Prostate Cancer Screening and Young Black Men: Can Early Communication Avoid Later Health Disparities?

This study aims to determine if younger men, across racial and ethnic groups, discussed the benefits/risks/harms of PSA screening with health care professionals. Publicly available data were obtained from the Health Information National Trends Survey https://hints.cancer.gov/ in March 2019. Cross-sectional analysis of 518 men between the ages of 18 and 49 years from men who completed the survey between October 2011 and February 2012 (HINTS cycle 4) was performed. We used logistic regression to evaluate the association between race/ethnicity and discussions around PSA. Less than 10% of the participants reported a prior PSA; Black and Hispanic men were more likely compared with White men. Compared with White men, Black and other race men reported receiving less communications from some doctors recommending PSA screening (ORblack: 0.16, 95% CIblack: 0.07-0.38; ORother: 0.10, 95% CIother: 0.04-0.25), and that no one is sure PSA testing saves lives (ORblack: 0.49, 95% CIblack: 0.04-6.91; ORother: 0.17, 95% CIother: 0.06-0.48). Minority men, while more likely to have had a PSA, were less likely to be told of the harms and benefits of PSA testing, compared with White men. Increasing communication surrounding screening advantages and disadvantages between providers and patients can increase awareness and knowledge among younger men. In a post-COVID-19 environment, communication regarding the return to preventative screenings within vulnerable populations is an important message to convey. Research shows preventive screenings have dropped across all population groups due to the pandemic yet the decline disproportionately affects Black and other minority men.

Surgical trends and patient factors associated with the treatment of apical pelvic organ prolapse from a national sample.

INTRODUCTION AND HYPOTHESIS: Prolapse of the vaginal apex can be treated using multiple surgical modalities. We describe national trends and patient characteristics associated with the surgical approach and compare perioperative outcomes of abdominal versus vaginal repair of apical pelvic organ prolapse (POP). METHODS: The 2006-2012 National Surgical Quality Improvement Program Database was queried for abdominal sacrocolpopexy (ASC) and vaginal apical suspensions. Patients were stratified by whether or not concomitant hysterectomy (CH) was performed or whether or not they were post-hysterectomy (PH). Multivariate logistic regressions were adjusted for confounding variables. RESULTS: A total of 6,147 patients underwent apical POP repair: 33.9% (2,085) ASCs, 66.1% (4,062) vaginal suspensions. 60.0% (3,689) underwent CH. In all cohorts, older patients were less likely to have ASC (CH: OR 0.48, CI 0.28-0.83, p = 0.008 for age ≥ 60; PH: OR 0.28, CI 0.18-0.43, p < 0.001). Over time, the proportion of all vaginal and abdominal repairs remained relatively stable. Use of minimally invasive ASC, however, increased over the study period (trend p < 0.001), and use of mesh for vaginal suspensions decreased (p < 0.001). ASC had a longer median operative time (PH 174 vs 95 min, p < 0.001; CH 192 vs 127 min, p < 0.001). Complication rates were the same for vaginal repairs and ASC, overall and when sub-stratified by hysterectomy status. CONCLUSIONS: Nationally, most apical POP repairs are performed via a vaginal route. Older age was predictive of the vaginal route for both CH and PH groups. ASCs had longer operative times. There has been increased utilization of minimally invasive ASC and decreased use of mesh-augmented vaginal suspensions over time.

Outcomes of minimally invasive abdominal sacrocolpopexy with resident operative involvement.

