646 Background: Gender disparity in the proportion of patients receiving nephron sparing strategies (NSS) for the treatment of localized renal masses has been demonstrated in large population series as well as in single centers of excellence. Reasons for the discrepancy remain elusive. We aimed to assess urologist treatment patterns for localized renal masses in both genders to gauge the existence of provider-based gender biases. We hypothesize that female patients may be recommended more aggressive treatment due to provider biases related to patient gender. Methods: Urologists were randomly emailed 1 of 2 surveys including 6 vignettes of various patients with renal masses. Both surveys were identical other than the vignette patient gender (VPG) which was male in 50% and female in 50%. Self-selected respondents chose the single best treatment option from the following choices: active surveillance (AS), percutaneous or laparoscopic ablation (ABL), partial nephrectomy (PN), and radical nephrectomy (RN). Fisher’s exact test was used to assess differences in treatment recommended based on VPG. Nominal logistic regression was performed to assess the magnitude of differences. Results: Of the 423 urologists who completed the survey there was an even response to both surveys (210 vs. 213). Most respondents were male (93%), married (89%) and in private practice (44%). Age and time practicing were evenly distributed and median number of nephrectomies done per year was 15. There were no significant differences in demographics between the respondents of the 2 surveys. When comparing AS, ABL, PN, and RN the only vignette that differed based on VPG was question 3 (p = 0.019). Comparison of any NSS vs. RN in question 3 showed male VPG was 1.67 times more likely to be recommended RN (p = 0.040). Urologist gender had no effect on these findings. Conclusions: In this survey study of practicing urologists we found that male patient gender increased recommendations for radical surgery and less nephron sparing strategies in a hypothetical older patient with a localized renal mass. Provider biases do not appear to be solely responsible for gender disparities seen in the treatment of a localized renal mass.

Local excision of small kidney cancers appears to treat cancer equally with added benefits of preserving more kidney tissue. After publication of guidelines recommending local excision where feasible, proportions of this procedure continue to increase and it is more widely spread. The rate of adoption of this complex procedure has slowed likely due to decreasing incidence of kidney cancer and emergence of other options.Background: The purpose of the study was to compare utilization and predictors of partial nephrectomy (PN) in the pre-and post-guideline eras. Materials and Methods: American Board of Urology certification/recertification operative logs were reviewed from 2003 to 2014. Nephrectomy cases were extracted using Current Procedural Terminology codes. The cases were then stratified according to pre-guidelines (2003-October 2009) and post-guidelines (November 2009-2014). Multivariable logistic regression was used to evaluate patient, surgeon, and practice characteristics as predictors of PN. A general linear model with regression analysis was used to evaluate the change in PN over time relative to the incidence of renal cell carcinoma (RCC). Results: We identified 20,402 and 20,729 nephrectomies in the pre-and post-guidelines eras, respectively. In multivariable analysis, the post-guidelines group was more likely to undergo PN (odds ratio, 1.87; P < .001). The pre-as well as post-guidelines groups had a higher likelihood of undergoing PN with an open approach, higher-volume surgeons, and younger patient age (P < .05). Surgeon subspecialty and US region were no longer significant factors after guidelines publication. Number of PN normalized to the incidence of RCC continued to increase over time (0.14%/y; R-2 = 0.77; P < .001). Conclusion: Partial nephrectomy in the post-guidelines era is no longer confined to urological subspecialists or certain densely populated US regions. Although rates of PN continue to increase relative to the recently decreasing overall incidence of RCC, the slope has leveled off somewhat. This is likely related to clinical intricacies of the best treatment modality and technologic advances rather than changes related to guidelines publication. Published by Elsevier Inc.

Objective: To assess the relationship of race and margin status among patients undergoing robotic partial nephrectomy (RPN) for T1 renal tumors from a contemporary population-based cohort. Methods: Using the National Cancer Database, we identified patients with localized renal cell carcinoma (RCC) (clinical T1N0M0) who underwent RPN from 2010 to 2013. The primary outcome was positive surgical margins (PSM). Multivariable logistic regression analyses were used to assess the association between race and PSM adjusting for patient clinicopathologic and hospital factors. Results: Among 12,515 patients undergoing RPN in our cohort, 8.3% had PSM (n = 1,045). When compared to white patients undergoing RPN for T1 RCC with PSM (7.9%), we observed a higher proportion of PSM among African American (AA) (10.8%; P = 0.005) and Hispanic/Latino patients (8.8%; P = 0.005), respectively. On multivariable analysis, AA patients had higher odds of PSM compared to white patients (odds ratio = 1.40; P = 0.008). Other factors associated with higher odds of PSM were treatment at nonacademic centers relative to academic centers (10.4% vs. 6.9%; odds ratio = 1.57; P < 0.001). Conclusions: In this contemporary population-based cohort, AA patients undergoing RPN for localized RCC tumors are at higher risk for PSM. These results suggest potential differences in quality of care and patient selection of RPN by race. (C) 2017 Elsevier Inc. All rights reserved.

