Holmium laser enucleation of the prostate (HoLEP) is an increasingly popular size-independent technique of treating male voiding dysfunction due to benign prostatic hypertrophy. Some patients after HoLEP may develop clinically significant prostate cancer and opt for definitive treatment with external beam radiation therapy (EBRT). Little is known about the safety of EBRT after HoLEP and how it may functionally impact voiding after HoLEP has altered the anatomy of the prostate. Our study aimed to assess patient-reported voiding outcomes following EBRT after HoLEP with a focus on incontinence related patient outcomes. This study was conducted with approval from our hospital’s institutional review board. Patients that underwent HoLEP followed by EBRT were identified and data were collected in a retrospective nature from a single surgeon HoLEP cohort over the past 4 years (2019–2023). Patient demographics, disease and radiation therapy characteristics, radiation therapy, and baseline voiding symptoms were recorded. Current functional voiding outcomes were also collected via phone-call or portal communication in a cross-sectional manner with questions pertaining to type of incontinence, IPSS quality of life score, and administration of the Michigan incontinence symptom index (M-ISI). Adverse events encountered during follow-up were recorded. 24 patients were identified who received RT for prostate cancer after HoLEP with an average age of 73.6 (± 5.3). One third of patients reported no incontinence whatsoever after radiation and of those who experienced incontinence, the majority felt that it was not worsened after radiation. Median IPSS QoL score following radiation was 1 (range 0–6), median M-ISI Severity Score was 4 out of a maximum of 32, and median M-ISI bother score was 0 out of a maximum of 8. One patient developed a bladder neck contracture (BNC) approximately 1 year following his radiation therapy (approximately 18 months after HoLEP) causing bothersome incontinence and LUTS. In our cohort most patients who received RT after HoLEP reported a high urinary-symptom related quality of life and a low rate of urinary incontinence. One patient who received SBRT suffered a BNC which is a known adverse event with RT but given our small sample size it remains unclear if the risk is higher in patients receiving RT after HoLEP. Larger studies should focus on examining the rate of bladder neck contracture in patients receiving RT after HoLEP, particularly focusing on whether the degree of dose fractionation may impact their development.

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Quality Improvement & Patient Safety II1 Apr 2017MP92-17 USE OF GUIDEWIRE DURING PLACEMENT OF PROPHYLACTIC URETERAL LOCALIZATION STENTS (PULSE) FOR COLORECTAL SURGERY (CRS) CASES DECREASES UROLOGIC-INDUCED OPERATIVE COMPLICATIONS Ram Pathak, Gregory Broderick, Kasey Cockerill, Ciarra Boyne, Todd Igel, Raymond Pak, Steven Petrou, Paul Young, Ryan Frank, Nicolette Chimato, and David Thiel Ram PathakRam Pathak More articles by this author , Gregory BroderickGregory Broderick More articles by this author , Kasey CockerillKasey Cockerill More articles by this author , Ciarra BoyneCiarra Boyne More articles by this author , Todd IgelTodd Igel More articles by this author , Raymond PakRaymond Pak More articles by this author , Steven PetrouSteven Petrou More articles by this author , Paul YoungPaul Young More articles by this author , Ryan FrankRyan Frank More articles by this author , Nicolette ChimatoNicolette Chimato More articles by this author , and David ThielDavid Thiel More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2878AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Prophylactic Ureteral Localization Stents (PULSe) aid in intraoperative localization and detection of suspected ureteral injury during complex Colorectal Surgery cases. We previously reported the incidence of urologic induced Clavien grade III complications of PULSe placement at our institution from July 2013 to June 2014 is estimated at 4%. As a quality health initiative, we sought to compare a modification of technique, mandatory use of guidewire assistance during PULSe placement to reduce urologic induced complications in this patient cohort. METHODS Following results of the above study, we made guidewire usage during PULSe placement mandatory at our institution. We reviewed all patients who underwent cystoscopy and PULSe placement at the time of CRS over a 12 month period (July 2015 to June 2016). Bilateral 5 French x 70 cm TigerTail (Bard Medical Division, Covington, GA) PULSe devices were placed with use of guidewire. Flouroscopy was not used. We compared this patient cohort to our prior cohort from July 2013 to June 2014 with the following variables: age, BMI, American Society of Anesthesiologists (ASA) score, preoperative creatinine, postoperative creatinine, pre/postoperative creatinine difference, and Clavien III urologic induced complications. RESULTS 132 patients with a mean age and BMI of 55.78 (18 to 89) and 27.02, respectively underwent bilateral PULSe placement with mandatory use of guidewire. Mean pre and postprocedural creatinine levels were 0.91 and 1.04, respectively with a mean pre/post procedural creatinine difference of 0.09. No Clavien III complications were encountered in the contemporary cohort, compared to the prior incidence of 4% (p≤0.001). Moreover, postoperative creatinine and pre/postprocedural creatinine difference also favored the contemporary cohort (p≤0.022 and p≤0.003, respectively). CONCLUSIONS Mandatory use of guidewire prior to PULSe placement reduced our incidence of urologic induced Clavien III complications to zero. Benefits were also observed in postoperative and pre/post procedural renal function with use of guidewire. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1234 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Ram Pathak More articles by this author Gregory Broderick More articles by this author Kasey Cockerill More articles by this author Ciarra Boyne More articles by this author Todd Igel More articles by this author Raymond Pak More articles by this author Steven Petrou More articles by this author Paul Young More articles by this author Ryan Frank More articles by this author Nicolette Chimato More articles by this author David Thiel More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyTechnology & Instruments: Surgical Education & Skills Assessment II1 Apr 2015MP23-07 VASECTOMY SIMULATION MODULE: DIDACTIC, AUDIO-VISUAL, AND LIVE-SIMULATION EXPERIENCE Ram Pathak, Scott Alford, and Todd Igel Ram PathakRam Pathak More articles by this author , Scott AlfordScott Alford More articles by this author , and Todd IgelTodd Igel More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1250AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To combat concerns over surgical cases, duty-hour restrictions, and ethical obligations of the patient-physician alliance, simulation has evolved as a necessary adjunct in residency education. Vasectomies, often performed on awake patients, create a peculiar atmosphere, with both patient and physician angst. Oftentimes, residents are not primary surgeons. We created a Vasectomy Simulation Module, equipped with a didactic power-point presentation and audio-visual component, as well as, skills training on a vasectomy simulator in the presence of an attending physician. The primary aim of the study was to determine the impact of the Vasectomy Simulation Module on resident education via questionnaires. METHODS A retrospective review quantifying the vasectomy experience, degree of anxiety and role of simulation of graduated residents at a single institution was performed. Results were tabulated anonymously. All current residents were asked to participate in a vasectomy simulation module, consisting of a didactic portion outlying the history of vasectomy, common techniques and pertinent AUA guidelines; a narrated video of both a ‘real’ and ‘simulated’ vasectomy performed by an attending physician; and demonstration of skills mastery in the presence of an attending physician. Responses were garnered from all participating residents. RESULTS Retrospective review of prior graduates revealed significant anxiety while performing their first vasectomy. A majority (>80%) wished they had access to simulation prior to performing their first vasectomy. In regards to the prospective part, of all who participated, only residents (n=4) without any clinical vasectomy experience were included in the analysis. 75‰ of residents stated they ‘strongly agree’ that the vasectomy simulation has increased comfort level with performing vasectomies, while 1 resident ‘agreed’ with the aforementioned statement. All residents agreed that simulation would reduce fear and anxiety when performing live vasectomy. CONCLUSIONS Our Vasectomy Simulation Module received overwhelmingly positive feedback. Residents felt they attained the necessary procedural skills to master the no scalpel vasectomy. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited byPathak R, Edge C, Thomas G, Thiel D, Broderick G, La Rosa D, Lannen A, Moore M, Frank R and Igel T (2019) Vasectomy Simulation Curriculum and Trainer with Enhanced Face, Content and Construct ValidityUrology Practice, VOL. 6, NO. 3, (180-184), Online publication date: 1-May-2019. Volume 193Issue 4SApril 2015Page: e269 Peer Review Report Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ram Pathak More articles by this author Scott Alford More articles by this author Todd Igel More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Evidence-based Medicine & Outcomes I1 Apr 2015MP5-14 RANDOMIZED, SINGLE CENTER TRIAL OF THE EFFECT OF EXTENDING TIME FROM PERI-PROSTATIC LIDOCAINE INJECTION TO ONSET OF TRANSRECTAL ULTRASOUND-GUIDED PROSTATE BIOPSY ON PATIENT-REPORTED PAIN SCORES Ram Pathak, Alexander Parker, Andrea Tavlarides, Julia Crook, Nancy Diehl, Scott Alford, Michael Heckman, and Todd Igel Ram PathakRam Pathak More articles by this author , Alexander ParkerAlexander Parker More articles by this author , Andrea TavlaridesAndrea Tavlarides More articles by this author , Julia CrookJulia Crook More articles by this author , Nancy DiehlNancy Diehl More articles by this author , Scott AlfordScott Alford More articles by this author , Michael HeckmanMichael Heckman More articles by this author , and Todd IgelTodd Igel More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.241AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Although