INTRODUCTION AND HYPOTHESIS: Resident involvement in complex surgeries is under scrutiny with increasing attention paid to health care efficiency and quality. Outcomes of urogynecological surgery with resident involvement are poorly described. We hypothesized that resident surgical involvement does not influence perioperative outcomes in minimally invasive abdominal sacrocolpopexy (ASC). METHODS: Using the 2006-2012 National Surgical Quality Improvement Program database, we identified 450 cases of laparoscopic or robotic ASC performed with resident involvement. Resident operative participation was stratified by experience (junior [PGY 1-3] vs senior level [PGY ≥4]). The primary outcome was operative time, and multinomial logistic regression was used to determine the effects of resident involvement and experience. Chi-squared analyses were used to assess the relationship between resident participation with length of stay (LOS) and 30-day complications and readmissions. RESULTS: Residents participated in 74% (n = 334) of these surgeries, and these cases were significantly longer (median 220 vs 195 min, p = 0.03). On multivariate analysis, senior level resident involvement was associated with longer operative times across all time intervals compared with <2 h (2 to ≤4 h relative risk reduction [RRR] 4.1, p = 0.007, CI 1.47-11.40; 4 to ≤6 h RRR 6.6, p = 0.001, CI 2.23-19.44; ≥6 h RRR 4.7, p = 0.020, CI 1.28-17.43). Resident participation was not associated with LOS, readmissions, or complications. CONCLUSIONS: Senior level resident involvement in minimally invasive ASC is associated with longer operative times, with no association with LOS or adverse perioperative outcomes. The educational benefit of surgical training does not adversely affect patient outcomes for ASC.

Suppression of antiviral innate immunity by sunitinib enhances oncolytic virotherapy.

The use of lytic viruses to preferentially infect and eliminate cancer cells while sparing normal cells is a promising experimental therapeutic approach for treating cancer. However, the efficacy of oncolytic virotherapy is often limited by two innate immunity pathways, the protein kinase PKR and the 2'-5'-oligoadenylate (OAS)/RNase L systems, which are widely present in many but not all tumor cell types. Previously, we reported that the anticancer drug, sunitinib, an inhibitor of VEGF-R and PDGF-R, has off-target effects against both PKR and RNase L. Here we show that combining sunitinib treatments with infection by an oncolytic virus, vesicular stomatitis virus (VSV), led to the elimination of prostate, breast, and kidney malignant tumors in mice. In contrast, either virus or sunitinib alone slowed tumor progression but did not eliminate tumors. In prostate tumors excised from treated mice, sunitinib decreased levels of the phosphorylated form of translation initiation factor, eIF2-α, a substrate of PKR, by 10-fold while increasing median viral titers by 23-fold. The sunitinib/VSV regimen caused complete and sustained tumor regression in both immunodeficient and immunocompetent animals. Results indicate that transient inhibition of innate immunity with sunitinib enhances oncolytic virotherapy allowing the recovery of tumor-bearing animals.

Impact of a Switch From Ciprofloxacin to Ceftriaxone Prophylaxis on Infectious Complications After Transrectal Ultrasound-Guided Biopsy of the Prostate.

In a 12-year single-center quasi-experimental study, a switch from ciprofloxacin to ceftriaxone prophylaxis for transrectal ultrasound-guided prostate biopsy procedures was associated with a significant reduction in 30-day postprocedure urinary tract infection, urinary tract infection-related hospitalizations, antibiotic prescriptions, and isolation of fluoroquinolone-resistant organisms from urine or blood cultures.

Automated closed-loop stimulation to inhibit neurogenic bladder overactivity.

Individuals with spinal cord injury (SCI) usually develop neurogenic detrusor overactivity (NDO), resulting in bladder urgency and incontinence, and reduced quality of life. Electrical stimulation of the genital nerves (GNS) can inhibit uncontrolled bladder contractions in individuals with SCI. An automated closed-loop bladder neuromodulation system currently does not exist but could improve this approach. We have developed a custom algorithm to identify bladder contractions and trigger stimulation from bladder pressure data without need for abdominal pressure measurement. The goal of this pilot study was to test the feasibility of automated closed-loop GNS using our custom algorithm to identify and inhibit reflex bladder contractions in real time. Experiments were conducted in a single session in a urodynamics laboratory in four individuals with SCI and NDO. Each participant completed standard cystometrograms without and with GNS. Our custom algorithm monitored bladder vesical pressure and controlled when GNS was turned on and off. The custom algorithm detected bladder contractions in real time, successfully inhibiting a total of 56 contractions across all four subjects. There were eight false positives, six of those occurring in one subject. It took approximately 4.0 ± 2.6 s for the algorithm to detect the onset of a bladder contraction and trigger stimulation. The algorithm maintained stimulation for approximately 3.5 ± 1.7 s, which was enough to inhibit activity and relieve feelings of urgency. Automated closed-loop stimulation was well-tolerated and subjects reported that algorithm decisions generally matched with their perceptions of bladder activity. The custom algorithm automatically, successfully identified bladder contractions to trigger stimulation to inhibit bladder contractions acutely. Closed-loop neuromodulation using our custom algorithm is feasible, but further testing is needed refine this approach for use in a home environment.

