Prostate Specific Antigen Testing Behaviors for Prostate Cancer Screening Among U.S. Immigrants: A Cross-sectional Analysis Using the National Health Interview Survey.

PURPOSE: Immigrants constitute 14% of the U.S. population, and this group is especially vulnerable to poor health care access. Prior research demonstrates U.S. immigrants have low rates of guideline-concordant breast and colorectal screening, but prostate cancer screening has not previously been evaluated. We sought to characterize screening behaviors among U.S. immigrants and to consider possible mechanisms to enhance PSA-based screening for this population. MATERIALS AND METHODS: Data were obtained from the 2010, 2013, 2015, and 2018 National Health Interview Survey reports, which were the recent survey years that included questions about PSA testing. Complex samples logistic regression was performed to assess the relationship between immigrant-specific characteristics including region of birth, citizenship status, length of residence within the U.S., English language proficiency, and history of PSA testing. RESULTS: There were 22,997 survey respondents; 3,257 were foreign-born and 19,740 were U.S.-born. Rates of PSA testing were much lower among the foreign-born population compared to the U.S.-born population (43% vs 60%). Citizenship status, length of residence in the U.S. for more than 15 years, and English proficiency were directly linked to increased rates of PSA testing. There was significant variability in PSA testing among immigrant subgroups and Asian immigrants had the lowest rate of PSA testing. Annual physician visits and English language proficiency were associated with increased PSA testing among the U.S. immigrant population. CONCLUSIONS: Immigrants have relatively low rates of PSA testing. Improving health care utilization and language services may help to narrow the gap in guideline-concordant prostate cancer screening between immigrants and nonimmigrants.

PRState: Incorporating genetic ancestry in prostate cancer risk scores for men of African ancestry.

BACKGROUND: Prostate cancer (PrCa) is one of the most genetically driven solid cancers with heritability estimates as high as 57%. Men of African ancestry are at an increased risk of PrCa; however, current polygenic risk score (PRS) models are based on European ancestry groups and may not be broadly applicable. The objective of this study was to construct an African ancestry-specific PrCa PRS (PRState) and evaluate its performance. METHODS: African ancestry group of 4,533 individuals in ELLIPSE consortium was used for discovery of African ancestry-specific PrCa SNPs. PRState was constructed as weighted sum of genotypes and effect sizes from genome-wide association study (GWAS) of PrCa in African ancestry group. Performance was evaluated using ROC-AUC analysis. RESULTS: We identified African ancestry-specific PrCa risk loci on chromosomes 3, 8, and 11 and constructed a polygenic risk score (PRS) from 10 African ancestry-specific PrCa risk SNPs, achieving an AUC of 0.61 [0.60-0.63] and 0.65 [0.64-0.67], when combined with age and family history. Performance dropped significantly when using ancestry-mismatched PRS models but remained comparable when using trans-ancestry models. Importantly, we validated the PRState score in the Million Veteran Program (MVP), demonstrating improved prediction of PrCa and metastatic PrCa in individuals of African ancestry. CONCLUSIONS: African ancestry-specific PRState improves PrCa prediction in African ancestry groups in ELLIPSE consortium and MVP. This study underscores the need for inclusion of individuals of African ancestry in gene variant discovery to optimize PRSs and identifies African ancestry-specific variants for use in future studies.

National Recommendations against Prostate Specific Antigen Screening versus Statewide Medicaid Expansion Initiatives: A Battle of the Titans.

PURPOSE: Medicaid expansion under the Patient Protection and Affordable Care Act occurred almost concurrently with 2012 U.S. Preventive Services Task Force recommendations against prostate specific antigen screening. Here the relative influence on prostate specific antigen screening rates by 2 concurrent and opposing system-level policy initiatives is investigated: improved access to care and change in clinical practice guidelines. MATERIALS AND METHODS: Behavioral Risk Factor Surveillance System data from years 2012 to 2018 were analyzed for trends in self-reported prostate specific antigen screening and insurance coverage. Subanalyses included state Medicaid expansion status and respondent federal poverty level. Multivariable logistic regression was performed to evaluate factors associated with prostate specific antigen screening. RESULTS: From 2012 to 2018 prostate specific antigen screening predominantly declined with a notable exception of an increase of 7.3% for men at <138% federal poverty level between 2011 and 2013 in early expansion states. Initial increases did not continue, and screening trends mirrored those of nonexpansion states by 2018. Notably, 2014 planned expansions states did not follow this trend with minimal change between 2015 and 2017 compared to declines in early expansion states and nonexpansion states (-0.4% vs -6.7% and -8.6%, respectively). CONCLUSIONS: Medicaid expansion was associated with increased rates of insured men at <138% federal poverty level from 2012 to 2018 in early expansion states. In this group, initial increases in prostate specific antigen screening were not durable and followed the trend of reduced screening seen across the United States. In planned expansions states the global drop in prostate specific antigen screening from 2016 to 2018 was offset in men at <138% federal poverty level by expanding access to care. Nonexpansion states showed a steady decline in prostate specific antigen screening rates. This suggests that policy such as U.S. Preventive Services Task Force recommendations against screening competes with and often outmatches access to care.

