Considerations from employed African-American and white prostate cancer survivors on prostate cancer treatment and survivorship: a qualitative analysis.

OBJECTIVE: To solicit information/suggestions from prostate cancer survivors to improve survivorship experiences specific to work/workability. DESIGN: The study employed a qualitative/phenomenological approach. Black/African-American and white prostate cancer survivors who: (1) had prostatectomy or radiation therapy 6-36 months prior, (2) were working for pay within 30 days before having treatment, and (3) expected to be working for pay 6 months later (n = 45) were eligible for this study. Survivors were engaged in 60-to-90-minute structured interviews. Content analysis was used to ascertain prominent themes. RESULTS: Participants had the following recommendations for survivors: ask about research on treatment options and side effects; speak with other survivors about cancer diagnosis; and inform family/friends and employers about needed accommodations. Considerations for family/friends emphasized the significance of instrumental (e.g. help finding information) and emotional support (e.g. encouragement). Employer/co-worker considerations most often related to work-related accommodations/support and avoiding stigmatization of the survivor. Considerations for healthcare providers commonly included the provision of unbiased, plain-language communication about treatment options and side effects. No major differences existed by race. CONCLUSIONS: Needs of employed PrCA survivors, regardless of their race or treatment type, are commonly related to their desire for informational, instrumental, and/or emotional support from family/friends, employers/co-workers, and healthcare providers. The requested supports are most often related to the side effects of prostate cancer treatment.

Five-Year Prospective Observational Study of African-American Men on Active Surveillance for Prostate Cancer Demonstrates Race Is Not Predictive of Oncologic Outcomes.

INTRODUCTION: This study aimed to evaluate if race impacted outcomes or risk of disease progression in men on active surveillance (AS) for prostate cancer. We present the results from our majority African-American cohort of men in an equal access setting over a 5-year follow-up period. PATIENTS AND METHODS: All patients who elected AS for prostate cancer at the Southeast Louisiana Veterans Health Care System are entered into a prospectively managed observational database. Patients were divided into groups based on self-reported race. Grade group progression was defined as pathologic upgrading above International Society of Urological Pathology Grade Group 1 disease on subsequent biopsies following diagnostic biopsy. All tests were 2 sided using a significance of .05. RESULTS: A total of 228 men met inclusion criteria in the study, including 154 non-Hispanic African American and 74 non-Hispanic Caucasian American men, with a median follow-up of 5 years from the initiation of AS. Race was not predictive of Gleason grade progression, AS discontinuation, or biochemical recurrence on Cox multivariate analysis (HR = 1.01, 0.94, 0.85, P = .96, .79, .81, respectively). On Kaplan-Meier analysis at 5 years, African-American progression-free, AS discontinuation free, and overall survival probability was comparable to their Caucasian American counterparts (P > .05 for all). CONCLUSIONS: Active surveillance is a safe treatment option for low and very low risk prostate cancer, regardless of race. African-American and Caucasian-American men did not have any significant difference in Gleason grade group progression in our cohort with 5-year follow-up.

Hematologic parameters are not predictors of upgrading or treatment in a racially diverse prospective study of men with prostate cancer on active surveillance.

INTRODUCTION: Neutrophil-to-lymphocyte (NLR) and platelet-to-lymphocyte ratios (PLR) are useful clinical biomarkers for prognosis in several malignancies. Their predictive value has been less clearly demonstrated with prostate cancer (PCa), particularly, their utility within active surveillance (AS) protocols. We aim to evaluate NLR and PLR in AS patients. METHODS: We identified 98 patients who met inclusion criteria in our cohort of 274 men diagnosed with PCa on AS. Patients were then categorized into high and low NLR and PLR groups. RESULTS: The 2.5 and 5-year Gleason upgrading free probability for our high NLR cohort was 73.9%(CI 56.3% to 97.0%) and 46.2%(CI 22.4% to 95.1%) compared to 76.3%(CI 65.7% to 88.7%) and 61.7%(CI 47.7% to 80.0%) in the low NLR cohort(p = .73). The 2.5 and 5-year Gleason upgrading free probability for our High PLR cohort was 73.5%(CI 57.3% to 94.2%) and 60.1(CI 41.4% to 87.4%) compared to 76.8%(CI 65.8% to 89.65) and 58.1%(CI 42.2% to 80.1%) in our low PLR group(p = .41). A multivariant analysis demonstrated these groups were not significant predictors of upgrading or treatment. CONCLUSION: Despite their usefulness in many types of malignancy, NLR and PLR were not predictors of upgrading or treatment in men on AS for localized PCa in our cohort.