Focal therapy in the management of localized prostate cancer.

OBJECTIVES: • To assess the rationale, efficacy, and morbidity of various methods of achieving focal prostatic ablation. • To determine the current role of focal therapy in the management of localized prostate cancer. METHODS: • We performed a literature review of focal therapy in prostate cancer, with an emphasis on more established methods such as cryoablation and high-intensity focused ultrasound. RESULTS AND CONCLUSIONS: • Focal ablative methods allow targeted destruction of prostatic tissue while limiting the morbidity associated with whole-gland therapy. • Local cancer control after focal therapy appears promising but does not approach that of established whole-gland therapies. • Until we have the ability to identify patients reliably with truly focal disease and predict their natural history, focal therapy cannot be considered to be the definitive therapy for localized prostate cancer.

Gender Disparity in Cystectomy Postoperative Outcomes: Propensity Score Analysis of the National Surgical Quality Improvement Program Database.

BACKGROUND: While female gender is considered a protective determinant in the majority of cancers, outcomes in women diagnosed with bladder cancer have continued to show disproportional mortality when compared with men. OBJECTIVE: The aim of this retrospective propensity score-matched analysis was to evaluate the intra- and postoperative differences among genders, as well as to evaluate reproductive organ-preserving radical cystectomy (ROPRC) as compared with radical cystectomy (RC) as a potential confounder in female cystectomy patients. DESIGN, SETTING, AND PARTICIPANTS: Utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), men and women undergoing a cystectomy between 2011 and 2017 were analyzed. In addition, females undergoing ROPRC and RC were analyzed for immediate postoperative outcomes. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Men and women undergoing a cystectomy were evaluated through propensity score matching (PSM) for baseline differences using a 1:1 caliper width of 0.2 to the nearest neighbor. Using multivariable logistic regression analysis, we evaluated differences in the risk of readmission, complications, and reoperation in the immediate postsurgical period in males and females. Similarly, differences were assessed in ROPRC and RC groups. RESULTS AND LIMITATIONS: We achieved a balance between males and females after PSM: 1263 males and 1263 females treated with cystectomy. The risks of readmission (adjusted odds ratio [aOR] 1.228 [1.005-1.510], p=0.045), superficial surgical site infection (aOR 1.507 [1.095-2.086], p=0.012), and transfusion (aOR 2.031 [1.713-2.411], p<0.001) were increased in females undergoing a cystectomy compared with males. No differences were observed in surgical outcomes in ovarian sparing/RC cohort. CONCLUSIONS: Using the 2011-2017 NSQIP database, we were able to demonstrate an increased rate of postoperative transfusion, readmission rate, and surgical site infection in females who underwent cystectomy. Our findings suggest that females experience an increased rate of complications in the immediate postoperative period. This may ultimately lead to worse oncologic outcomes in females after an RC. Lastly, we did not find any increased rate of complications in ROPRC as compared with RC. PATIENT SUMMARY: This study highlights differences in immediate postoperative outcomes between males and females undergoing cystectomy for bladder cancer. Some of these potential differences include higher risk of infection, transfusion, and readmission. These differences may predispose females to worse long-term outcomes. In addition, due to potential benefits of ovarian preservation in the recent literature, we also evaluated the risks and complications of ovarian sparing cystectomy. We found ovarian preservation to be a safe and feasible procedure in a highly selected group of patients.