You have accessJournal of UrologyProstate Cancer: Detection & Screening VII1 Apr 2016MP53-02 NEGATIVE PREDICTIVE VALUE OF A NEGATIVE MULTI-PARAMETRIC MRI OF PROSTATE Joseph Mahon, Ronald P Kaufman Jr., Rebecca O'Malley, Badar Mian, Hugh Fisher, and Ahmed Essa Joseph MahonJoseph Mahon More articles by this author , Ronald P Kaufman Jr.Ronald P Kaufman Jr. More articles by this author , Rebecca O'MalleyRebecca O'Malley More articles by this author , Badar MianBadar Mian More articles by this author , Hugh FisherHugh Fisher More articles by this author , and Ahmed EssaAhmed Essa More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.499AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES A significant number of men with clinical indications for prostate biopsy are found to have no evidence of disease on multi-parametric MRI (MP-MRI) of prostate. We sought to determine the prostate biopsy results in this cohort of men to further elucidate the negative predictive value of MP-MRI in the setting of clinical suspicion of prostate cancer. METHODS We reviewed the records of 395 men with clinical suspicion for prostate cancer who underwent MP-MRI of prostate prior to the biopsy. Men without any lesions on the MRI or lesions graded PiRADS 1-2 were included in the benign or the MRI negative group. We identified 169 (43%) men with negative pre-biopsy MRI of prostate. Clinical and demographic data were recorded. Mean PSA was 5.6 ng/ml and 69% had normal DRE. These men with clinical suspicious of prostate cancer but a negative MRI underwent random systematic (12-core) biopsy procedure. RESULTS Of the 169 men with negative pre-biopsy MP-MRI of prostate, 124 (73%) were biopsy-naive while 45 (27%) had previous biopsy. Overall, prostate cancer was noted in 54 (32%) men. Among biopsy-naive men 44 (35%) had cancer on their first biopsy, while 10 (22%) of those with a previous biopsy had cancer. Overall, mean number of positives cores was 2.3 (range 1-10). Among the men with cancer, 47 (88%) had Gleason score 6 or uni-focal Gleason 3+4. Predominant pattern 4+3 in 10% and 4+4 was noted in 2%, all of whom were biopsy-naive men. CONCLUSIONS Negative MP-MRI of prostate has high negative predictive value to rule out high risk or multi-focal intermediate risk prostate cancer. These findings may allow us to give patients the option to omit or postpone the prostate biopsy. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e697 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Joseph Mahon More articles by this author Ronald P Kaufman Jr. More articles by this author Rebecca O'Malley More articles by this author Badar Mian More articles by this author Hugh Fisher More articles by this author Ahmed Essa More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

INTRODUCTIONIntracorporeal suturing is considered to be the most challenging aspect of laparoscopic and robotic surgery. To overcome this problem, barbed self-retaining sutures have been effectively employed in various minimally invasive endourologic surgeries. However, the use of this suture has been recently cautioned for pyeloplasty due to a high failure rate. Our objective was to report our experience using barbed suture during robotic pyeloplasty.METHODSWe retrospectively identified 13 consecutive patients who underwent robotic pyeloplasty with a barbed monofilament (4-0 V-Loc™) suture for the ureteropelvic anastomosis from 2011 to 2014. We compared these patients to 12 consecutive patients who underwent robotic pyeloplasty with a 4-0 nonbarbed suture from 2007 to 2011. We evaluated patient demographics, operative times, preoperative and postoperative symptoms, renal function, and diuretic renograms (DRG). Successful repair was defined as resolution of preoperative symptoms and/or T½ improvement on DRG to less than 20 minutes.RESULTSThe median age was 26 (interquartile range [IQR] 20.7-38) years and 35 (IQR 18.3-44) years for the barbed and nonbarbed suture groups, respectively. In the barbed suture group, preoperative DRG revealed ureteropelvic junction obstruction (UPJO) in 11 patients, equivocal UPJO (T½ 10-20 minutes) in one patient, and no obstruction in one patient. In the nonbarbed group, preoperative DRG revealed UPJO in 10 patients, equivocal UPJO in one patient, and no obstruction in one patient. In the barbed suture group, postoperative DRG was obtained in 11 patients, which showed no obstruction in 10/11 patients with 92% of patients experiencing symptom resolution. Similarly, postoperative DRG was obtained in 11 patients in the nonbarbed group, which showed no obstruction in 10/11 patients with 100% postoperative symptom resolution.CONCLUSIONSIn the largest series reporting use of V-Loc suture for robotic pyeloplasty, the V-Loc suture was safely and effectively used for robotic pyeloplasty repair.

Objective: To determine whether presurgical sunitinib reduces primary renal cell carcinoma (RCC) size and facilitates partial nephrectomy (PN).Methods: Data from potential candidates for PN treated with sunitinib with primary RCC in situ were reviewed retrospectively. Primary outcome was reduction in tumor bidirectional area.Results: Included were 72 potential candidates for PN who received sunitinib before definitive renal surgery on 78 kidneys. Median primary tumor size was 7.2 cm (interquartile range [IQR]: 5.3-8.7 cm) before and 5.3 cm (JOR: 4.1-7.5 cm) after sunitinib treatment (P < 0.0001), resulting in 32% reduction in tumor bidirectional area (IQR: 14%-46%). Downsizing occurred in 65 tumors (83%), with 15 partial responses (19%). Tumor complexity per R.E.N.A.L. score was reduced in 59%, with median posttreatment score of 9 (IQR: 8-10). Predictors of lesser tumor downsizing included clinical evidence of lymph node metastases (P < 0.0001), non clear cell histology (P = 0.0017), and higher nuclear grade (P = 0.023). Surgery was performed for 68 tumors (87%) and was not delayed in any patient owing to sunitinib toxicity. Grade >= 3 surgical complications occurred in 5 patients (7%). PN was performed for 49 kidneys (63%) after sunitinib, including 76% of patients without and 41% with metastatic disease (P = 0.0026). PN was completed in 100%, 86%, 65%, and 60% of localized CT1a, cT1b, cT2, and cT3 tumors, respectively.Conclusion: Presurgical sunitinib leads to modest tumor reduction in most primary RCC, and many patients can be subsequently treated with PN with acceptable morbidity and preserved renal function. A randomized trial is required to definitively determine whether presurgical therapy enhances feasibility of PN. (C) 2015 Elsevier Inc. All rights reserved.