Receipt of Survivorship Care Plans and Self-Reported Health Status among Patients with Genitourinary Malignancy.

PURPOSE: Implementation of survivorship care plans has been emphasized as a key component to improving care for cancer survivors. Our objective was to determine the prevalence of survivorship care plan receipt for survivors of genitourinary malignancy including kidney, prostate and bladder cancer, and evaluate whether receipt was associated with a measurable health benefit. MATERIALS AND METHODS: Data from the Behavioral Risk Factor Surveillance System Cancer Survivorship modules in 2012, 2014, 2016 and 2017 were analyzed. The proportion of patients with bladder, kidney or prostate cancer receiving a survivorship care plan was calculated. Complex samples multivariable logistic regressions were performed to determine the association of survivorship care plan receipt with sociodemographic variables, and assess the relationship between survivorship care plan receipt and self-reported health status (general, physical and mental). RESULTS: Survivorship care plan distribution increased from 27.5% in 2012 to 39.5% in 2017. Patients with low income, less formal education and extremes of age were less likely to receive a survivorship care plan. Those receiving a survivorship care plan were less likely to report poor physical health (OR 0.70, CI 0.52-0.96, p=0.026). Subanalysis showed a similar result for physical health of patients with prostate cancer (OR 0.68, CI 0.48-0.96, p=0.030) and general health of patients with kidney cancer (OR 0.37, CI 0.19-0.75, p=0.006). CONCLUSIONS: Distribution of survivorship care plans to genitourinary malignancy survivors has increased since 2012 in response to advocacy from national organizations. Nonetheless, utilization is low and there is heterogeneity in the populations likely to receive a survivorship care plan. There is a measurable association between survivorship care plans and improved health status but further study is needed to determine causality.

Gleason 6 Prostate Cancer: Translating Biology into Population Health.

PURPOSE: Gleason 6 (3+3) is the most commonly diagnosed prostate cancer among men with prostate specific antigen screening, the most histologically well differentiated and is associated with the most favorable prognosis. Despite its prevalence, considerable debate exists regarding the genetic features, clinical significance, natural history, metastatic potential and optimal management. MATERIALS AND METHODS: Members of the Young Urologic Oncologists in the Society of Urologic Oncology cooperated in a comprehensive search of the peer reviewed English medical literature on Gleason 6 prostate cancer, specifically focusing on the history of the Gleason scoring system, histological features, clinical characteristics, practice patterns and outcomes. RESULTS: The Gleason scoring system was devised in the early 1960s, widely adopted by 1987 and revised in 2005 with a more restrictive definition of Gleason 6 disease. There is near consensus that Gleason 6 meets pathological definitions of cancer, but controversy about whether it meets commonly accepted molecular and genetic criteria of cancer. Multiple clinical series suggest that the metastatic potential of contemporary Gleason 6 disease is negligible but not zero. Population based studies in the U.S. suggest that more than 90% of men newly diagnosed with prostate cancer undergo treatment and are exposed to the risk of morbidity for a cancer unlikely to cause symptoms or decrease life expectancy. Efforts have been proposed to minimize the number of men diagnosed with or treated for Gleason 6 prostate cancer. These include modifications to prostate specific antigen based screening strategies such as targeting high risk populations, decreasing the frequency of screening, recommending screening cessation, incorporating remaining life expectancy estimates, using shared decision making and novel biomarkers, and eliminating prostate specific antigen screening entirely. Large nonrandomized and randomized studies have shown that active surveillance is an effective management strategy for men with Gleason 6 disease. Active surveillance dramatically reduces the number of men undergoing treatment without apparent compromise of cancer related outcomes. CONCLUSIONS: The definition and clinical relevance of Gleason 6 prostate cancer have changed substantially since its introduction nearly 50 years ago. A high proportion of screen detected cancers are Gleason 6 and the metastatic potential is negligible. Dramatically reducing the diagnosis and treatment of Gleason 6 disease is likely to have a favorable impact on the net benefit of prostate cancer screening.