the efficacy of peri-prostatic lidocaine injection in terms of site, dosage and method of administration has been previously described in prospective randomized control trials elsewhere, the time from lidocaine injection to prostate biopsy has not been thoroughly investigated. The primary aim was to compare Visual Analog Scale (VAS) pain scores between patients with a 2-minute delay of lidocaine injection to onset of prostate biopsy and patients with a 10-minute delay. Secondary aims compared VAS scores with 2 injections versus 3 injections. METHODS A total of 80 prostate-biopsy naive males underwent standard 12 core transrectal ultrasound-guided prostate biopsy by a single surgeon in this prospective, single-blinded randomized study between September 2011 and July 2014. Patients were randomized into four treatment arms: bibasilar injection at 2 minutes, bibasilar and single apical injection at 2 minutes, bibasilar injection at 10 minutes, and bibasilar and single apical injection at 10 minutes. Patients were asked to report their level of pain on the VAS (1–10, with 10 indicating unbearable pain). All analyses were performed on the basis of intention-to-treat principle. RESULTS The mean age of the 80 patients was 65.0 years (41.9-90.3) with a median BMI of 29.5 (22.3-52.1). 92.4% of patients were Caucasian. All groups were comparable with respect to age, BMI and prostatic volume. In general, VAS scores were fairly low with a mean of 1.7. Only 16% of patients reported a VAS score greater than 4 for any one core. VAS scores were significantly higher for the 2-minute delay group compared to the 10-minute delay group when subtracted from the baseline VAS score (mean: -0.7 vs. -1.6, p=0.025). Subset analysis of mean VAS scores during biopsies 1–3, 4–6, 7–9 and 10–12 minus baseline VAS score also demonstrated statistical significance when comparing 2-minute to 10-minute delay (p=0.023, p=0.020, p=0.021 and p=0.043, respectively). Secondary aims comparing mean VAS scores subtracted from baseline VAS scores of 2-injection vs. 3-injection groups demonstrated a trend toward significance with a mean of -0.8 vs. -1.4, p=0.11. CONCLUSIONS Extending the time from lidocaine injection to prostate biopsy results in lower VAS scores. Although this may lengthen the time of each individual prostate biopsy session, patients experience less pain, thereby reducing anxiety. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e50 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ram Pathak More articles by this author Alexander Parker More articles by this author Andrea Tavlarides More articles by this author Julia Crook More articles by this author Nancy Diehl More articles by this author Scott Alford More articles by this author Michael Heckman More articles by this author Todd Igel More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Despite the rising incidence of clear cell renal cell carcinoma, the molecular events that support its development and progression remain unclear. Herein, we evaluate the association of endothelin 2 expression with both clear cell renal cell carcinoma development and progression-free survival. We conducted real-time polymerase chain reaction to determine endothelin 2 expression levels on 238 patients who underwent nephrectomy for localized clear cell renal cell carcinoma, 161 of whom also had adjacent normal kidney samples available for analysis. To evaluate associations with clear cell renal cell carcinoma development, linear mixed models were used to compare differential expression between tumor and a normal kidney as well as to explore interactions with clinicopathologic features. To evaluate associations with prognosis, Cox proportional hazards models were used to assess the association of progression-free survival and endothelin 2 expression in tumor tissue. Overall, endothelin 2 expression was higher in tumor samples versus patient-matched normal kidney samples, with an average fold change of 1.99 (95% confidence interval, 1.48-2.60; P < .0001). This overexpression in tumor versus normal kidney samples was more pronounced in low- compared with high-grade tumors (interaction, P = .0002), in early- compared with late-stage tumors (interaction, P = .001), and in tumors without compared with those with necrosis (interaction, P = .001). Moreover, an increasing endothelin 2 expression in tumors was associated with a longer progression-free survival (hazard ratio, 0.89; 95% confidence interval, 0.80-0.99; P = .03); however, after controlling for known clinicopathologic factors, this association was attenuated (hazard ratio, 0.99; 95% confidence interval, 0.89-1.09; P = .7). Up-regulation of endothelin 2 is a common and early event in localized clear cell renal cell carcinoma. Higher tumor expression of endothelin 2 is associated with a longer progression-free survival but not after adjustment for well-known pathologic indices. Thus, although endothelin 2 does not appear to be an independent prognostic marker, there is evidence of a putative role in clear cell renal cell carcinoma progression. If supportive mechanistic data can be produced, endothelin 2 could represent a potential target for chemopreventive or neoadjuvant therapeutics for clear cell renal cell carcinoma.

