Multicenter Investigation of Fungal Infections of Inflatable Penile Prostheses.

BACKGROUND: Fungal infections of inflatable penile prostheses (IPPs) are inadequately understood in the literature. AIM: To review a multi-institution database of IPP infections to examine for common patient and surgical factors related to IPP fungal infections. METHODS: This is a retrospective Institutional Review Board-approved analysis of 217 patients at 26 institutions who underwent salvage or device explant between 2001 and 2018. Patient data were compiled after an extensive record review. OUTCOMES: 26 patients (12%) with fungal infections were identified. RESULTS: 23 of 26 patients (83%) with a fungal IPP infection were either diabetic or overweight. 15 patients had undergone primary IPP implantation, and the other 11 had previously undergone an average of 1.7 IPP-related surgeries (range 1-3; median 2). The average age at implantation was 63 years (range 31-92; median 63). 18 of the 26 patients with fungal infection had diabetes (69%), with a mean hemoglobin A1c (HbA1c) value of 8.4 (range 5.8-13.3; median 7.5). Twenty-two patients (85%) were overweight or obese. The mean body mass index for all patients was 30.1 kg/m2 (range 23.7-45 kg/m2; median 28.4 kg/m2), and that for diabetic patients was 30.8 kg/m2 (range 24.1-45 kg/m2, median 29.7 kg/m2). Ninety-one percent of implants were placed with intravenous antibiotics, consistent with current American Urological Association guidelines: an aminoglycoside plus first- or second-generation cephalosporin or vancomycin or ampicillin/sulbactam or piperacillin/tazobactam. 65% (17 of 26) of infected IPPs had only fungal growth in culture. No patient had concomitant immunosuppressive disease or recent antibiotic exposure before IPP implantation. CLINICAL IMPLICATIONS: More than two-thirds of the fungal infections occurred in diabetic patients and 85% occurred in overweight or obese patients, suggesting that antifungal prophylaxis may be appropriate in these patients. STRENGTHS & LIMITATIONS: This is the largest series of fungal infections reported to date in the penile prosthesis literature. The overall number of such cases, however, remains small. CONCLUSION: Fungal infections represent 12% of all penile prosthesis infections in our series and were seen mostly in diabetic or overweight patients, who may benefit from antifungal prophylaxis. Gross MS, Reinstatler L, Henry GD, et al. Multicenter Investigation of Fungal Infections of Inflatable Penile Prostheses. J Sex Med 2019;16:1100-1105.

Conversion from Cystine to Noncystine Stones: Incidence and Associated Factors.

PURPOSE: Patients with cystinuria are often treated with medical alkalization and shock wave lithotripsy, although each treatment is hypothesized to increase the risk of calcium phosphate stones. We performed a multicenter retrospective review to evaluate whether stones of another composition develop in patients with cystinuria and with what frequency. MATERIALS AND METHODS: We retrospectively reviewed the records of a multi-institutional cohort of patients with cystinuria. We assessed medications, stone analyses, 24-hour urinalyses and types of procedures. We compared patients who formed only cystine stones vs those with noncystine stones. RESULTS: We identified 125 patients from a total of 5 institutions who were followed a mean of 5.2 years (range 0 to 26). Stones with noncystine components were submitted by 37 patients (29.6%). Potassium citrate medication was not associated with a noncystine composition (p = 0.1877). Regarding surgical management 18 patients (13%) underwent at least 1 shock wave lithotripsy session (range 0 to 9) and 79 (63%) underwent percutaneous nephrolithotomy at least once (range 0 to 10). When stratified based on pure cystine vs converted stones, the average total number of shock wave lithotripsy and percutaneous nephrolithotomy procedures was higher in the group with cystine and subsequent noncystine stone compositions (0.94 vs 0.10, p <0.0001, and 1.7 vs 1.5, p = 0.0053, respectively). On logistic regression male gender (OR 3.1, p = 0.0280) and the number of shock wave lithotripsy sessions (OR 3.0, p = 0.0170) were associated with an increased likelihood of the development of stones with a noncystine composition. CONCLUSIONS: Stones with noncystine components develop in more than 25% of patients with cystinuria, underscoring the importance of continued stone analysis. In this study prior shock wave lithotripsy was associated with conversion to a noncystine stone composition while urinary alkalization therapy was not associated.