Fibrils of prostatic acid phosphatase fragments boost infections with XMRV (xenotropic murine leukemia virus-related virus), a human retrovirus associated with prostate cancer.

The xenotropic murine leukemia virus-related virus (XMRV) has recently been detected in prostate cancer tissues and may play a role in tumorigenesis. It is currently unclear how this virus is transmitted and which factors promote its spread in the prostate. We show that amyloidogenic fragments known as semen-derived enhancer of virus infection (SEVI) originating from prostatic acid phosphatase greatly increase XMRV infections of primary prostatic epithelial and stromal cells. Hybrid simian/human immunodeficiency chimeric virus particles pseudotyped with XMRV envelope protein were used to demonstrate that the enhancing effect of SEVI, or of human semen itself, was at the level of viral attachment and entry. SEVI enhanced XMRV infectivity but did not bypass the requirement for the xenotropic and polytropic retrovirus receptor 1. Furthermore, XMRV RNA was detected in prostatic secretions of some men with prostate cancer. The fact that the precursor of SEVI is produced in abundance by the prostate indicates that XMRV replication occurs in an environment that provides a natural enhancer of viral infection, and this may play a role in the spread of this virus in the human population.

Performance of prostate cancer prevention trial risk calculator in a contemporary cohort screened for prostate cancer and diagnosed by extended prostate biopsy.

PURPOSE: Statistical models such as the Prostate Cancer Prevention Trial risk calculator have been developed to estimate the cancer risk in an individual and help determine indications for biopsy. We assessed risk calculator performance in a large contemporary cohort of patients sampled by extended biopsy schemes. MATERIALS AND METHODS: The validation cohort comprised 3,482 men who underwent a total of 4,515 prostate biopsies. Calculator performance was evaluated by ROC AUC and calibration plots. A multivariate regression model was fitted to address important predictor variables in the validation data set. Prediction error was calculated as the response variable in another multivariate regression model. RESULTS: Using an average of 13 cores per biopsy prostate cancer was detected in 1,862 patients. The calculator showed an AUC of 0.57 to predict all cancers and 0.60 for high grade cancer. Multivariate analysis of the predictive ability of various clinical factors revealed that race and the number of biopsy cores did not predict overall or high grade cancer at biopsy. Prior negative biopsy, patient age and free prostate specific antigen were significantly associated with prediction error for overall and high grade cancer. Race and family history had a significant association with prediction error only for high grade disease. CONCLUSIONS: To our knowledge our external validation of the Prostate Cancer Prevention Trial risk calculator was done in the largest cohort of men screened for prostate cancer to date. Results suggest that the current calculator remains predictive but does not maintain initial accuracy in contemporary patients sampled by more extensive biopsy schemes. Data suggest that the predictive ability of the calculator in current clinical practice may be improved by modeling contemporary data and/or incorporating additional prognostic variables.

Racial disparities in urologic health care.

In the United States, disparities in health care delivery and access are apparent between different racial and ethnic groups. Minorities, including African Americans, often suffer disproportionately from disease compared to Caucasians. In the urologic arena, this is apparent in urologic cancer screening, treatment choices, and survival, as well as in the arena of chronic kidney disease, transplant allocation, and transplant outcomes. Latino men also seem to be affected more often by erectile dysfunction than Caucasian counterparts. Disparities such as these have been identified as a problem in the delivery of health care in the United States, and resources have been allocated to help allay the disparity. Through organizations such as the Cleveland Clinic Minority Men's Health Center, policy initiatives, and increased cultural awareness by physicians, steps can be made to reduce and eliminate health care disparities.

Epidural Anesthesia is Associated With Increased Complications in Cystectomy Patients: A NSQIP Analysis.