Purpose Cancer control of partial nephrectomy for high-risk localized renal cell carcinoma is unclear. To assess whether PN provides adequate cancer control in high-risk disease (HRD), survival outcomes were compared in both a population-based cohort and an institutional cohort. Methods Surveillance, Epidemiology, and End Results database and a prospectively maintained institutional database were queried for patients with RCC who underwent PN or RN for a localized tumor ≤7 cm and were found to have high-grade and/or high-stage disease (HRD). Cancer-specific (CSS) or recurrence-free survival (RFS) and overall survival (OS) were primary outcomes measured and were compared between those who underwent PN and RN using multivariable Cox proportional hazards and propensity analysis. Results The population cohort consisted of 12,757 (24.9 %) patients with HRD, 85.2 and 14.8 % of which underwent RN and PN, respectively. RN was not associated with CSS (HR 1.23, p = 0.08) but was independently associated with poor OS (HR 1.16, p = 0.031). Propensity analysis showed that RN resulted in a 20 % increased risk of death from all causes ( p = 0.008). In the institutional cohort, of 317 patients, 35.9 % had HRD, 56 and 52 of which underwent RN and PN, respectively. Adjusting for age-adjusted Charlson index, RN was a predictor of poor OS (OR 6.20, p = 0.041). Propensity analysis showed that RFS and OS were not related to nephrectomy type (RN HR 0.65, p = 0.627 and RN HR 1.70, p = 0.484). Conclusions In patients with pathologic high-risk RCC, partial excision is associated with similar cancer control as compared to radical excision.

You have accessJournal of UrologyKidney Cancer: Localized V1 Apr 2014MP64-13 NON-METASTATIC RENAL CANCERS OF MODERATE TO HIGH COMPLEXITY ARE AMENABLE TO PARTIAL NEPHRECTOMY AFTER NEOADJUVANT SUNITINIB Cesar Ercole, Brian Lane, Hyung Kim, Ithaar Derweesh, Rebecca O'Malley, Joseph Klink, Kerrin Palazzi, Brian Rini, and Steven Campbell Cesar ErcoleCesar Ercole More articles by this author , Brian LaneBrian Lane More articles by this author , Hyung KimHyung Kim More articles by this author , Ithaar DerweeshIthaar Derweesh More articles by this author , Rebecca O'MalleyRebecca O'Malley More articles by this author , Joseph KlinkJoseph Klink More articles by this author , Kerrin PalazziKerrin Palazzi More articles by this author , Brian RiniBrian Rini More articles by this author , and Steven CampbellSteven Campbell More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1930AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Systemic therapy with sunitinib has been shown to facilitate surgery with unresectable renal cell carcinoma (RCC). We sought to evaluate the effect of sunitinib on moderate- to high-complexity RCC in efforts to determine tumor characteristics that favor the conversion of a mass not initially readily amenable to partial nephrectomy (PN) to one that may be managed successfully with systemic therapy and a subsequent PN. METHODS Patient information at 4 institutions was reviewed to assess outcomes of radical nephrectomy (RN) or PN after sunitinib therapy for localized RCC. Data were collected for pre- and post-treatment characteristics of the primary renal mass (e.g. size, RENAL score, venous involvement), renal function, and surgical outcomes. Patient who completed presurgical sunitinib therapy with the intent for subsequent surgical intervention were included in this analysis. RESULTS Of 83 patients treated with presurgical sunitinib, 43 patients presented with moderate- to high-complexity renal masses (median clinical size: 7.2cm, interquartile range(IQR): 5.2-8.2; median RENAL score: 10, IQR: 9-11), in the absence of clinical evidence of lymph node or distant metastases. Absolute indications for PN included 9 patients with solitary kidney, 8 with bilateral RCC, and 27 patients with preoperative GFR<60. Following a median of 2 cycles of sunitinib (range: 2-5), median tumor size was 5.1cm (IQR: 4.1-7) and RENAL was 9 (IQR: 8-10). A total of 49 kidneys met criteria for this analysis and surgery was performed in 48 (98%) as one patient was deemed unfit for surgery. PN was completed successfully for 36 tumors (75%), including 10 using a minimally-invasive approach. A reduction in tumor area was observed in 94% (median decrease: 32.5%,IQR 19.5– 46.5%) and reduction in RENAL score was determined in 74% (26 by 1 point, 10 by 2 points). Main sunitinib side effects were fatigue related. Surgical complications of Grade ≥3 occurred in 5% of PN, where one patient required attention for a wound hernia and another patient required embolization for an AV fistula presenting with gross hematuria. CONCLUSIONS PN can be safely performed after sunitinib, including for some tumors not considered amenable to PN at initial presentation. We feel that presurgical sunitinib therapy for biopsy-proven clear cell RCC for which PN is not deemed feasible is a reasonable approach in select patients. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e705 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Cesar Ercole More articles by this author Brian Lane More articles by this author Hyung Kim More articles by this author Ithaar Derweesh More articles by this author Rebecca O'Malley More articles by this author Joseph Klink More articles by this author Kerrin Palazzi More articles by this author Brian Rini More articles by this author Steven Campbell More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

OBJECTIVE:To investigate gender effects on the type of nephrectomy performed for a stage I renal mass and differences that might account for disparity in treatment patterns according to gender. METHODS:Using a single-institution database, patients who underwent nephrectomy at a tertiary referral center for a localized, solitary tumor, ≤ 7 cm with a normal contralateral kidney were identified. Variables thought to affect selection for type of nephrectomy were compared between male and female patients. Using multivariable logistic regression, the effect of gender on the likelihood of radical vs partial nephrectomy and the likelihood of malignancy were assessed. Renal function outcomes were also compared. RESULTS:No difference between genders was seen in age, race, smoking status, body mass index, tumor size, RENAL score or operating surgeon. Only Charlson index and preoperative creatinine significantly differed with women having a more favorable comorbidity profile (Charlson >1 in 38% vs 50%; P = .027) and lower mean preoperative creatinine (0.09 ± 0.3 vs 1.1 ± 0.3; P <.001). Despite lower creatinine, women had inferior preoperative renal function with a mean estimated glomerular filtration rate of 71.4 ± 21 vs 78.9 ± 21 mL/min/1.73 m2 in men (P <.001). Multivariable analysis indicated that female patients were 2.5 times more likely to undergo radical nephrectomy compared with their male counterparts (P = .022). Women were less likely to have malignancy (odds ratio male gender 2.50; P = .013). CONCLUSION:Women are more likely than men to undergo radical vs partial excision of a localized renal mass, despite less comorbid burden, inferior renal function, and increased likelihood of benign disease.