Cancer control of partial nephrectomy for high-risk localized renal cell carcinoma: population-based and single-institutional analysis.

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.

Impact of surgeon and volume on extended lymphadenectomy at the time of robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium (IRCC).

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Lymph node dissection and it's extend during robot-assisted radical cystectomy varies based on surgeon related factors. This study reports outcomes of robot-assisted extended lymphadenectomy based on surgeon experience in both academic and private practice settings. OBJECTIVE: To evaluate the incidence of, and predictors for, extended lymph node dissection (LND) in patients undergoing robot-assisted radical cystectomy (RARC) for bladder cancer, as extended LND is critical for the treatment of bladder cancer but the role of minimally invasive surgery for extended LND has not been well-defined in a multi-institutional setting. PATIENTS AND METHODS: Used the International Robotic Cystectomy Consortium (IRCC) database. In all, 765 patients who underwent RARC at 17 institutions from 2003 to 2010 were evaluated for receipt of extended LND. Patients were stratified by age, sex, clinical stage, institutional volume, sequential case number, and surgeon volume. Logistic regression analyses were used to correlate variables to the likelihood of undergoing extended LND. RESULTS: In all, 445 (58%) patients underwent extended LND. Among all patients, a median (range) of 18 (0-74) LNs were examined. High-volume institutions (≥100 cases) had a higher mean LN yield (23 vs 15, P < 0.001). On univariable analysis, surgeon volume, institutional volume, and sequential case number were associated with likelihood of undergoing extended LND. On multivariable analysis, surgeon volume [odds ratio (OR) 3.46, 95% confidence interval (CI) 2.37-5.06, P < 0.001] and institution volume [OR 2.65, 95% CI 1.47-4.78, P = 0.001) were associated with undergoing extended LND. CONCLUSIONS: Robot-assisted LND can achieve similar LN yields to those of open LND after RC. High-volume surgeons are more likely to perform extended LND, reflecting a correlation between their growing experience and increased comfort with advanced vascular dissection.

Safety and outcomes of surgical treatment of renal cell carcinoma in the elderly.

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.

Racial/ethnic differences in receipt of pelvic lymph node dissection among men with localized/regional prostate cancer.

BACKGROUND: Black and Hispanic men have a lower prostate cancer (PCa) survival rate than white men. This racial/ethnic survival gap has been explained in part by differences in tumor characteristics, stage at diagnosis, and disparities in receipt of definitive treatment. Another potential contributing factor is racial/ethnic differences in the timely and accurate detection of lymph node metastases. The current study was conducted to examine the association between race/ethnicity and the receipt of pelvic lymph node dissection (PLND) among men with localized/regional PCa. METHODS: Logistic regression was used to estimate the adjusted odds of undergoing PLND among men who were diagnosed during 2000 to 2002 with PCa, who underwent radical prostatectomy or PLND without radical prostatectomy, and who were diagnosed in regions covered by the Surveillance, Epidemiology, and End Results database (n = 40,848). RESULTS: Black men were less likely to undergo PLND than white men (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.84-0.98). When the analysis was stratified by PCa grade, black men with well differentiated PCa (OR, 0.48; 95% CI, 0.27-0.84) and poorly differentiated PCa (OR, 0.73; 95% CI, 0.60-0.89) were less likely to undergo PLND than their white counterparts, but racial differences were not observed among men with moderately differentiated PCa (OR, 0.96; 95% CI, 0.88-1.05). CONCLUSIONS: Among men with poorly differentiated PCa, failure to undergo PLND was associated with worse survival. Racial disparities in the receipt of PLND, especially among men with poorly differentiated PCa, may contribute to racial differences in prostate cancer survival.

Renal cell carcinoma in octogenarians: nephron sparing surgery should remain the standard of care.