OBJECTIVE: To identify differences in short-term outcomes and readmission rates in cystectomy patients managed with general anesthesia compared to those undergoing general anesthesia and adjuvant epidural anesthesia. METHODS: Utilizing the National Surgical Quality Inpatient Program database, patients who underwent a cystectomy with ileal conduit between 2014 and 2017 were included. Patients were further subdivided based on additional anesthesia modality; general anesthesia vs general anesthesia plus epidural anesthesia. Propensity score-matching was used to adjust for baseline differences between cohorts using 1:1 caliper width of 0.15 for the propensity score through the nearest neighbor. Stepwise multivariable logistic regression was used to identify preoperative and intraoperative predictors associated with 30-day procedure related readmission, complications, and length of stay. RESULTS: About 2956 patients met our inclusion and exclusion criteria and eligible for propensity score matching. Compared to general anesthesia, adjuvant epidural anesthesia showed an increased odds of procedure related complications (adjusted Odds Ratio (aOR): 1.264, 95% CI: 1.019-1.567, P = .033). There was an increased trend for development of pulmonary emboli (13 [1.8%] vs 4 [0.5%], P = .051) in the adjuvant epidural cohort. Combined general with epidural anesthesia demonstrated no difference in length of stay, readmission, or reoperation rate in comparison to general anesthesia alone. CONCLUSION: Cystectomy patients who underwent general anesthesia plus epidural anesthesia demonstrated a higher percentage of any procedural related complication without change in postoperative stay, reoperation rate, or readmission rate compared to patients undergoing general anesthesia alone.

Superfluous Hospital Expenditure Associated with Unnecessary Renal Cyst Surveillance.

INTRODUCTION: To measure the cost expenditure associated with renal cyst surveillance, we examined renal cyst surveillance patterns at our institution and the associated surplus cost of unindicated imaging. METHODS: Patients with a renal cyst diagnosis between January 2017 and June 2018 were identified and their respective clinical and imaging data were reviewed for surveillance patterns. Unindicated renal cyst followup was defined by the Radiographic Society of North America and Canadian Urological Association. Total unnecessary expenditures from ultrasound, computerized tomography and magnetic resonance imaging were calculated using cost of services provided by FAIRHealth Consumer®. Univariate and multivariable analyses were performed with statistical significance defined as p <0.05. RESULTS: A total of 1,100 patients were identified, with a random sample of 292 selected for analysis. Of these patients 271 were diagnosed with Bosniak I and II renal cysts. Overall 52 (19%) of these patients underwent unindicated imaging, which totaled 60 ultrasound, 19 computerized tomography and 5 magnetic resonance imaging. A total superfluous cost of $347,501 was calculated when extrapolating to the entire nephrology cohort. Multivariable analysis showed higher unindicated imaging for Bosniak II renal cysts compared to Bosniak I renal cysts (OR 3.2, 95% CI 1.6-6.3, p <0.001) and decreased surveillance imaging for African American compared to Caucasian patients (OR 0.29, 95% CI 0.13-0.59, p <0.001). CONCLUSIONS: Among patients diagnosed with Bosniak I and II renal cysts, unnecessary surveillance imaging was associated with higher hospital costs. Adherence to strict renal imaging guidelines for renal cysts can significantly reduce unnecessary expenditures, patient anxiety and patient harm.

The specific definition of high risk prostate cancer has minimal impact on biochemical relapse-free survival.

PURPOSE: Accurate categorization of high risk prostate cancer cases remains elusive. Various schemes based on clincopathological criteria have been proposed to stratify cases by presumed recurrence risk. We determined whether survival outcomes are dependent on the specific definition. MATERIALS AND METHODS: The study population included men who underwent radical prostatectomy from 1987 to 1995 (708) and 1996 to 2007 (3,351). Patients who received adjuvant therapy or had no postoperative prostate specific antigen were excluded from analysis. High risk patients were identified based on 6 commonly used definitions. Biochemical failure was defined as a prostate specific antigen of 0.4 ng/ml or greater and increasing or initiation of salvage therapy. Estimates of biochemical relapse-free survival were generated with the Kaplan-Meier method. Hazard ratios for disease recurrence were estimated using Cox proportional hazards analysis. RESULTS: High risk patients determined by the 6 definitions demonstrated a 2.7 to 5.3-fold increased hazard of biochemical relapse, and 5 and 10-year biochemical relapse-free survival rates were 36% to 58% and 25% to 43%, respectively. When stratified by date of treatment high risk patients from 1987 to 1995 generally had worse biochemical relapse-free survival compared to those treated after 1996. Within each era the variation in biochemical relapse-free survival among various high risk definitions was not substantial. CONCLUSIONS: Biochemical relapse-free survival after radical prostatectomy does not vary substantially based on the specific definition of high risk prostate cancer. There is a trend toward improved biochemical relapse-free survival in patients treated more recently, perhaps reflecting stage migration or changes in surgical technique. The data suggest that high risk prostate cancer may represent a relatively homogeneous population.