Assessing the safety of bladder-preserving therapy as an alternative to surgical intervention in elderly patients with muscle invasive bladder cancer.

BACKGROUND: There is interest in using bladder-preserving therapy as an alternative definitive therapy for muscle invasive bladder cancer in certain high-risk groups such as the elderly. OBJECTIVE: To determine if bladder-preserving therapy represents a safer alternative to surgical intervention in elderly patients with muscle invasive bladder cancer. METHODS: We surveyed the Surveillance, Epidemiology and End Results database (SEER) for cases of non-metastasized malignant bladder cancer in patients aged 80+. Survival outcomes with radical cystectomy (RC) with or without chemotherapy were compared to those after chemotherapy and radiation without cystectomy. We performed log-rank tests and Kaplan-Meier and cox regression and hazard analyses before and after propensity score matching. RESULTS: A total of 2995 patients were identified, with 49.98% treated with RC only, 8.65% treated with RC/chemotherapy, and 41.37% treated with chemotherapy and radiation without RC. Median overall survival for the RC only, RC/chemotherapy and chemotherapy/radiation groups were 31.4, 44.1, and 24.6 months, respectively. On multivariate analysis, hazard ratios (reference: RC/chemotherapy group) were RC Only (HR = 1.408 (95% CI 1.188-1.669), p < 0.0001) and chemotherapy/radiation (HR = 1.650 (95% CI 1.390-1.959), p < 0.0001). After matching the chemotherapy/radiation and RC/chemotherapy groups, the former continued to show survival hazard (HR = 1.744 (95% CI 1.414-2.155), p < 0.0001). CONCLUSIONS: Octogenarians should be offered definitive local therapy for their localized bladder cancer including RC and chemotherapy. Bladder-sparing alternatives should be reserved for patients unfit for surgery.

Annual mpMRI surveillance: PI-RADS upgrading and increasing trend correlated with patients who harbor clinically significant disease.

INTRODUCTION: Prostate cancer screening has routinely identified men with very low- or low-risk disease, per the National Comprehensive Cancer Network guidelines. Current literature has demonstrated that the most appropriate management strategy for these patients is active surveillance (AS). The mainstay of AS includes periodic biopsies and biannual prostate-specific antigen tests. However, multiparametric magnetic resonance imaging (mpMRI) is uniquely posed to improve patient surveillance. This study aimed to evaluate the utility of an annual mpMRI in patients on AS, focusing on radiologic upgrading and Prostate Imaging-Reporting and Data System (PI-RADS) trends as indicators of clinically significant disease. METHODS: This prospective, single intuition, study enrolled 208 patients on AS who had at least two biopsies and 1 mpMRI with a median follow-up of 5.03 years. The main outcome variable was time to Gleason grade (GG) reclassification. RESULTS: After delineating patients on their initial PI-RADS score, men with score 3 and 5 lesions at first MRI had comparable GG reclassification-free survival to their counterparts. Conversely, men with initial PI-RADS 4 lesions showed a lower 5-year GG reclassification-free survival compared to those with PI-RADS score 1-2. The cohort was then subset to 70 patients who obtained ≥2 mpMRIs on protocol. Men experiencing uptrending mpMRI scores had an increased risk of GG reclassification, with a 35.4% difference in 5 year GG reclassification-free survival probability on the Kaplan-Meier curve analysis. CONCLUSION: In conclusion, this study demonstrates that for men on AS with stable recapitulated disease, an annual MRI may replace repeat biopsies after confirmatory sampling has been obtained. On the other hand, men who initiate AS with PI-RADS 4 and/or who display uptrending mpMRI scores require periodic biopsies along with repeat imaging. This study highlights the utility of integrating an annual MRI into AS protocols, thus promising a more effective approach to management.