PURPOSE: Data regarding clinical outcomes in elderly patients with renal cell carcinoma are scarce. We determined management, and overall and cancer specific survival in elderly patients with renal cell carcinoma. MATERIALS AND METHODS: Using the Surveillance, Epidemiology, and End Results database we identified 59,944 patients who underwent partial or radical nephrectomy for renal cell carcinoma between 1988 and 2005. Patients were separated into 2 groups of those younger than 80 years, and those 80 years old or older, and were stratified by clinical variables. Chi-square, multivariate logistic regression and Kaplan-Meier analyses were used to determine differences between the cohorts in terms of surgical approach, and overall and cancer specific survival. RESULTS: In total, 4,227 patients (7.5%) were older than 80 years old. Younger patients more likely underwent partial nephrectomy than their older counterparts (13% vs 8%, p <0.001). At a median followup of 37 months (range 0 to 215) for patients younger than 80 years, and 27 months (range 0 to 203) for octogenarians, older patients were 2.32 times more likely to die (95% CI 2.22-2.42, p <0.001) and 1.33 times more likely to die of renal cell carcinoma (95% CI 1.23-1.43, p <0.001) than their younger counterparts. Older patients who underwent radical nephrectomy were 2.54 times more likely to die of renal cell carcinoma (95% CI 1.68-3.84, p <0.001) than older patients who underwent partial nephrectomy. CONCLUSIONS: Older patients are less likely to undergo partial nephrectomy than their younger counterparts. Octogenarians treated with partial nephrectomy are less likely to die of renal cell carcinoma than those who undergo radical nephrectomy.

RENAL nephrometry score predicts surgical outcomes of laparoscopic partial nephrectomy.

OBJECTIVE: • To assess the use of the RENAL Nephrometry Score (RNS), which has been proposed as an anatomical classification system for renal masses, aiming to predict surgical outcomes for patients undergoing laparoscopic partial nephrectomy (LPN). MATERIALS AND METHODS: • In the present study, 159 consecutive patients who underwent LPN were reviewed and RNS was calculated for 141 patients with solitary renal masses who had complete radiographic data. • Renal tumours were categorized by RNS as low (nephrometry sum 4-6), intermediate (sum 7-9) and high (sum 10-12). RESULTS: • Of the 141 patients, there were 43 (30%) low, 91 (65%) intermediate and seven (5%) high score lesions. There was no statistically significant difference in the demographics of the three groups. • There was a significant difference in warm ischaemia time (16 vs 23 vs 31 min; P < 0.001), estimated blood loss (163 vs 312 vs 317 mL; P= 0.034) and length of hospital stay (1.2 vs 1.9 vs 2.3 days; P < 0.001) between the low, intermediate and high score groups, respectively. There was no difference in overall operative time (P= 0.862), transfusion rate (P= 0.665), complication rate (P= 0.419), preoperative creatinine clearance (P= 0.888) or postoperative creatinine clearance (P= 0.473) between the groups. • Sixty-one lesions (43%) were anterior and 80 (57%) were posterior. No difference was found among any intra-operative, pathological or postoperative outcomes when comparing anterior vs posterior lesions. CONCLUSIONS: • In patients undergoing LPN, a higher RNS was significantly associated with an increased estimated blood loss, warm ischaemia time and length of hospital stay. • The RNS may stratify tumours based on the technical difficulty of performing LPN.

Is patient outcome compromised during the initial experience with robot-assisted radical cystectomy? Results of 164 consecutive cases.

OBJECTIVE: • Robot-assisted radical cystectomy (RARC) remains controversial in terms of oncologic outcomes, especially during the initial experience. The purpose of this study was to evaluate the impact of initial experience of robotic cystectomy programs on oncologic outcomes and overall survival. PATIENTS AND METHODS: • Utilizing a prospectively maintained, single institution robotic cystectomy database, we identified 164 consecutive patients who underwent RARC since November 2005. • After stratification by age group, gender, pathologic T stage, lymph node status, surgical margin status, and sequential case number; we used chi-squared analyses to correlate sequential case number to operative time, surgical blood loss, lymph node yield, and surgical margin status. • We also addressed the relationship between complications and sequential case number. We then utilized Cox proportional hazard modeling and Kaplan-Meier survival analyses to correlate variables to overall mortality. RESULTS: • Sequential case number was not significantly associated with increased incidence of complications, surgical blood loss, or positive surgical margins (P= 0.780, P= 0.548, P= 0.545). Case number was, however, significantly associated with shorter operative time and mean number of lymph nodes retrieved (P < 0.001, P < 0.001). • Sequential case number was not significantly associated with survival; however, tumour stage, the presence of lymph node metastases, and positive surgical margins were significantly associated with death. • Although being the largest of its kind, this was a small study with short follow-up when compared to open cystectomy series. CONCLUSION: • Initial experience with RARC did not affect the incidence of positive surgical margins, operative/postoperative complications, or overall survival in a single-institution series.