You have accessJournal of UrologyTransplantation, Urolithiasis & Hydronephrosis1 Apr 2011V500 ROBOTIC-ASSISTED LAPAROSCOPIC URETEROURETEROSTOMY FOR OBSTRUCTING RETROCAVAL URETER Tim Leroy, David Thiel, and Todd Igel Tim LeroyTim Leroy Jacksonville, FL More articles by this author , David ThielDavid Thiel Jacksonville, FL More articles by this author , and Todd IgelTodd Igel Jacksonville, FL More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.596AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Widespread use of the da VInci surgical system (Intuitive Surgical, Sunnyvale, CA) has led to the expansion of robotic technology for use in complex reconstructive procedures of the urinary tract. We present our technique for robotic-assisted laparoscopic ureteroureterostomy for obstructing retrocaval ureters. METHODS Pre-operative imaging, patient selection, patient positioning, port placement, intra-operative dissection, retrocaval ureter excision and repair are all demonstrated in this video. Special attention is given to robotic docking technique for this complex dissection and reconstruction. RESULTS Tips presented in this video may aid in successful completion of robotic ureteroureterostomy for an obstructing retrocaval ureter. CONCLUSIONS Tips presented in this video may aid in successful completion of robotic ureteroureterostomy for obstructing retrocaval ureter. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e203 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Tim Leroy Jacksonville, FL More articles by this author David Thiel Jacksonville, FL More articles by this author Todd Igel Jacksonville, FL More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

INTRODUCTION The da Vinci Surgical System has become extremely popular in the field of urology for procedures requiring complex reconstructive maneuvers, such as radical prostatectomy and pyeloplasty. A natural extension of these procedures is the use of the da Vinci system for complex urinary tract reconstruction deep in the pelvis, such as bladder diverticulectomy.TECHNICAL CONSIDERATIONS In our report and accompanying Video, we have demonstrated some technical tips and tricks with regard to patient selection, preoperative imaging, patient positioning, port placement, intraoperative diverticulum recognition/excision, and cystotomy repair that the surgeon might find beneficial for successful completion of robotic-assisted bladder diverticulectomy.CONCLUSIONS The tips and tricks we have presented might aid in the successful completion of robotic bladder diverticulectomy. UROLOGY 77: 1238-1243, 2011. (C) 2011 Elsevier Inc.