Does experience in creating a robot-assisted partial nephrectomy (RAPN) programme in an academic centre impact outcomes or complication rate?

OBJECTIVE: To evaluate the impact of increased experience in robot-assisted partial nephrectomy (RAPN) on perioperative and oncological outcomes To detail the complications encountered in establishing a RAPN programme at a tertiary referral centre and the factors associated with these complications. PATIENTS AND METHODS: The initial consecutive 233 patients undergoing RAPN between March 2008 and May 2012 at our institution were identified. Patients were divided into quartiles to evaluate outcomes, and uni- and multivariate predictors of complications were calculated. RESULTS: In progressive quartiles, patients tended to have more complex renal tumours as evaluated by R.E.N.A.L. nephrometry (P < 0.01) or preoperative aspects and dimensions used for an anatomical classification (PADUA) scores (P = 0.003), and percentage endophytic (P = 0.01). Developing technique increased the patients undergoing unclamped PN (P < 0.01). The mean time in the operating room (from skin incision to closure) decreased significantly from 225 to 183 min (P < 0.01) and warm ischaemia time decreased from 28 to 15 min, when clamping (P < 0.01). Clavien graded complication rate (P = 0.26) and positive margin rate (P = 0.32) was unchanged by quartile. CONCLUSION: We show that increasing experience allows more complex tumours to be removed with similar outcomes in patients undergoing RAPN. The complication rates and perioperative outcomes were similar in four successive quartiles of an initial experience of RAPN.

Robot-assisted laparoscopic vs open radical cystectomy: comparison of complications and perioperative oncological outcomes in 200 patients.

OBJECTIVE: To compare perioperative morbidity and oncological outcomes of robot-assisted laparoscopic radical cystectomy (RARC) to open RC (ORC) at a single institution. PATIENTS AND METHODS: A retrospective analysis was performed on a consecutive series of patients undergoing RC (100 RARC and 100 ORC) at Wake Forest University with curative intent from 2006 until 2010. Complication data using the Clavien system were collected for 90 days postoperatively. Complications and other perioperative outcomes were compared between patient groups. RESULTS: Patients in both groups had comparable preoperative characteristics. The overall and major complication (Clavien ≥ 3) rates were lower for RARC patients at 35 vs 57% (P = 0.001) and 10 vs 22% (P = 0.019), respectively. There were no significant differences between groups for pathological outcomes, including stage, number of nodes harvested or positive margin rates. CONCLUSION: Our data suggest that patients undergoing RARC have perioperative oncological outcomes comparable with ORC, with fewer overall or major complications. Definitive claims about comparative outcomes with RARC require results from larger, randomised controlled trials.

Comparison of clamping technique in robotic partial nephrectomy: does unclamped partial nephrectomy improve perioperative outcomes and renal function?