You have accessJournal of UrologyKidney Cancer: Localized V1 Apr 20121848 PREDICTING MALIGNANCY AND AGGRESSIVE HISTOLOGY IN PATIENTS WITH SMALL RENAL MASSES: A NOVEL EXTERNALLY VALIDATED NOMOGRAM Rebecca L. O'Malley, Timothy Ito, Kristopher Attwood, Matthew H. Hayn, Katherine A. Brewer, Hyung L. Kim, Ramkishen Narayanan, Michael A. Poch, Samir S. Taneja, Michael D. Stifelman, William C. Huang, Willie Underwood, and Thomas Schwaab Rebecca L. O'MalleyRebecca L. O'Malley Buffalo, NY More articles by this author , Timothy ItoTimothy Ito New York, NY More articles by this author , Kristopher AttwoodKristopher Attwood Buffalo, NY More articles by this author , Matthew H. HaynMatthew H. Hayn Portland, ME More articles by this author , Katherine A. BrewerKatherine A. Brewer Buffalo, NY More articles by this author , Hyung L. KimHyung L. Kim Los Angeles, CA More articles by this author , Ramkishen NarayananRamkishen Narayanan Buffalo, NY More articles by this author , Michael A. PochMichael A. Poch Buffalo, NY More articles by this author , Samir S. TanejaSamir S. Taneja New York, NY More articles by this author , Michael D. StifelmanMichael D. Stifelman New York, NY More articles by this author , William C. HuangWilliam C. Huang New York, NY More articles by this author , Willie UnderwoodWillie Underwood Buffalo, NY More articles by this author , and Thomas SchwaabThomas Schwaab Buffalo, NY More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1958AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Developing reliable means of identifying patients with an aggressive small renal mass is crucial to selecting appropriate treatment. Existing nomograms predict risk of malignancy and high risk disease independently. We aimed to develop a novel nomogram to assess likelihood that small renal mass histology will be 1 of 3 possibilities; benign, low-risk malignant (LRM) or high-risk malignant (HRM). METHODS Using a renal tumor database we identified patients with solitary, localized tumors ≤7cm, with normal renal function and contralateral kidney. HRM was defined as pathologic stage ≥T3 or grade ≥3. Clinical covariates analyzed included: age, gender, race, smoking status, pack years, personal or family history of other cancer, family history of renal cancer, hypertension, diabetes, body mass index (BMI), Charlson index, glomerular filtration rates, tumor size, tumor centrality (abutting renal sinus or collecting system) and RENAL score. Patients were categorized by outcome (benign, LRM and HRM). Associations between outcome and covariates were explored using Kruskal Wallis and Chi-square tests. 7 unique models were generated: (1) using stepwise selection, (2) based on univariate (UV) associations alone, (3-5) based on univariate associations with various interaction terms, (6-7) using stepwise and researcher selection. The 2 models with the highest bootstrap corrected concordance indices (cCI) were investigated further. Data from an outside institution was used to identify and validate the superior model. RESULTS Of 300 patients identified, benign, LRM and HRM disease was seen in 16, 54 and 30%, respectively. UV analysis showed differences between groups in tumor size (<0.01), tumor centrality (p<0.01), smoking status (p=0.09) and gender (p=0.07). Model 1 included covariates with significant UV associations (tumor size, gender) and the interaction term tumor size & smoking status, with a cCI 0.68. Model 2 included tumor size and gender along with BMI, age, Charlson, and smoking status, with a cCI 0.67. Both models show a significant interaction between smoking status and tumor size indicating that tumor size is a more important predictor in non-smokers than in current or past smokers. Using external data the concordance index for model 1 was 0.69 and for model 2 was 0.74, while the Brier score was 0.56 and 0.55, respectively. CONCLUSIONS We have developed and externally validated a nomogram (Model 2) for the prediction of malignant and aggressive histology in patients with small renal masses. Further validation will help to refine the model. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e747 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rebecca L. O'Malley Buffalo, NY More articles by this author Timothy Ito New York, NY More articles by this author Kristopher Attwood Buffalo, NY More articles by this author Matthew H. Hayn Portland, ME More articles by this author Katherine A. Brewer Buffalo, NY More articles by this author Hyung L. Kim Los Angeles, CA More articles by this author Ramkishen Narayanan Buffalo, NY More articles by this author Michael A. Poch Buffalo, NY More articles by this author Samir S. Taneja New York, NY More articles by this author Michael D. Stifelman New York, NY More articles by this author William C. Huang New York, NY More articles by this author Willie Underwood Buffalo, NY More articles by this author Thomas Schwaab Buffalo, NY More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