Delayed nephrectomy has comparable long-term overall survival to immediate nephrectomy for cT1a renal cell carcinoma: A population-based analysis.

OBJECTIVES: Early surgical resection remains the recommended treatment option for most small renal mass (≤4 cm). We examined the long-term overall survival (OS) of patients managed with delayed and immediate nephrectomy of cT1a renal cancer. PATIENT AND METHODS: We utilized the National Cancer Database (2005-2010) to identify 14,677 patients (immediate nephrectomy: 14,050 patients vs. late nephrectomy: 627 patients) aged <70 years with Charlson Comorbidity Index 0 and cT1aN0M0 renal cell carcinoma. Immediate nephrectomy and late nephrectomy were defined as nephrectomy performed <30 days and >180 days from diagnosis, respectively. Inverse probability of treatment weighting-adjusted Kaplan-Meier curves and Cox proportional hazards regression analyses were used to compare OS of patients in the 2 treatment arms. Influence of patient age and Charlson Comorbidity Index on treatment effect was tested by interactions. Sensitivity analysis was performed to explore the outcome of delaying nephrectomy for >12 months. RESULTS: Median patient age was 55 years with a median follow-up of 82.5 months. Inverse probability of treatment weighting-adjusted Kaplan-Meier curves suggest no significant difference between treatment arms (immediate nephrectomy [<30 days] vs. delayed nephrectomy [>180 days]) (Hazard ratio 0.96; 95% confidence interval 0.73-1.26; P = 0.77). This outcome was consistent between all patients regardless of age (P = 0.48). Sensitivity analysis reports no difference in OS even if nephrectomy was delayed by >12 months (P = 0.60). CONCLUSIONS: We report that delayed and immediate nephrectomy for cT1a renal cell carcinoma confers comparable long-term OS. These findings suggest that a period of observation of between 6 and 12 months is safe to allow identification of renal masses, which will benefit from surgical resection.

Transperitoneal laparoscopic radical and partial nephrectomy in patients with cirrhosis: report of three cases.

INTRODUCTION: Surgical stress in patients with liver disease is associated with hepatorenal syndrome, coagulopathy, encephalopathy, sepsis, ARDS, and abnormalities of volume and electrolytes. These risks as well as the surgical difficulties associated with portal hypertension, varices, ascites, and thrombocytopenia limit the treatment options available to cirrhotic patients with renal masses. The decreased stress of laparoscopy may benefit patients with significant liver disease. METHODS: We performed a retrospective chart review of three patients with cirrhosis and renal masses who underwent laparoscopic renal surgery. RESULTS: The mean patient age was 56 years old. Two patients had Child-Pugh class B cirrhosis and one had Child-Pugh class A cirrhosis. Two hand-assisted laparoscopic radical nephrectomies and one laparoscopic partial nephrectomy were performed via a transperitoneal approach. Relevant data for the radical nephrectomies includes: mass size 4.5 cm and 4.0 cm, operative time 145 and 230 minutes, estimated blood loss 25 cc and 150 cc, and postoperative hospitalization of 4 and 3 days, respectively. Data for the partial nephrectomy includes: mass size 1.3 cm, operative time 130 minutes, estimated blood loss 50 cc, and postoperative hospitalization of 2 days. No case required open conversion nor suffered postoperative complications. Final pathology revealed clear cell renal cell carcinoma, stage pT1a, Fuhrman grade 2/4 in two patients and sarcomatoid renal cell carcinoma, stage pT1b, Fuhrman grade 4/4 in one patient. Intraoperative findings included thickened peritoneum with dense vascular adhesions due to chronic ascites. Platelets and fresh frozen plasma were administered intraoperatively during the partial nephrectomy to prevent bleeding. A peritoneal drain was placed during one of the radical nephrectomies for postoperative monitoring of ascites volume. CONCLUSIONS: Patients with cirrhosis and a renal mass represent challenging cases. With careful patient selection and management in conjunction with their hepatologist, laparoscopic renal surgery can be performed safely by experienced laparoscopists.

Loss of structural integrity of a coil based ureteral stent.