INTRODUCTION: Partial nephrectomy without renal vascular occlusion has been introduced to improve outcomes in patients undergoing robotic partial nephrectomy (RPN). We prospectively evaluated unclamped RPN at our institution and compared this to other clamping techniques in a non-randomized fashion. MATERIALS AND METHODS: Ninety-five consecutive patients who successfully completed RPN between June 2010 and October 2011 are included in this analysis. All RPNs were performed by a single surgeon. Clamping technique was artery and vein (AV), artery alone (AO) or unclamped (U) without hypotensive anesthesia. Clamping decision was based on surgeon preference and feasibility of minimizing ischemia. All patients had bilateral functional renal units. RESULTS: Eighteen (19%), 58 (61%) and 19 (20%) patients had AV, AO and U technique respectively. Preoperative characteristics including age (p = 0.43), body mass index (p = 0.40) and RENAL nephromety distribution (p = 0.10) were similar. In AV and AO, mean warm ischemia time were 19 and 17 minutes and similar between the two cohorts (p = 0.39). Mean glomerular filtration rate (GFR) and overall percentage decrease in GFR at time of at last follow up were (64, 69, 81, p = 0.12) and (6%, 6%,and 2%,p = 0.79) for AV, AO and U respectively. Median follow up for last serum creatinine was 113 days and was similar between all cohorts (p = 0.37). Complication rate (p = 0.37), positive margin rate (p = 0.84), and change in hemoglobin concentration postoperatively (p = 0.94) were similar between cohorts. CONCLUSIONS: Unclamped partial nephrectomy is possible in patients undergoing RPN. In this study, it does not significantly alter perioperative or postoperative renal function or change rate of complications. Minimal ischemia, irrespective of clamping technique, in patients with bilateral renal units does not appear to adversely effect intermediate term renal function in these patients.

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for patients with peritoneal carcinomatosis secondary to urachal adenocarcinoma.

BACKGROUND AND OBJECTIVES: Urachal adenocarcinoma with peritoneal dissemination is an unusual presentation of a rare disease. It is associated with patients experiencing significant pain, poor outcomes, and historical median survival times between 12 and 24 months. We describe our 18-year experience in managing these patients with cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS: Five patients who underwent six CRS with HIPEC for disseminated urachal cancer were identified. Demographics, perioperative data, and oncologic results were reviewed. RESULTS: All patients successfully completed CRS followed by HIPEC with Mitomycin C. Three patients had prior urachal mass excision and one had previous cystoprostatectomy with ileal conduit. At time of surgery, complete resection of all visible disease was only achieved in two patients. All patients developed local or distant disease recurrence at a median of 13 months postoperatively (range 7-31). The majority of patients (3/5) underwent postoperative intravenous chemotherapy for recurrence (2) or residual disease (1). All patients died of their disease, with median survival following date of surgery of 27 months (range 21-87). Symptomatic control of peritoneal disease was achieved in 2/5 (40%) of the cases. CONCLUSIONS: Urachal adenocarcinoma with peritoneal dissemination is an aggressive, rare disease, which is uniformly fatal. In our experience, CRS followed by HIPEC with Mitomycin C may increase patient survival and palliation, although further treatment improvements are clearly required.

A narrative review of biparametric MRI (bpMRI) implementation on screening, detection, and the overall accuracy for prostate cancer.

Prostate cancer is the most common malignancy in American men following skin cancer, with approximately one in eight men being diagnosed during their lifetime. Over the past several decades, the treatment of prostate cancer has evolved rapidly, so too has screening. Since the mid-2010s, magnetic resonance imaging (MRI)-guided biopsies or 'targeted biopsies' has been a rapidly growing topic of clinical research within the field of urologic oncology. The aim of this publication is to provide a review of biparametric MRI (bpMRI) utilization for the diagnosis of prostate cancer and a comparison to multiparametric MRI (mpMRI). Through single-centered studies and meta-analysis across all identified pertinent published literature, bpMRI is an effective tool for the screening and diagnosis of prostate cancer. When compared with the diagnostic accuracy of mpMRI, bpMRI identifies prostate cancer at comparable rates. In addition, when omitting dynamic contrast-enhanced (DCE) protocol to the MRI, patients incur reduced costs and shorter imaging time while providers can offer more tests to their patient population.

Prospective Observational Study of a Racially Diverse Group of Men on Active Surveillance for Prostate Cancer.