e15046 Background: Whether increased risk of complication (Cx) is balanced by the renal preserving benefits of partial nephrectomy (PN) in those with shortened lifespan is unclear. We compared Cx and renal function outcomes of PN and radical nephrectomy (RN) in the elderly. Methods: From a prospectively maintained renal tumor database, we retrospectively identified patients ≥ 75 years old who had RN or PN for a solitary, localized tumor ≤ 7cm and a normal contralateral kidney. CKD-EPI formula estimated glomerular filtration rate (eGFR). Propensity analysis was used to account for population selection bias: probability of RN was calculated by multivariate logistic regression, including variables thought to influence selection for nephrectomy type, yielding a propensity score based on quintile of RN probability. Odds ratios for any Cx, high grade Cx and postoperative stage ≥ 4 chronic kidney disease [CKD4] by nephrectomy type were recalculated using logistic regression adjusting for propensity score. Other statistical tests used were Student′s t, Wilcoxon rank-sum and Fisher′s exact. Results: 57 patients met inclusion criteria: 47% and 53% had PN and RN, respectively. Age, gender, baseline Cr, BMI and Charlson index were similar between the PN and RN groups. In both groups, surgical approach was minimally invasive in 93%. Mean tumor size with RN was larger than with PN (4.6 v. 3.6 cm, p<0.01). EBL was higher with PN (360 v. 122 mL, p=0.02), although intraoperative transfusion rate was similar (p=0.13). With similar preoperative eGFR between groups, mean postoperative eGFR was lower in the RN group (36 v. 50 ml/min/1.73m2, p<0.01). Propensity analysis showed likelihood of CKD4 was significantly higher with RN (OR 5.5, p=0.04). Cx rate was similar between PN and RN (30% v.37%, p=0.39), but most high grade Cxs were seen with PN (56% v. 23%, p=0.01). Propensity analysis supported these data in that risk of total Cxs was not increased with PN (p=0.46) but risk of high grade Cxs was significantly higher with PN (OR 9.2, p<0.01). Conclusions: Risk of significant renal dysfunction following RN was 5-fold that of PN, but risk of high grade complications with PN is 9-fold that of RN. Evaluating the clinical impact of these risks should be done on an individual patient basis.

INTRODUCTION:Treatment of the elderly patient with a small renal mass is becoming a common conundrum with scant data available to support treatment decisions. Goals were to assess risk of surgical treatment for renal cell carcinoma (RCC) in the elderly as compared to their younger counterparts.MATERIALS AND METHODS:A prospectively maintained database consisting of all renal tumors between August 2004 and November 2009 was utilized. Patients who underwent extirpative treatment for RCC were divided into groups based on age cutoff of < 75 and ≥ 75 years old. Primary outcome measures were likelihood of partial nephrectomy versus radical nephrectomy, complication rates, and overall and cancer-specific survival. A secondary outcome investigated was renal function.RESULTS:Of 347 patients identified, 273 were < 75, and 74 were ≥ 75 years old. The elderly group was less likely to undergo partial nephrectomy (26% versus 43%, p = 0.045). They also had a higher rate of pT3 disease (20% versus 11%, p = 0.018), worse baseline renal function (46 mL/min/m(2) versus 92 mL/min/m(2), p < 0.001) and a longer length of stay (3.5 days versus 2.2 days, p < 0.001). Complication rates and survival outcomes were similar between the groups. Only Eastern Cooperative Oncology Group (ECOG) ≥ 1 and Charlson index ≥ 2 predicted likelihood of experiencing a complication.CONCLUSIONS:Despite a longer length of stay, renal surgery is safe in selected elderly patients with minimal comorbidity and good functional status. The elderly have reduced baseline renal function indicating nephron sparing should be chosen whenever possible, when surgical intervention is elected.

429 Background: Partial nephrectomy in upper pole kidney tumors represents a distinct surgical challenge. Data on minimally invasive nephron sparing surgery in this context are scarce. We set out to investigate the role of laparoscopic and open approaches to partial nephrectomy in these tumors. Methods: The Roswell Park Cancer Institute prospective, IRB-approved kidney surgery database was reviewed containing 690 patients. Only patients completing a radical or partial nephrectomy for unilateral, localized, non-metastatic tumors < 7cm were included. The resulting cohort contained 400 patients. Average patient age at surgery was 59.9 ± 13.2 years (range: 22-88). Tumor stages included benign (13.5%), T1a (53.0%), T1b (25.0%), T2 (1.5%), T3a (7.0%). Upper pole tumors (n=128; 27%) and lower pole/ mid-pole tumors (n=270; 67.5%) were recorded. Intraoperative complications were recorded; postoperative complications were tabulated as low or high grade per Clavien-Dindo classification. SPSS (version 19.0) software was used to analyze the dataset. Results: Total intraoperative complication rate was 11.3% (45/400 cases). After stratification by tumor location and partial vs. radical nephrectomy, intraoperative complication rates were higher for laparoscopic/robotic partial nephrectomies involving upper pole tumors (72.7% of all intraoperative complications) compared to lower pole tumors (27.3%, p=0.04), in Chi-Square test. In the delayed postoperative period, total low-grade Clavien complication rate was 97.8% (391/400 cases); high-grade complication rate was 2.3% (9/400). After controlling for tumor location and nephrectomy extent, the high-grade delayed complications were present only in the open nephrectomies involving upper-pole tumors. However, laparoscopic/robotic partial nephrectomies involving upper-pole tumors had significantly more delayed low-grade complications (92.4% of all delayed complications) compared to lower-pole tumors (7.6%, p<0.01), in Chi-Square. Conclusions: Upper pole kidney tumors represent a challenging surgical situation. We here demonstrate that minimally invasive partial nephrectomy in this context requires significant surgical expertise and an open approach could be considered.