You have accessJournal of UrologyProstate Cancer: Localized IX1 Apr 20101958 PRE-TREATMENT PSA LEVEL AND GLEASON SCORE ARE NOT ASSOCIATED WITH CANCER-SPECIFIC ANXIETY PRIOR TO SURGICAL TREATMENT FOR NEWLY DIAGNOSED PROSTATE CANCER Alexander Parker, Andrea Tavlarides, Rebecca McNeil, Krisitin Green, Steven Ames, and Todd Igel Alexander ParkerAlexander Parker More articles by this author , Andrea TavlaridesAndrea Tavlarides More articles by this author , Rebecca McNeilRebecca McNeil More articles by this author , Krisitin GreenKrisitin Green More articles by this author , Steven AmesSteven Ames More articles by this author , and Todd IgelTodd Igel More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1947AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Despite marked improvements in prostate cancer (PCa) survival over the past two decades, many men experience considerable cancer-specific anxiety prior to PCa treatment. Related to this, there are data suggesting that lower pre-treatment PSA level and biopsy Gleason score are associated with improved PCa survival following surgery. Herein, we utilize data from our prospective registry to evaluate whether pre-treatment PSA level and biopsy Gleason score are associated with PCa-specific anxiety among men with newly diagnosed PCa. METHODS We identified 313 men in our registry who completed the self administered MAX-PC questionnaire following a diagnosis of PCa but prior to initiation of surgical treatment (a higher score on MAX-PC indicates higher cancer-specific anxiety). In addition, we abstracted data on demographic, lifestyle and clinicopathologic covariates from our registry database. In order to examine the association with cancer-specific anxiety, we compared median scores on the MAX-PC across clinically relevant categories of pre-treatment PSA level and biopsy Gleason score. In addition, we also constructed univariable and multivariable linear regression models using MAX-PC score as the dependent variable. RESULTS For the entire cohort, the median score on the MAX-PC was 14 (min =12, max=24). We observed no difference in median scores on the MAX-PC for men with PSA levels of <4 ng/ml, 4-10 ng/mL and > 10 ng/mL (14, 15 and 14 respectively; p=0.97). Similarly, we noted no differences in median MAX-PC scores among men with biopsy Gleason scores of <6, 7 or 8-10 (14, 16 and 14 respectively; p=0.38). In linear regression analysis, pre-treatment PSA level (p=0.66) and biopsy Gleason score (p=0.42) were not associated with MAX-PC score. Multivariable adjustment for age, marital status, body mass index and type of surgery (open radical, laparoscopic, cryosurgery) did not alter these results. CONCLUSIONS Given the impact on overall quality of life, coupled with potential effects related to immune suppression, cancer-specific anxiety remains an important clinical issue among men with newly diagnosed PCa. Despite evidence that lower PSA level and biopsy Gleason score prior to surgery are associated with improved PCa survival, we report no association of cancer-specific anxiety level with these two features. If validated, our data suggest there is an opportunity to develop more targeted interventions to better manage cancer-specific anxiety among men with newly diagnosed PCa. Jacksonville, FL© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e761 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alexander Parker More articles by this author Andrea Tavlarides More articles by this author Rebecca McNeil More articles by this author Krisitin Green More articles by this author Steven Ames More articles by this author Todd Igel More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

You have accessJournal of UrologyKidney Cancer: Localized III1 Apr 20101242 EVALUATION OF AWARENESS REGARDING RISK FACTORS FOR RENAL CELL CARCINOMA Alexander Parker, Michelle Arnold, Nancy Diehl, and Todd Igel Alexander ParkerAlexander Parker More articles by this author , Michelle ArnoldMichelle Arnold More articles by this author , Nancy DiehlNancy Diehl More articles by this author , and Todd IgelTodd Igel More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.786AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Greater than 80% of kidney cancers are classified as renal cell carcinoma (RCC) and incidence for this cancer is rising steadily. Currently, smoking and obesity are widely-accepted as factors for RCC. While these well-established associations are known among urologists, there are limited data evaluating whether this knowledge has been appropriately disseminated to patient populations. Herein, we evaluate the level of awareness regarding risk factors for RCC compared to other cancers among a population of patients presenting to a tertiary referral center. METHODS We prospectively identified 172 consecutive patients presenting for the first time to our urology clinic between May 1, 2009 and August 31, 2009. To assess risk factor awareness, patients completed a questionnaire that requested responses to whether certain lifestyle factors increased, decreased or had no effect on a variety of cancers. Patients were also