OBJECTIVE: To evaluate the risk upgrading of active surveillance (AS), we reviewed the outcomes of African American men (AA) after electing AS. AS is the standard of care for men with low-grade prostate cancer (PCa). AA are known to have more advanced PCa features and are more likely to die from PCa, thus subsequent disease progression for AA on AS is unclear. METHODS: A prospectively maintained AS database from the Southeast Louisiana Veterans Administration Medical Center, New Orleans, Lousiana was queried. We identified men with low- and very low-risk PCa (Gleason 3 + 3, PSA <10, ≤CT2a) who had undergone at least 2 prostate biopsies, including initial diagnostic and subsequent confirmatory prostate biopsies. Descriptive and comparative statistical analysis was performed using R version 3.5.1. RESULTS: From a total of 274 men on AS (70% AA), 158 men met inclusion criteria (104 AA [66%]). All patients underwent at least 2 biopsies, and 29% underwent 3 or more biopsies. The median follow-up was 2.7 years. At 3 years on AS protocol, 57% AA and 61% Caucasians demonstrated no evidence of upgrading or treatment. No significant difference was observed between upgrading or progression to treatment when comparing racial groups. Seven (4%) patients in this cohort died from non PCa-specific causes, but no patients demonstrated metastasis or death from PCa over the course of study. CONCLUSION: AA men with low-risk PCa can be safely followed with the same AS protocol as non-AA men. Further analysis with longer follow up is ongoing.

Men presenting for radical prostatectomy on preoperative statin therapy have reduced serum prostate specific antigen.

PURPOSE: Studies have suggested that statin (3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitors) medication use may decrease prostate specific antigen in healthy men. We determined the effect of preoperative statin use on total preoperative prostate specific antigen and the risk of biochemical recurrence in patients with prostate cancer presenting for radical prostatectomy. MATERIALS AND METHODS: A retrospective review of 3,828 patients undergoing radical prostatectomy from January 2001 to July 2008 at our institution identified 1,031 on statin medications. We compared these 1,031 patients to the remaining 2,797 not on statins preoperatively. We evaluated differences in prostate specific antigen overall, and when patients were stratified by age specific groups, body mass index and Gleason grades on final pathology. We also investigated differences in biochemical recurrence rates. RESULTS: Overall median serum prostate specific antigen was lower in patients on preoperative statins (5.0 vs 5.2 ng/ml, p = 0.002). Median prostate specific antigen was lower in men on statins with Gleason grades 7 or 8/9 disease (p <0.05). Using a multivariate logistic regression model statin therapy was associated with a 4.7% decrease in prostate specific antigen (p <0.001). Statin therapy was not associated with an overall decreased risk of biochemical recurrence (p = 0.73) at a mean followup of 26 months. CONCLUSIONS: In this cohort of men presenting for radical prostatectomy serum prostate specific antigen is significantly lower in patients with prostate cancer on preoperative statins compared to those not taking these medications. Prospective studies are required to evaluate if this decrease in prostate specific antigen leads to later detection of prostate cancer or variations in oncological outcomes.

Early oncological outcomes of robot-assisted radical prostatectomy for high-grade prostate cancer.

OBJECTIVE: To evaluate the oncological outcomes of patients with specimen Gleason 8 and 9 prostate cancers and to determine factors that predict biochemical recurrence-free survival (BCRFS) after robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: Of 4156 patients who underwent RARP from January 2001 to 2009, we identified 368 men with Gleason 8 or 9 tumours who met the inclusion criteria. BCR was defined as a PSA level of ≥0.2 ng/mL with a second rising value. The Kaplan-Meier method and log-rank test were used to compare BCRFS while factors that predict BCRFS were determined by Cox proportional hazards modelling. RESULTS: The median age and PSA level were 62 years and 6.4 ng/mL for men with Gleason 8, and 63 years and 6.7 ng/mL for Gleason 9 cancers. The median (interquartile range, IQR) overall follow-up was 23 (10-46) months and 19 (7-37) months for Gleason 8 and 9 tumours, respectively. At 60 months the mean (se) overall BCRFS was 36 (5)% and for Gleason 8 it was 47 (6)% and for Gleason 9 it was 21 (7)% (P < 0.001). At 5 years, extraprostatic extension (pT3a) resulted in BCRFS of 52 (9)% for Gleason 8 tumours and 21 (11)% for Gleason 9 (P= 0.012). On multivariable analysis, lymph node invasion, specimen Gleason score, pathological stage and tumour volume predicted BCRFS. CONCLUSIONS: Early results suggest RARP monotherapy performs comparably to RP for BCRFS in men with high-grade prostate cancer. There are significant oncological differences between Gleason 8 and 9 tumours.