You have accessJournal of UrologyProstate Cancer: Epidemiology and Natural History I1 Apr 2012165 LIVE BETTER: THE EFFECT OF LIFESTYLE BEHAVIORS ON POST-PROSTATECTOMY HEALTH RELATED QUALITY OF LIFE OUTCOMES Michael A. Poch, Diana C. Mehedint, Rebecca L. O'Malley, Chi-Chen Hong, Levi Ross, Khurshid A. Guru, and Willie Underwood Michael A. PochMichael A. Poch Buffalo, NY More articles by this author , Diana C. MehedintDiana C. Mehedint Buffalo, NY More articles by this author , Rebecca L. O'MalleyRebecca L. O'Malley Buffalo, NY More articles by this author , Chi-Chen HongChi-Chen Hong Buffalo, NY More articles by this author , Levi RossLevi Ross Buffalo, NY More articles by this author , Khurshid A. GuruKhurshid A. Guru Buffalo, NY More articles by this author , and Willie UnderwoodWillie Underwood Buffalo, NY More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.216AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Modifiable lifestyle behaviors, including tobacco use, alcohol consumption, and physical activity, have been shown to affect genitourinary health in men. The goal of this study was to assess the impact of lifestyle behaviors on health-related quality of life (HRQL) outcomes for patients undergoing robotic radical prostatectomy (RARP) using a novel composite index: Lifestyle Index of Vascular and Erectile health (LIVE score). METHODS The prospective IRB approved localized prostate cancer database at Roswell Park Cancer Institute was queried for patients who underwent RARP from 2004 to 2009. HRQL outcomes were measured using the UCLA-PCI at standard postoperative time points. Lifestyle behavior data were obtained from the Institutional Data Bank and BioRepository which collects extensive epidemiological information regarding dietary, social, and health practices at the time of cancer diagnosis. LIVE scores were generated by assigning values to smoking status, pack year history, physical activity level and body mass index (BMI). Patients with LIVE scores ≤ 2 were categorized as low, 3-4 average, and >4 high. The relationship between LIVE scores and HRQOL outcomes was assessed using ANOVA and multivariable regression analysis. RESULTS 409 patients were included in the study. Mean age at operation was 60 (SD ± 6 years) with mean pre-operative PSA 6.5 ng/ml (SD ± 5.1). 130 (32%) patients reported adequate sexual function by 12 months postoperatively. 179(44%) patients returned to baseline sexual bother score by 12 months. At 6 months 359 (88%) patients were using ≤2 pads per day and (217) 53% had perfect continence. Urinary bother scores returned to baseline in 219 (53%) patients by 12 months. 77 (19%), 246 (60%) and 73 (18%) patients had high, average and low LIVE scores, respectively. Patients with average and high LIVE scores had higher sexual function scores than patients with low LIVE scores preoperatively (p <0.001), at 6 (p = 0.01), 12 (p = 0.013) and 24 months (p = 0.036). Better erection quality (p = 0.02) and orgasmic function (p = 0.01) were positively associated with LIVE scores after adjustments for age, preoperative sexual function, and receipt of nerve sparing technique. There was no difference in pad count between LIVE groups at 6 and 12 months after adjustment for age and nerve-sparing technique. CONCLUSIONS As demonstrated by the LIVE index, healthy lifestyle behaviors are associated with improved postoperative sexual function for patients undergoing RARP. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e68-e69 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Michael A. Poch Buffalo, NY More articles by this author Diana C. Mehedint Buffalo, NY More articles by this author Rebecca L. O'Malley Buffalo, NY More articles by this author Chi-Chen Hong Buffalo, NY More articles by this author Levi Ross Buffalo, NY More articles by this author Khurshid A. Guru Buffalo, NY More articles by this author Willie Underwood Buffalo, NY More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

e15039 Background: Obesity adds significant operative challenge to kidney surgery. Its impact on minimally invasive kidney surgery has not been well defined. We evaluated the impact of obesity on open and minimally invasive kidney surgery (MIS) for kidney tumors. Methods: Patients in our prospectively collected IRB-approved kidney database were divided into 5 groups as determined by the World health organization Body mass index (BMI) classification: less than 25.0, 25.0-30.0, 30.0-35.0, 35.0-40.0, and more than 40.0 Kg/m2. Patient characteristics, and peri-operative data were recorded and compared between the different groups and between surgical approches(open vs. MIS) using the Kruskal Wallis and Chi Square tests for continuous and categorical data, respectively. The potential association between BMI and the continuous measures of OR time, Post op stay and EBL were assessed using spearman Correlations. Results: Of the 620 patients identified, 142 (22.9 %) had healthy weight, 180 (29.0%) were overweight, and 298 (48.1%) were obese. Most had grade 1 obesity (BMI 30-34, 167, 26.9%), grade 2 obesity (BMI 35-40, 76, 12.3%), and grade 3 obesity (BMI > 40, 55, 8.9%). As expected, the ASA score rose with degree of obesity (p=<.001). EBL (estimated blood loss), OR (operative time) time, Room time and post-operative stay differed significantly in the 5 groups of patients (p=0.001, p=0.003, p=<0.002, p= <.001, p=.002), respectively. While intra-operative complications did not differ between the obesity groups, obese patients had a higher rate of high grade Clavien complications (p=0.026). Interestingly, the surgical approach (open vs. MIS) and type of nephrectomy ( radical vs. partial) did not correlate with degree of obesity or complications, even when adjusted for stage. Conversion rates for MIS did not correlate with degree of obesity. Conclusions: Nephrectomy in obese patients results in incresed high grade of postoperative complications. Surgical approach does not appear to have any impact on peri-operative outcomes.