Acquired Hemophilia presenting as Gross Hematuria following Kidney Stone - A Case Report and Review of the Literature.

A rare condition in itself, acquired hemophilia A, seldom presents as isolated gross hematuria. It is a serious condition with a high mortality rate and thus clinical suspicion followed by prompt diagnosis is imperative (1). In fact, only 8 cases of such presentation of this condition have been reported thus far in the literature. Of these, none describe the initial presentation of hematuria with the inciting event of a kidney stone. We present a case of a 67-year-old man with signs and symptoms of nephrolithiasis accompanied by profuse hematuria, who was subsequently found to have developed expression of factor VIII inhibitor leading to acquired hemophilia A.

Association of Pregnancy with Stone Formation among Women in the United States: A NHANES Analysis 2007 to 2012.

PURPOSE: Lithogenic urinary changes develop during pregnancy. Such changes may increase stone proclivity thereafter in working and child rearing aged women. However, to our knowledge such an association has not been previously identified. MATERIALS AND METHODS: We analyzed nationally representative data from the 2007 to 2012 NHANES (National Health and Nutrition Examination Survey) to assess the association between pregnancy and nephrolithiasis. RESULTS: The weighted national prevalence of nephrolithiasis among women 50 years or younger was 6.4% (95% CI 5.4-7.6). The prevalence of nephrolithiasis was significantly higher among women who had been pregnant compared with those who had never been pregnant (7.5% vs 3.2%, p = 0.0004). On univariate regression those who had been pregnant had more than twice the odds of having had kidney stones (OR 2.44, 95% CI 1.50-3.98). An increased likelihood of nephrolithiasis in those with a history of pregnancy persisted on multivariable logistic regression adjusting for age, ethnicity, obesity, history of diabetes, gout, hormone use, water intake and high sodium diet (OR 2.13, 95% CI 1.31-3.45). Finally, the adjusted prevalence of nephrolithiasis increased significantly with an increasing number of pregnancies from 5.2% in those with 0 reported pregnancies to 12.4% in those with 3 or more pregnancies (p = 0.001). CONCLUSIONS: Nephrolithiasis is strongly associated with prior pregnancies. Among women of reproductive age the odds of stones are greater than doubled in those who had been pregnant compared with those who had never been pregnant. Nephrolithiasis prevalence also increases with the increasing number of pregnancies. Future investigation and identification of modifiable risk factors among pregnant patients may allow for a reduction in the burden of stone disease in women.

Comorbidity Is a Competing Factor for Disease Recurrence Postnephrectomy.

OBJECTIVE: There is a relation between tumor stage and grade with the risk of cancer recurrence in patients undergoing surgical treatment for kidney cancer. The association of patient comorbidity with disease recurrence is less well characterized. The objective of this study was to explore the association between comorbidity and the recurrence of kidney cancer. METHODS: We performed a retrospective analysis of 263 patients who received a partial or radical nephrectomy from January 1, 2000 through April 30, 2013. Patient data included race, sex, body mass index, age-adjusted Charlson Comorbidity Index (aaCCI) score, tumor histology, tumor T classification, and Fuhrman grade. The primary outcome was cancer recurrence, either local or distant. Logistic regression was used to assess the association of these risk factors with the outcome. RESULTS: The median follow-up time was 19.6 months (interquartile range 5.2-53.7). There were 101 (38.4%) African American patients and 150 (57.0%) men. The median body mass index was 28.3 and the median aaCCI was 3.0. The Fuhrman grade was G1 in 9.5% of patients, G2 in 45.2%, G3 in 32.8%, and G4 in 12.5%. Nineteen (7.2%) patients experienced disease recurrence, including 13 (4.9%) patients with metastatic disease. The risk factors significantly associated with recurrence included Fuhrman grade (odds ratio [OR] 3.0, 95% confidence interval [CI] 1.23-7.30), tumor T classification (OR 1.33, 95% CI 1.00-1.76), and CCI (OR 0.74, 95% CI 0.57-0.95). CONCLUSIONS: Physiologic factors, in addition to tumor characteristics, play a significant role in predicting cancer-specific survival in patients with kidney cancer. The reduced odds of recurrence with higher aaCCI may indicate that competing health factors have an impact before recurrence on survival in certain patients.