Acute Urinary Retention Due to Late Migration of a Retained Bullet to the Urethral Meatus.

Urethral obstruction due to retained bullets migrating into the genitourinary system has rarely been reported. The literature describes 2 main methods of retained bullet removal from the genitourinary system: (1) spontaneous expulsion during voiding and (2) manual extraction due to urethral obstruction causing acute urinary retention. We present a case in which a 21-year-old man presented with acute urinary retention 3 years after suffering a gunshot wound to the abdomen. A retained bullet eroded through the bladder wall, migrated through the bladder and urethra, and eventually became lodged in the external urethral meatus, causing obstruction and urinary retention.

Observed racial disparity in the negative predictive value of multi-parametric MRI for the diagnosis for prostate cancer.

OBJECTIVE: To evaluate the trend that despite recent advances in the screening, diagnosis, and management of prostate cancer (PCa), African-Americans (AAs) continue to have poorer outcomes compared to their Caucasian (CAU) counterparts. The reason for this may be rooted in biological differences in the cancer between the two groups; however, there may be some inherent disparities within the efficacy of the screening modalities. In this study, we aim to evaluate the negative predictive value (NPV) of multi-parametric MRI (mpMRI) between AA compared to CAUs. METHODS: All mpMRI between January 2014 and June 2017 were evaluated. The MRIs were read by dedicated genitourinary radiologists. Subsequently, the readings were correlated to final pathology after the patients underwent radical prostatectomy. The NPV and negative likelihood ratios (-LR) of mpMRI were evaluated in AAs versus CAUs based on four cutoffs (≥ Grade I, ≥ Grade II, ≥ Grade III and ≥ Grade IV). RESULTS: The mpMRI was almost equally as effective between AAs and CAUs in excluding Grade III (NPV = 89 and 94, respectively), and Grade IV or above (NPV = 96 and 98, respectively) PCa; however, the NPV of mpMRI was significantly lower for Grade I (NPV = 32 and 52, respectively) and Grade II (NPV = 50 and 79, respectively) PCa. CONCLUSION: Despite advances in the screening for PCa, there are disparities noted in the efficacy of screening tools between AAs and CAUs. For this reason, patients should be risk stratified and their screening results should be evaluated with consideration given to their baseline risk.

Topical anesthesia with EMLA does not decrease pain during vasectomy.

PURPOSE: Previous studies show conflicting results of the ability of EMLA (eutectic mixture of local anesthetics) to decrease pain during vasectomy. We examined the effectiveness of EMLA cream to decrease pain in patients undergoing bilateral percutaneous no-scalpel vasectomy. MATERIALS AND METHODS: A prospective study was performed in which 316 patients used EMLA cream (178) or no topical anesthesia (138) before vasectomy. EMLA cream was applied by patients 1 hour before the scheduled time of surgery. Bilateral percutaneous no-scalpel vasectomy was then performed in the 2 groups with local infiltration of 1% lidocaine into the scrotal wall and vasal sheath. Following the procedure patients were asked to rate their associated pain using a visual analog scale. Statistical analysis was performed using the 2-sided Student t test. RESULTS: Mean patient age was similar in the groups with and without EMLA (39.1 and 39.0 years, respectively). No significant difference in mean visual analog pain scores were noted between the EMLA and control groups (21.5 vs 21.0, p = 0.8). CONCLUSIONS: Topical anesthesia with EMLA did not significantly decrease the pain associated with percutaneous vasectomy.