You have accessJournal of UrologyKidney Cancer: Localized V1 Apr 20121854 WOMEN ARE MORE LIKELY THAN MEN TO UNDERGO RADICAL EXCISION OF A SMALL RENAL MASS DESPITE INFERIOR PREOPERATIVE RENAL FUNCTION Rebecca L. O'Malley, Katherine A. Brewer, Matthew H. Hayn, Hyung L. Kim, Diana C. Mehedint, Ramkishen Narayanan, Mohab W. Safwat, Willie Underwood, William C. Huang, and Thomas Schwaab Rebecca L. O'MalleyRebecca L. O'Malley Buffalo, NY More articles by this author , Katherine A. BrewerKatherine A. Brewer Buffalo, NY More articles by this author , Matthew H. HaynMatthew H. Hayn Portland, ME More articles by this author , Hyung L. KimHyung L. Kim Los Angeles, CA More articles by this author , Diana C. MehedintDiana C. Mehedint Buffalo, NY More articles by this author , Ramkishen NarayananRamkishen Narayanan Buffalo, NY More articles by this author , Mohab W. SafwatMohab W. Safwat Buffalo, NY More articles by this author , Willie UnderwoodWillie Underwood Buffalo, NY More articles by this author , William C. HuangWilliam C. Huang New York, NY More articles by this author , and Thomas SchwaabThomas Schwaab Buffalo, NY More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1964AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Population based analysis and investigation at tertiary centers have demonstrated that women are more likely to undergo radical versus partial nephrectomy for small renal masses. Reasons for this disparity in receipt of standard of care treatment are unclear. The purpose of this study is to investigate whether this disparity exists at an NCI designated cancer center and to attempt to elucidate the etiology of the discrepancy. METHODS Using a prospectively maintained, renal tumor database patients who were candidates for elective partial nephrectomy (solitary, localized tumors ≤7cm with a normal contralateral kidney) were identified. Factors thought to affect selection for type of nephrectomy were compared between male and female patients, including; race, smoking status, surgical approach (minimally invasive vs. open), age, Charlson index (CCI), body mass index, preoperative creatinine, year of surgery, tumor size and R.E.N.A.L. score. Preoperative estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration formula. Using multivariable logistic regression the effect of gender on likelihood of undergoing radical (vs. partial) nephrectomy was assessed. RESULTS Of 386 patients identified, 60% were male, 91% were white and CCI was >1 in 45%. Mean preoperative creatinine was 1.04 (±0.3) mg/dL, maximal tumor dimension 3.6 (±1.6) cm and mean R.E.N.A.L. score 7.6 (±1.8). Approach was minimally invasive in 84% and 39% underwent radical nephrectomy. Comparing male and female patients, radical nephrectomy was undertaken in 37% and 43%, respectively. The only factors that differed between men and women were preoperative creatinine and CCI, both of which were higher in male patients (creatinine 1.10 vs. 0.96 ng/dL, p<0.01 and CCI 1.1 vs. 0.6, p=0.02). Despite this, preoperative renal function was actually better in men (eGFR 77 vs. 71 ml/min/1.73m2, p<0.01). Adjusting for all other factors, female patientsweare almost 3 times more likely to undergo radical nephrectomy compared to their male counterparts [OR 2.80 (CI 1.16-6.76), p=0.02]. CONCLUSIONS Women are more likely than men to undergo radical vs. partial excision of a small renal mass. Reasons for this disparity remain unclear but may be related to a perception of better preoperative renal function in women because creatinine tends to be lower, though renal function is actually inferior. Further elucidation of reasons for this gender disparity are paramount in order to ensure standard of care treatment in all patients. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e749-e750 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rebecca L. O'Malley Buffalo, NY More articles by this author Katherine A. Brewer Buffalo, NY More articles by this author Matthew H. Hayn Portland, ME More articles by this author Hyung L. Kim Los Angeles, CA More articles by this author Diana C. Mehedint Buffalo, NY More articles by this author Ramkishen Narayanan Buffalo, NY More articles by this author Mohab W. Safwat Buffalo, NY More articles by this author Willie Underwood Buffalo, NY More articles by this author William C. Huang New York, NY More articles by this author Thomas Schwaab Buffalo, NY More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PURPOSE:To compare operative and functional outcomes of minimally invasive partial nephrectomy (MPN) and minimally invasive radical nephrectomy (MRN) for T(1b) and T(2a) renal tumors.PATIENTS AND METHODS:All patients who underwent MPN or MRN for a localized, solitary renal mass 4 to 10 cm were included. Perioperative and renal function outcomes were compared. Propensity analysis was used to account for selection bias in type of nephrectomy when evaluating complication rates.RESULTS:One hundred and eight patients underwent MRN and 45 underwent MPN between August 2004 and September 2010. Preoperative patient and tumor characteristics were similar between groups. Tumor size was larger in the MRN group (5.3 vs 6.8 cm, P<0.001). Operative times and positive margin rates were similar between the groups (P=0.956 and P=0.207, respectively). Estimated blood loss was higher in the MPN group (401.8 vs 157.1 mL, P<0.001), but transfusion rates were similar (P=0.225). Rates of intraoperative (P=0.724), postoperative (P=0.806), and high Clavien-grade postoperative complications (P=0.966) were similar. Propensity analysis indicated that the likelihood of any complication (odds ratio [OR] 0.810, confidence interval [CI] 0.331-1.982, P=0.645) or of a high-grade complication (OR 0.164, CI 0.011-2.513, P=0.194) was unrelated to type of nephrectomy. With similar preoperative renal function parameters, postoperative development of new stage III to V chronic kidney disease (CKD) was greater in the MRN group (58 vs 31%, P=0.011). Propensity analysis showed that the likelihood of new CKD was 2.8 times higher in the MRN group (P=0.048).CONCLUSION:In selected patients and with appropriate surgical expertise, MPN can result in similar rates of complications but superior renal function outcomes in larger kidney tumors.