offered the opportunity to answer “I don't know” for all questions. We collected information on demographics and other covariates via questionnaire responses as well as medical chart abstraction. To compare the percentage reporting that smoking or obesity increases risk across different cancer types, we constructed 95% confidence intervals (95% CI) and performed Fisher's Exact tests. RESULTS Our cohort is predominantly male (78%), Caucasian (83%), married or living as married (80%) and college educated (75% completed at least some college). The percentage reporting that smoking increases the risk of RCC (36%, 95% CI: 29%-44%) was significantly lower than for lung cancer (96%, 95% CI: 92%-99%; p<0.001) and similar to that for breast cancer (47%, 95% CI 39%-55%; p=0.07) and prostate cancer (30%, 95% CI 23%-38%; p=0.24) (i.e. two cancers that have not been linked to smoking). Similarly, the percentage reporting that obesity increases the risk of RCC (32%, 95% CI 25%-40%) was significantly lower than for colon cancer (45%, 95% CI 37%-53% CI; p-value=0.02) and similar to that for breast cancer (31%, 95% CI 24%-39%; p=1.00) and pancreas cancer (33%, 26%-41%; p=0.9) (i.e. two cancers that have not been linked to obesity). CONCLUSIONS Generalizability to other populations notwithstanding, our data suggest a low level of awareness of two well-known risk factors for RCC. Ultimately, the success of primary prevention efforts to lower RCC incidence will depend in part on more widespread education efforts regarding risk factors for RCC. Jacksonville, FL© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e480-e481 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alexander Parker More articles by this author Michelle Arnold More articles by this author Nancy Diehl More articles by this author Todd Igel More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

OBJECTIVES:Cigarette smoking is a well known risk factor for the development of renal cell carcinoma (RCC); however, its association with tumor aggressiveness and patient outcome remains in question. Herein, we test the hypothesis that cigarette smoking is associated with a more aggressive phenotype and poorer outcome among patients with RCC.METHODS:We examined data on 2242 patients treated with radical nephrectomy or nephron-sparing surgery for unilateral, sporadic, clear cell RCC at Mayo Clinic Rochester between 1970 and 2002. Associations of self-reported smoking status with death from RCC were assessed using Cox proportional hazards regression models summarized with hazard ratios (HR) and 95% confidence intervals (CI).RESULTS:While former cigarette smoking was not associated with an increased risk of RCC death, current cigarette smokers were 31% more likely to die from RCC compared with non-smokers on a hazard ratio scale (HR 1.31; 95% CI 1.09-1.58; P = 0.004). Interestingly, current smokers were more likely to present with advanced disease (i.e. later TNM stage) compared with both former and never smokers. After adjustment for TNM stage group and tumor grade, there was no longer a statistically significant increase in the risk of death from RCC for current cigarette smokers (HR 0.99; 95% CI 0.82-1.19; P = 0.875).CONCLUSIONS:Patients who report current smoking at time of surgery are at increased risk of RCC death; however, this association is attenuated after adjustment for standard pathological indices and is therefore of little prognostic value. Nevertheless, the association of current smoking with more advanced disease at presentation (e.g. metastatic spread) warrants further investigation.

Objectives. To determine whether actual expression of the von Hippel-Linclau (VHL) protein product itself (pVHL) is associated with clear cell renal cell carcinoma (CC-RCC) survival. Recent data have suggested that somatic mutations of the VHL tumor suppressor gene are associated with better cancer-specific survival in patients with CC-RCC.Methods. Using a large, clinic-based cohort of 273 patients with CC-RCC, we tested the hypothesis that those patients with CC-RCC tumors lacking pVHL expression [pVHL(-)] will experience better cancer-specific survival than those patients with tumors that show pVHL expression [pVHL(+)].Results. Using a Cox proportional hazard model adjusting for age, patients with pVHL(-) tumors were not at a decreased risk of CC-RCC death compared with patients with pVHL(+) tumors (hazard ratio 1.0, 95% confidence interval 0.7 to 1.5). Adjustment for the Mayo SSIGN score had little effect on the risk estimate (hazard ratio 0.8; 95% confidence interval 0.5 to 1.2). In our stratified analysis, we found evidence of an inverse association with loss of pVHL expression among those patients presenting with early-stage disease (hazard ratio 0.4; 95% confidence interval 0.2 to 0.8), even after adjustment for the Mayo SSIGN score.Conclusions. Although we report no overall association, the data from this investigation are consistent with earlier findings that suggest somatic VHL alteration is associated with better cancer-specific survival among those patients presenting with early-stage (pT1 and pT2) CC-RCC.

