvant chemotherapy. On univariate analysis, TE was significantly (p<0.05) associated with neoadjuvant chemotherapy (odds ratio [OR] 3.6), continent urinary diversion (OR 2.8), surgical time (OR 1.3) and younger age (OR 1.1). A strong but non-significant trend towards association with TE was observed with extravesical disease, total nodes taken, >4 (+)nodes and blood transfusion (p=0.06-0.11), and a weaker trend was observed for robotic surgical approach (p=0.21). Subjecting all 9 variables to regression multivariate analysis, we identified neoadjuvant chemotherapy, extravesical disease and a robotic surgical approach as the most important variables for predicting TE. (see Table) Lower age, while statistically significant, had questionable clinical significance given a hazard ratio near 1. CONCLUSIONS Patients with prior neoadjuvant chemotherapy, extravesical disease and a robotic surgical approach were most likely to experience TE following RC. The risk increase with a robotic approach may relate to pneumoperitoneum-compression of deep pelvic veins and/or consequences of prolonged Trendelenberg positioning. Aggressive peri-operative TE prophylaxis should be considered in patients with these risk factors. New York, NY© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e706 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Eric Kauffman More articles by this author Casey Ng More articles by this author Ming Ming Lee More articles by this author Brandon Otto More articles by this author Gerald J. Wang More articles by this author Douglas S. Scherr More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Study Type – Therapy (case series) Level of Evidence 4OBJECTIVETo better characterize short‐ and long‐term complications in patients after robotic‐assisted radical cystectomy (RRC) using standardized complications‐reporting systems, and to identify preoperative and operative risk factors predicting their occurrence.PATIENTS AND METHODSData were collected for 79 consecutive patients with bladder cancer undergoing RRC with extracorporeal urinary diversion by one surgeon at our institution. Complications occurring ≤90 days after RRC were graded according to two standardized reporting methods (Memorial Sloan Kettering Cancer Center and Modified Clavien), and additionally stratified by organ system. Nineteen preoperative and operative variables were tested by univariate analysis for association with the occurrence of one or more postoperative complications. Variables with a significant (P < 0.05) or near‐significant (P < 0.20) association on univariate analysis were included in multivariate analysis to identify independent risk factors.RESULTSPatients were of relatively poor health, with 58% having an American Society of Anesthesiology class or Charlson Index score of ≥3. Advanced bladder disease was frequent (41% had pT3/pT4). After RRC, one or more complications occurred within 90 days of surgery for 39/79 (49%) patients. The vast majority of complications were low grade (79%), and mostly infectious (41%) or gastrointestinal (27%). Sixteen high‐grade complications occurred in 13/79 (16%) patients. Urinary obstruction, abscess, enteric fistula, gastrointestinal bleeding and thromboembolism constituted most of the high‐grade complications, nearly half (seven of 16) of which occurred 31–90 days after RRC. On multivariate analysis, only preoperative renal insufficiency and intraoperative intravenous (i.v.) fluids of >5000 mL were significantly associated with postoperative complications of any grade, with respective odds ratios (ORs) of 4.2 and 4.1. For high‐grade complications, significant independent risk factors included an age of ≥65 years, operative blood loss of ≥500 mL and intraoperative i.v. fluids of >5000 mL, with respective ORs of 12.7, 9.7 and 42.1.CONCLUSIONEven among relatively sick patients with frequent advanced disease, the vast majority of complications after RRC are low grade. High‐grade complications are infrequent and similar in nature to high‐grade events after open RC, and a notable proportion may occur at >30 days after RRC underscoring the importance of longer reporting intervals. The surgeon’s ability to limit blood loss and i.v. fluids during RRC may provide effective risk reduction, particularly for high‐grade events.