Robotic vs. open surgical management of ureteroenteric anastomotic strictures: technical modifications to enhance success.

Development of ureteroanastamotic strictures (UAS) after urinary diversion is not uncommon, but is challenging to treat. Poor outcomes are likely with endoscopic and radiologic management, and definitive surgical treatment can cause significant morbidity. The comparative advantages of an operative approach have not yet been fully described in the literature. We retrospectively reviewed the prospectively maintained Tulane University Department of Urology quality assurance database of 12 patients who underwent operative UAS repair between 2012 and 2018. Data were reviewed for operative approach, demographics, baseline disease characteristics, operative variables, and perioperative and pathological outcomes. Of the 12 patients analyzed, 5 underwent open repair (OR) (2 bilateral, 2 right, 1 left) and 7 underwent robotic repair (RR) (3 right, 4 left). One robotic case required conversion to open due to significant intestinal and peri-ureteral adhesions. The median ages were 59 years in OR and 60 years in RR. Two patients in each group had failed previous endoscopic repair. Median time from cystectomy to treatment of enteroanastamotic stricture was 13 months for OR and 10 months for RR (p = 0.25). Median estimated blood loss was 80 mL in both OR and RR (p = 1.0), median operative time was 260 min in OR and 255 min in RR (p = 0.13), and median hospital stay was 8 and 4 days, respectively (p = 0.06). There were two intra-operative and one post-operative complication in the OR group, one of whom required further surgical intervention, and no complications in the robotic cohort. A minimally invasive, robotic approach offers a non-inferior alternative to OR with similar outcomes for appropriately selected patients with UAS. High success rates combined with minimal morbidity may provide definitive therapy at an earlier stage of the stricture state.

Salvage robotic-assisted radical prostatectomy: initial results and early report of outcomes.

OBJECTIVE: To evaluate the initial results of salvage robotic-assisted radical prostatectomy (SRARP) after recurrence following primary radiotherapy (RT) for localized prostate cancer. PATIENTS AND METHODS: Between December 2002 and January 2008, 11 patients had SRARP with pelvic lymph node dissection by one surgeon from one institution. Six patients had brachytherapy, three had external beam RT (EBRT), one intensity-modulated RT, and one received brachytherapy with an EBRT boost. All patients had prostate cancer on biopsy after RT, with negative computed tomography and bone scan. The mean (range) follow-up was 20.5 (1-77) months. RESULTS: The mean interval from RT to SRARP was 53.2 months; the mean preoperative prostate-specific antigen (PSA) level was 5.2 ng/mL, the operative duration 183 min and the estimated blood loss 113 mL. One patient had prolonged lymphatic drainage, one had an anastomotic leak, and one had an anastomotic stricture requiring direct vision internal urethrotomy at 3 months. The mean duration of catheterization was 10.4 days and the hospital stay 1.4 days. Three patients had a biochemical recurrence, at 1, 2 and 43 months. In one of two patients with node-positive carcinoma of the prostate the PSA level failed to reach a nadir of zero after surgery. In patients with a minimum follow-up of 2 months, eight of 10 are continent (defined as zero to one pad per day) and two have erections adequate for intercourse with the use of phosphodiesterase-5 inhibitors. CONCLUSION: SRARP after RT-resistant disease recurrence is feasible with minimal perioperative morbidity. Early functional outcomes appear to be at least equivalent with historical salvage RP series. Robotic extended pelvic lymph node dissection is safe and can improve the accuracy of surgical staging. A longer follow-up is necessary to better assess the functional and oncological outcomes.