We present the first reported complication of the Silhouette, (Applied Medical, Santa Margarita, CA) 4 Fr. soft, nitinol coil-reinforced double-J ureteral stent, that is specifically related to its unique construct and design. These novel ureteral stents were placed in a medically unstable patient with bilateral partially obstructing proximal ureteral calculi. At the time of ureteroscopy, it was noted that a mild to moderate amount of encrustation was present on the distal curl of the ureteral stent. Upon removal of the stent, resistance was encountered and disintegration and fragmentation of the stent was noted. The patient eventually underwent staged ureteroscopy and shock wave lithotripsy (SWL) to remove the remaining portions of the encrusted ureteral stent.

Partial nephrectomy without hilar control or cooling: longitudinal data over 5 years.

INTRODUCTION: Partial nephrectomy for the management of small renal masses has become a well accepted technique. Contemporary series have shown its safety and efficacy in well selected patients. We present our experience of partial nephrectomies exclusively without hilar control or parenchymal cooling stratified into imperative and elective patients. METHODS: We retrospectively reviewed our experience in 124 patients who underwent partial nephrectomy between December 1995 and September 2003. Patients were followed with regular radiographic and laboratory studies at 6 months postsurgery and then annually. Renal function was followed by serum creatinine. RESULTS: Of the 124 patients, 105 were performed without hilar control or renal cooling and met our criteria for analysis. The operation was elective in 78 patients (74%) and imperative in 27 patients (26%). Mean specimen size was 2.8 cm for elective cases and 3.3 cm for imperative cases. The mean estimated blood loss was 606 533 cc and 950 656 cc in elective and imperative cases respectively. Surgical margins were positive in 6.6% with an overall recurrence rate of 3.8%. At a mean follow up time of 31 months and 23 months in the elective and imperative groups respectively, there were no statistically significant differences between baseline and follow up serum creatinine levels in either elective or imperative cases at time intervals of 0-12, 13-24, 25-48 and > 48 months. The intraoperative complication rate was 5.7% and the postoperative complication rate was 4.7% including three patients requiring blood transfusions. CONCLUSION: Partial nephrectomy without hilar control or renal cooling is a safe and reliable method of removing small renal tumors. In this cohort, intraoperative blood loss is slightly higher than historical series. However, blood transfusion rates, complications, renal function and oncologic outcomes are comparable to historical series of patients in whom vascular control and renal cooling are used.

Squamous cell carcinoma of the renal pelvis with inferior vena cava and iliac vein tumor thrombus.

Renal cell carcinoma with inferior vena cava (IVC) tumor thrombus is a well described clinical entity. We report a case of 64-year-old man that developed an aggressive renal pelvic squamous cell carcinoma (SCC) with extensive IVC and bilateral iliac vein tumor thrombus. To our knowledge this is the fifth reported case of renal pelvic SCC with IVC tumor thrombus and the first involving the iliac veins. We review the current therapeutic options for treatment of SCC with IVC involvement.

Intermittent torsion of the spermatic cord portends an increased risk of acute testicular infarction.

PURPOSE: Intermittent torsion of the spermatic cord is an episode of acute torsion of the spermatic cord that resolves spontaneously. We compared the outcomes in boys with intermittent spermatic cord torsion treated electively with testicular fixation with those in boys with a history of recurrent scrotal pain who required emergent operation for acute spermatic cord torsion without spontaneous resolution. MATERIALS AND METHODS: A retrospective review revealed 17 boys who required emergency operation for acute spermatic cord torsion and 30 who underwent elective surgery for intermittent spermatic cord torsion. The clinical presentation, number of recurrent painful episodes, lead time to operation, prior alternate diagnoses, intraoperative findings and clinical outcomes were recorded. RESULTS: There was a mean of 2 recurrent painful episodes in the elective group and 3 in the emergency group (p <0.005). In the elective group all boys were cured of pain after bilateral testicular fixation with 100% testicular preservation at a mean of 4 months of followup. In the emergency group at a mean of 10 months of followup the testicular preservation rate was 47% (p <0.01). Intraoperatively an ipsilateral bell clapper malformation was found in 100% of boys in each group. A contralateral bell clapper malformation was noted in 90% and 88% of boys in the elective and emergency groups, respectively. CONCLUSIONS: When diagnosed accurately, intermittent spermatic cord torsion can be treated with elective testicular fixation with an excellent outcome. Misdiagnosis may create a cohort of boys with intermittent spermatic cord torsion who are at risk for acute unresolved torsion and potential testicular loss. Urologists should be proactive in recommending elective scrotal exploration when intermittent spermatic cord torsion is a likely diagnosis.