The Impact of Radical Cystectomy and Urinary Diversion on Suicidal Death in Patients With Bladder Cancer.

PURPOSE: Compared to the general population, suicide is more common in the elderly and in patients with cancer. We sought to examine the incidence of suicide in patients with bladder cancer and evaluate the impact of radical cystectomy in this high-risk population. METHODS: Patients diagnosed with urothelial carcinoma from 1988 to 2010 were identified in the Survey, Epidemiology, and End Results (SEER) database. Contingency tables of suicide rates and standardized mortality ratios (SMRs) and 95% confidence intervals were calculated. Multivariable logistic regression models were performed to generate odds ratios (ORs) for the identification of factors associated with suicide in this population. RESULTS: There were 439 suicides among patients with bladder cancer observed for 1,178,000 person-years (Standard Morbidity Ratio [SMR] = 2.71). All demographic variables analyzed had a higher SMR for suicide compared to the general population, in particular age ≥80 years (SMR = 3.12), unmarried status (SMR = 3.41), and white race (SMR = 2.60). The incidence of suicide was higher in the general population for patients who underwent radical cystectomy compared to those who did not (SMR = 3.54 vs SMR = 2.66). On multivariate analysis, the strongest predictors of suicide were male gender (vs female; OR = 6.63) and distant disease (vs localized; OR = 5.43). CONCLUSIONS: Clinicians should be aware of risk factors for suicide in patients diagnosed with bladder cancer, particularly older, white, unmarried patients with distant disease, and/or those who have undergone radical cystectomy. A multidisciplinary team-based approach, including wound ostomy care trained nursing staff and mental health care providers, may be essential to provide care required to decrease suicide rates in this at-risk population.

Factors associated with suicide in patients with genitourinary malignancies.

BACKGROUND: Approximately 70% of all suicides in patients aged >60 years are attributed to physical illness, with higher rates noted in patients with cancer. The purpose of the current study was to characterize suicide rates among patients with genitourinary cancers and identify factors associated with suicide in this specific cohort. METHODS: Patients with prostate, bladder, kidney, testis, and penile cancer were identified in the Surveillance, Epidemiology, and End Results database (1988-2010). Standardized mortality ratios (SMRs) and 95% confidence intervals (95% CIs) were calculated for each anatomic site. Multivariable logistic regression models generated odds ratios (ORs) for the identification of factors associated with suicide for each malignancy. RESULTS: There were 2268 suicides identified among 1,239,522 individuals with genitourinary malignancies observed for 7,307,377 person-years. The SMRs for patients with cancer were 1.37 for prostate cancer (95% CI, 0.99-1.86), 2.71 for bladder cancer (95% CI, 2.02-3.62), 1.86 for kidney cancer (95% CI, 1.32-2.62), 1.23 for testis cancer (95% CI, 0.88-1.73), and 0.95 for penile cancer (95% CI, 0.65-1.35). On multivariable analysis, male sex was found to be associated with odds of suicide among patients with bladder cancer (OR, 6.63) and kidney cancer (OR, 4.98). Increasing age was associated with suicide for patients with prostate, bladder, and testis cancer (OR range, 1.03-1.06). Distant disease was associated with suicide in patients with prostate, bladder, and kidney cancer (OR range, 2.82-5.43). Among patients with prostate, bladder, and kidney cancer, African American patients were less likely to commit suicide compared with white individuals (OR range, 0.26-0.46). CONCLUSIONS: Suicide in patients with genitourinary malignancies poses a public health dilemma, especially among men, the elderly, and those with aggressive disease. Clinicians should be aware of risk factors for suicide in these patients.

Body mass index and comorbidity are associated with postoperative renal function after nephrectomy.