To evaluate the results and prognostic factors associated with radiotherapy (RT) for a detectable prostate specific antigen (PSA) level after radical prostatectomy (RP). From July 1987 through July 2003, 368 patients received RT for a detectable PSA level (biochemical relapse {BCR}) as sole evidence of recurrence after RP for node negative prostate cancer. The following variables were assessed with respect to their association with biochemical relapse and survival: age, pathologic tumor stage, tumor grade, Gleason score (GS), margin status, DNA ploidy, pre-RP PSA, pre-RT PSA, pre-RT PSA doubling time, RT dose and pre-RT hormone therapy. Biochemical relapse was defined as a single post-RT value ≥0.4 ng/ml and not declining. Estimated survival and relapse-free probabilities were obtained via Kaplan-Meier estimation. Associations of patient factors with time until death and time until biochemical relapse were investigated using log-rank tests. Cox proportional hazards models with forward selection were used to investigate which variables showed evidence independent associations. With a median follow-up of 5 years, the 5 and 10-year freedom from BCR and survival for the entire cohort were an estimated 46% (95% CI: 41%-52%) and 30% (95% CI: 21%-37%) and 92% (95% CI: 89%-95%) and 76% (95% CI: 68%-83%). Patient and treatment variables showing evidence of association with biochemical relapse included: pathologic stage; ≤T3a vs. T3b, (p = 0.002); pathologic GS ≤7 vs. ≥8; (p < 0.001); Broders’ grade 1, 2 vs. 3, 4; (p = 0.01); pre-RT PSA; <1.0 vs. ≥1.0 (p < 0.001); pre-op PSA <15 vs. ≥15 (p = 0.01), RT dose; ≤64.8 vs. >64.8 Gy (p < 0.001); DNA ploidy: diploid vs. non-diploid (p = 0.004) and pre-RT PSA doubling time; <7.5 vs. ≥7.5 months (p = 0.001). Forward selection of variables indicated that pathologic stage, Gleason score and pre-radiotherapy PSA were the only variables showing clear evidence of independent associations. Others no longer showed evidence of association after adjusting for these three variables. Variables showing evidence of association with patient survival were: pathologic stage ≤ T3a vs. T3b, (p = 0.005), Broders’ grade 1, 2 vs. 3, 4 (p = 0.001) and DNA ploidy: diploid vs. non-diploid (p = 0.02). Forward selection of variables indicated that Broders’ grade was the only variable showing evidence of an association independent of the other variables considered. Exploratory analysis indicated that of patients with pathologic stage ≤T3a, Gleason score ≤7 and a pre-radiotherapy PSA <1.0 (low-risk category), approximately 50% had freedom from biochemical failure at 10 years versus approximately 20% for other patients. The presence of seminal vesicle invasion and high GS in the RP specimen are inherent predictors of adverse outcome. Higher pre-RT PSA levels also lead to a worse outcome after RT, but the influence of this factor can be mitigated through patterns of referral with early introduction of salvage RT. One half of patients with a combination of low-risk features may be expected to be free of a second BCR 10 years after salvage RT

BACKGROUND. A proportion of patients diagnosed with pathologic T1 (pT1) clear cell renal cell carcinoma (CC-RCC) will experience disease progression and death after surgery, whereas the majority remain disease free. The authors conducted a case-cohort investigation to examine the association of insulin-like growth factor I receptor (IGF-IR) expression and disease-specific survival in patients who underwent surgery for pT1 CC-RCC.METHODS. Eligible patients included those diagnosed with solitary, nonfamilial pT1 CC-RCC who underwent radical nephrectomy at the Mayo Clinic-Rochester between 1970 and 2000 (n = 886 patients). Among this group, 136 patients died of CC-RCC (cases). Archived tumor blocks were not available for 62 patients, leaving a final study group of 74 cases. Stratified, random sampling was used to select a cohort of at least 3 year-matched controls (no CC-RCC death) for each case (n = 263 patients). Detection of IGF-IR was performed using a commercially available monoclonal antibody. Cox proportional hazards models were fit to assess the association between IGF-IR expression and disease-specific survival.RESULTS. After adjustment for age, the risk of death from CC-RCC was greater for patients who had tumors that stained positive for IGF-IR compared with patients who had tumors that showed no IGF-IR expression (hazard ratio [HR], 1.5; 95% confidence interval, [95% CI], 0.9-2.4). In a stratified analysis, the risk was stronger among patients who had high-grade tumors (HR, 2.2; 95% CI, 1.1-4.3) compared with patients who had low-grade tumors (HR, 0.7; 95% CI, 0.3-1.5). Multivariate adjustment for tumor size and histologic tumor necrosis attenuated the association among all patients (HR, 1.3; 95% CI, 0.8-2.1) but strengthened the association among patients with high-grade tumors (HR, 2.7; 95% CI, 1.3-5.6).CONCLUSIONS. The current data suggest that IGF-IR expression is associated with poor survival in patients who are diagnosed with early-stage CC-RCC, especially among those with high-grade disease. (C) 2004 American Cancer Society.