370 Background: Analyses of population-based databases have demonstrated a striking under-utilization of partial nephrectomy (PN) despite its superiority in functional outcomes. Disparities in treatment patterns exist in the community and at some tertiary centers, based on age, gender and some comorbidities. The goal of the current study was to determine predictors of PN utilization at a cancer center in the modern era. Methods: An institutional renal tumor database was used to identify patients who were potential candidates for elective PN (solitary tumors ≤ 7cm, baseline creatinine ≤ 1.5 mg/dL and a normal contralateral kidney). We estimated the effects of hypothesized predictors on the likelihood of undergoing radical nephrectomy (RN) versus PN by univariable (UV) and multivariable (MV) logistic regression. Variables included were: age, gender, race, smoking status, Charlson comorbidity index, body mass index (BMI), preoperative creatinine, year of surgery (YOS), radiographic tumor size, and whether diagnostic biopsy was performed. Results: Of the 244 patients identified, 64% underwent PN and 37% underwent RN between August 2004 and June 2010. The cohort was composed of 11% non-Caucasians, 59% males and 22% current smokers with a mean age, BMI and tumor size of 61 years, 31 kg/m 2 and 3.5cm, respectively. Of the cohort, 17% underwent biopsy. On UV analysis advanced age, larger tumor size, earlier YOS and Caucasian race all predicted RN (OR 1.03 CI 1.02-1.06, OR 2.09 CI 1.70-2.58, OR 0.56 CI 0.46-0.70, OR 0.36 CI 0.13-0.99, respectively). On MV analysis using all variables, tumor size and YOS remained independent predictors (OR 2.89 CI 2.11-3.95, OR 0.44 CI 0.33-0.59, respectively). Renal cell carcinoma (RCC) on biopsy was also independently predictive on MV analysis (OR 0.37 CI 0.14- 0.97). Conclusions: Predictors of PN utilization at a cancer center differ from previous analyses and include decreasing tumor size, more recent YOS and RCC on biopsy. Appropriately, age and gender (when comorbidity is included) are not predictors of type of surgery. The significance of RCC on biopsy as a predictor of PN is unclear but may represent co-varying selection bias for lesions that are both accessible to biopsy and more appropriate candidates for PN. No significant financial relationships to disclose.

You have accessJournal of UrologyKidney Cancer: Localized1 Apr 20111075 IMPROVED FUNCTIONAL OUTCOMES WITH SIMILAR CANCER OUTCOMES IN PATIENTS WITH HIGH RISK LOCALIZED RENAL CELL CARCINOMA TREATED WITH PARTIAL AS COMPARED TO RADICAL NEPHRECTOMY Rebecca L. O'Malley, MD Matthew H. Hayn, MD Hyung L. Kim, MD Katherine A. Brewer, Michael A. Poch, andMD Thomas SchwaabMD, PhD Rebecca L. O'MalleyRebecca L. O'Malley Buffalo, NY More articles by this author , Matthew H. HaynMatthew H. Hayn Buffalo, NY More articles by this author , Hyung L. KimHyung L. Kim Los Angeles, CA More articles by this author , Katherine A. BrewerKatherine A. Brewer Buffalo, NY More articles by this author , Michael A. PochMichael A. Poch Buffalo, NY More articles by this author , and Thomas SchwaabThomas Schwaab Buffalo, NY More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1113AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Cancer outcomes are similar for radical (RN) and partial nephrectomy (PN) for low-stage renal cell carcinoma (RCC). However, when pathologic analysis reveals disease at high risk for recurrence, i.e. stage ≥pT3 or grade ≥3, outcomes are unclear. We undertook this analysis to investigate survival and renal function outcomes of PN and RN in pts with high risk disease (HRD). METHODS From our institutional renal tumor database, we identified pts with a localized, solitary tumor ≤ 7 cm in size, who underwent PN or RN, from June 1997 to September 2010. Those with HRD were those with pathologic stage ≥pT3 or grade ≥3. Survival and renal functional outcomes were compared between those with HRD who underwent PN and those who underwent RN. RESULTS Of the 326 pts fitting inclusion criteria, 118 pts (36.1%) had HRD, 62 and 56 of which underwent RN and PN, respectively. Mean age, race distribution, smoking history, Eastern Cooperative Oncology Group performance status, and mean body mass index were similar between the PN and RN groups. Charlson comorbidity index (CCI) of >1 was seen in 52% of the PN group and 45% of the RN group (p=0.720). Pre-operative tumor size was larger in the RN group (5.1 vs. 3.6 cm, p<0.001). Rates of positive surgical margins and of non-clear cell histology were similar. Mean glomerular filtration rates (eGFR), as estimated by the Chronic Kidney Disease Epidemiology Collaboration formula and pre-operative rates of stage 3 chronic kidney disease (CKD) in the PN group were 75 ml/min/1.73m2 and 23% vs. 71 ml/min/1.73m2 and 27% in the RN group (p=0.352 and p=0.600, respectively). Post-operatively, the PN group had a lower mean decrease in eGFR (8 vs. 22 ml/min/1.73m2, p<0.001) and lower rate of development of stage 3 CKD (13 vs. 26%, p<0.001). At a mean follow-up was 30 months, 2-year overall survival (OS) tended to be worse in the RN group (Figure) but this did not reach statistical significance (86 vs 97%, p=0.224). OS was predicted only by high CCI (HR 10.5, p<0.001). At 2 years, recurrence-free survival was similar between the PN and RN groups (100 and 93%, p=0.556). CONCLUSIONS Intermediate term survival outcomes of those with high risk, localized RCC are similar if treated by RN or PN. PN is the preferred treatment due to superior renal function outcomes. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185 Issue 4S April 2011 Page: e432 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.Metrics Author Information Rebecca L. O'Malley Buffalo, NY More articles by this author Matthew H. Hayn Buffalo, NY More articles by this author Hyung L. Kim Los Angeles, CA More articles by this author Katherine A. Brewer Buffalo, NY More articles by this author Michael A. Poch Buffalo, NY More articles by this author Thomas Schwaab Buffalo, NY More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...