Posterior support for urethrovesical anastomosis in robotic radical prostatectomy: single surgeon analysis.

INTRODUCTION: Posterior urethrovesical anastomotic support has been reported to improve early return of urinary continence following radical prostatectomy. We adapted this technique to evaluate enhancement of early urinary control in patients undergoing robotic radical prostatectomy. MATERIALS AND METHODS: Forty-two consecutive men undergoing radical prostatectomy by a single surgeon between September and December 2007 received a posterior urethrovesical supporting stitch prior to the standard urethrovesical anastomosis (group 1). Operative data, postoperative complications, and follow up data were compared with those of the 42 consecutive men who underwent robotic radical prostatectomy by the same surgeon between March and August 2007 with a standard urethrovesical anastomosis (group 2). Continence was assessed at routine follow up visit 6 to 8 weeks following catheter removal. Continence was defined as zero pads or small security liner for infrequent urinary leakage in 24 hours. RESULTS: Thirty-four (81%) and 37 (88%) men in groups 1 and 2 respectively had follow up available between 45 and 75 days following prostatectomy. Preoperative demographics were similar between the two groups. At a mean follow up of 60 and 53 days following surgery, 29/34 (85%) of men in group 1 and 32/37 (86%) of men in group 2 were continent. On multivariate logistic regression analysis, no factors were associated with improved continence between the two groups. CONCLUSIONS: Posterior urethrovesical anastomotic support did not result in improved early urinary control following radical prostatectomy. Excellent urinary control can be achieved in the patients undergoing robotic radical prostatectomy without posterior urethrovesical anastomotic support.

Reviewing the Demographic, Prognostic, and Treatment Factors of Primary Adenocarcinoma of the Bladder: A SEER Population-based Study.

INTRODUCTION: The objective of this study was to characterize the demographic, prognostic, and treatment factors for patients with primary adenocarcinoma of the bladder by analyzing the impact of histologic subtype in a large sample size and interpreting newly released Surveillance, Epidemiology, and End Results (SEER) chemotherapy data. MATERIALS AND METHODS: The SEER 18 Registry was utilized to identify cases of primary adenocarcinoma diagnosed from 1973 to 2015. Demographic data, tumor and disease characteristics, treatment information, and survival outcome data were collected. Overall survival and disease-specific survival were determined using Kaplan-Meier curve analysis. Univariate and multivariate Cox regression analysis were then completed using SAS JMP. RESULTS: A total of 2305 cases of primary adenocarcinoma of the bladder were identified. Overall survival at 2-, 5- and 10-year intervals was 54.8%, 36.1%, and 25.4%, respectively. Disease-specific survival at 2-, 5- and 10-year intervals was 62.0%, 47.1%, and 40.1%, respectively. Patients were treated with surgery (86.4%), chemotherapy (21.9%), and radiation (15.0%) (P < .0001). Multivariate Cox regression analysis showed independent prognostic value for gender, stage, grade, primary tumor location, and histologic subtype. The urachus/dome location conferred survival advantage over non-urachal locations on univariable and multivariable Cox regression analysis. The papillary adenocarcinoma subtype conferred the best survival outcome, whereas signet cell carcinoma (hazard ratio, 2.069; P < .0001) and unclassified adenocarcinoma (not otherwise specified) (hazard ratio, 1.524; P < .0001) conferred the worst prognoses. CONCLUSION: This study utilized a population-based analysis to showcase the utility of various prognostic features in primary bladder adenocarcinoma cases. In characterizing treatments, we find the prevailing treatment remains surgical intervention, whereas a sizable minority receives chemotherapy and/or radiation, often in combination with surgery.

Synchronous Urothelial Bladder and Renal Malignancies. Case Report and Review of Urologic Cancers in Patients With Familial Rb Mutations.