Office based vasectomy can be performed by supervised urological residents with patient pain and morbidity comparable to those of a staff surgeon procedure.

PURPOSE: Although it is routinely performed in the ambulatory setting, vasectomy is an intricate surgical procedure with the potential for significant pain and morbidity. We determined from our prospective, institutional review board approved database whether vasectomy pain was affected by whether a staff surgeon or resident was the primary surgeon on the case. MATERIALS AND METHODS: One staff surgeon and 14 residents in training year 2, 3 or 5 performed bilateral percutaneous no-scalpel vasectomy. Men scheduled to undergo vasectomy were assigned to the staff urologist (134) or to a resident (133) as the primary surgeon. The staff surgeon demonstrated the first vasectomy each month when a new resident rotated on service and all residents were directly assisted by the staff surgeon. Pain associated with each side of the bilateral vasectomy was assessed with a 0 to 100 mm visual analog scale. RESULTS: The average visual analog scale score of the 2 sides was 19.5 in patients in the staff cohort and 21.8 in those in the resident cohort. Although mean scores were slightly lower when vasectomy was performed by the staff surgeon, the difference between the staff surgeon and residents was neither statistically nor clinically significant. Furthermore, there were no significant differences in visual analog scale scores among residents of different training years. CONCLUSIONS: Office based vasectomy can be performed by residents under staff supervision with pain comparable to that of the procedure performed by a staff urologist. Urological resident training can be accomplished without compromising high standards of care.

Surgical salvage of renal cell carcinoma recurrence after thermal ablative therapy.

PURPOSE: Thermal ablative therapies, including cryoablation and radio frequency ablation, have become viable options for the management of small renal tumors. However, initial data have suggested higher local recurrence rates for ablation compared to partial nephrectomy. We evaluated options for salvage of ipsilateral tumor recurrence after previous ablation. MATERIALS AND METHODS: Records of renal surgeries performed at our institution between September 1997 and December 2006 were reviewed to identify patients with ipsilateral tumor recurrence after radio frequency ablation or cryoablation, and clinical characteristics and treatment were defined. RESULTS: Recurrence rates at our hospital were 13 of 175 (7.4%) after cryoablation and 26 of 104 (25%) after radio frequency ablation, and 3 additional cases of post-cryoablation recurrence were referred from elsewhere. Overall repeat ablation was performed in 26 patients who experienced post-ablative recurrence. However, 12 patients (33%) were not candidates for repeat ablation due to large tumor size, disease progression or repeat ablative failure. In this group 1 patient received systemic therapy, 1 refused further treatment and 10 underwent attempted extirpation. Partial nephrectomy was only possible in 2 patients and both required an open approach. Remaining patients were treated with radical nephrectomy (7) or had the procedure aborted due to strong patient preference to avoid dialysis (1). Laparoscopic surgery was only possible in 4 cases. Extensive perinephric scarring was encountered in all salvage operations following cryoablation. CONCLUSIONS: Primary thermal ablation for small renal masses may preclude or complicate subsequent surgical salvage. Cryoablation in particular can lead to extensive perinephric fibrosis which can complicate attempts at salvage. Appropriate patient selection for thermal ablation remains of paramount importance.

Choice of operation for clinically localized renal tumor.

The cornerstone of treatment for localized renal tumors is surgical excision, which until recently was accomplished primarily through radical nephrectomy. The last 2 decades have seen a rapid evolution in the surgical management of renal cell carcinoma, marked by the increased use of nephron-sparing surgery and the application of minimally invasive techniques. A plethora of surgical options now are available. This article discusses the optimal surgical approach to renal tumors in various clinical scenarios. In all these discussions we assume that a proactive approach to treatment is indicated and desired, recognizing that active surveillance is always an additional option to consider in certain subpopulations such as the elderly or infirm.