We present a urologic case report associated with retinoblastoma (RB1) mutation. A 65-year-old man, who has a history of bilateral retinoblastoma treated with primary radiation therapy at approximately 1 year of age. He presented with a 3-month history of gross hematuria and, on initial workup, was found to have synchronous renal and urothelial malignancies. The patient underwent complete transurethral resection of high grade Ta urothelial cancer and robotic-assisted partial nephrectomy for a pT3a leiomyosarcoma. He remains responsive to Bacillus Calmette-Guerin, and shows no recurrence of his renal malignancy. Through targeted sequencing, Rb mutations can predispose patients to several urologic malignancies.

A four-step technique of robotic right adrenalectomy: initial experience.

OBJECTIVE: To report a safe, quick and reproducible technique of robotically assisted right adrenalectomy (RRA), developed by assessing the surgical anatomy of the right adrenal gland, its vascularity, and the surrounding structures, through a high definition, magnified three-dimensional view of the operating field provided by the da Vinci surgical system (Intuitive Surgical, Sunnyville CA, USA). PATIENTS AND METHODS: Four patients had RRA between January and July 2007 at the Vattikuti Urology Institute, for varied indications. We extensively reviewed published anatomical and surgical reports of the anatomy of the region to plan the surgical steps for RRA, careful reconfirming recognized anatomical facts and their probable significance. The surgical steps involved: (i) complete division of the hepatocolic ligament; (ii) definition of the right adreno-caval junction (ACJ); (iii) division of the right adrenal vein; (iv) dissection and removal of the adrenal gland circumferentially. The surgery was digitally recorded and reviewed. RESULTS: All the adrenalectomies were done transperitoneally through five ports, replicating predetermined surgical steps. There were no anaesthesia or surgery related events and no patient required conversion to open surgery. All the patients had an uneventful recovery and were discharged home 0-3 days after RRA. With increasing experience it was possible to reach the ACJ with minimal peripheral dissection. From a lateral approach, we visualized the adrenal vein travelling along the anterior portion of the gland before terminating at the inferior vena cava and the retrocaval location of the medial edge of the adrenal gland. The right adrenal vein (singular or duplicate) was the only surgically significant vessel, as the other vessels encountered were controlled with bipolar diathermy. CONCLUSIONS: Robotic assistance facilitated microdissection of fine anatomical planes around the right adrenal gland and provided direct access to the crucial ACJ. This technique permits ligation of the adrenal vein as an initial step, with no need to handle the adrenal gland. In the initial experience with four patients this technique was reproducible, regardless of indication or anatomical variance.

Proteomic analysis of proteome and histone post-translational modifications in heat shock protein 90 inhibition-mediated bladder cancer therapeutics.

Heat shock protein 90 (HSP90) inhibition is an attractive strategy for cancer treatment. Several HSP90 inhibitors have shown promising effects in clinical oncology trials. However, little is known about HSP90 inhibition-mediated bladder cancer therapy. Here, we report a quantitative proteomic study that evaluates alterations in protein expression and histone post-translational modifications (PTMs) in bladder carcinoma in response to HSP90 inhibition. We show that 5 HSP90 inhibitors (AUY922, ganetespib, SNX2112, AT13387, and CUDC305) potently inhibited the proliferation of bladder cancer 5637 cells in a dose- and time-dependent manner. Our proteomic study quantified 518 twofold up-regulated and 811 twofold down-regulated proteins common to both AUY922 and ganetespib treatment. Bioinformatic analyses revealed that those differentially expressed proteins were involved in multiple cellular processes and enzyme-regulated signaling pathways, including chromatin modifications and cell death-associated pathways. Furthermore, quantitative proteome studies identified 14 types of PTMs with 93 marks on the core histones, including 34 novel histone marks of butyrylation, citrullination, 2-hydroxyisobutyrylation, methylation, O-GlcNAcylation, propionylation, and succinylation in AUY922- and ganetespib-treated 5637 cells. Together, this study outlines the association between proteomic changes and histone PTMs in response to HSP90 inhibitor treatment in bladder carcinoma cells, and thus intensifies the understanding of HSP90 inhibition-mediated bladder cancer therapeutics.