PURPOSE: To explore the association of body mass index (BMI) and comorbidity with renal function after nephrectomy. MATERIALS AND METHODS: We retrospectively analyzed 263 patients submitted to partial or radical nephrectomy from 2000-2013. Variables assessed included BMI, Charlson Comorbidity Index (CCI), race, tobacco use, tumor histology, surgical approach, Fuhrman nuclear grade, and tumor (T) classification. Glomerular filtration rate (GFR) was estimated using the Cockroft-Gault equation, adjusted for gender. Logistic regression was performed and included all interaction terms. RESULTS: Median follow-up was 19.6 months (IQR 5.2, 53.7). Median preoperative GFR was 86.2 mL/min/1.73 m2 and median postoperative GFR was 68.4 mL/min/1.73 m2. BMI (OR 1.07, 95%CI 1.02-1.11), CCI (OR 1.19, 95%CI 1.04-1.37), and radical nephrectomy (OR 3.09, 95%CI 1.51-6.33) were significantly associated with a decline in renal function of ≥ 25%. CONCLUSION: BMI and CCI are associated with postoperative decline in renal function after nephrectomy. Additionally, radical nephrectomy is significantly associated with decreasing renal function compared to partial nephrectomy. These findings highlight the importance of assessing patient comorbidity in the decision making process for patients presenting with a renal mass.

Beyond biology: the impact of marital status on survival of patients with adrenocortical carcinoma.

PURPOSE: To analyze the association of marital status and survival of patients with ACC using a population-based database. MATERIAL AND METHODS: Patients with ACC were abstracted from the Surveillance Epidemiology and End Results (SEER) database from 1988-2010 (n=1271). Variables included marital status (married vs single/divorced/widowed (SDW)), gender, age, race, tumor (T) and node (N) classification, receipt of surgery, and SEER stage. Statistical analysis was performed using Cox proportional hazard models to generate hazard ratios and 95% confidence intervals. RESULTS: There were 728 (57.3%) females and median age was 56 years (IQR 44-66). Patients who were alive were more frequently married (65.6% vs 61.6%, p=0.008), female (61.1% vs 58.0%, p=0.001), younger (median 51 vs 57 years, p=0.0001), submitted to adrenalectomy (88.6% vs 63.8%, p<0.0001), and more favorable SEER stage (localized- 64.9% vs 29.9%; regional-25.1% vs 30.1%; distant 4.8% vs 31.5%, p<0.0001) compared to patients dead of disease (DOD). On multivariable analysis, factors significantly associated with all-cause mortality were SDW status (HR 1.28, 95% CI 1.09-1.51), age, non-operative management, and N+ disease. Risk factors for disease-specific mortality included SDW status (HR 1.30, 95% CI 1.07-1.56), age, non-operative management, T-classification, and N+ disease. CONCLUSIONS: Marital status is significantly associated with survival in patients with ACC. Our results suggest that the decreased survival seen among SDW individuals highlights an area for further research and needed intervention to reduce disparity.

Molecular basis for the thiol sensitivity of insulin-degrading enzyme.

Insulin-degrading enzyme (IDE) is a ubiquitous zinc-metalloprotease that hydrolyzes several pathophysiologically relevant peptides, including insulin and the amyloid beta-protein (Abeta). IDE is inhibited irreversibly by compounds that covalently modify cysteine residues, a mechanism that could be operative in the etiology of type 2 diabetes mellitus (DM2) or Alzheimer's disease (AD). However, despite prior investigation, the molecular basis underlying the sensitivity of IDE to thiol-alkylating agents has not been elucidated. To address this topic, we conducted a comprehensive mutational analysis of the 13 cysteine residues within IDE. Our analysis implicates C178, C812, and C819 as the principal residues conferring thiol sensitivity. The involvement of C812 and C819, residues quite distant from the catalytic zinc atom, provides functional evidence that the active site of IDE comprises two separate domains that are operational only in close apposition. Structural analysis and other evidence predict that alkylation of C812 and C819 disrupts substrate binding, whereas alkylation of C178 interferes with the apposition of active-site domains and subtly repositions zinc-binding residues. Unexpectedly, alkylation of C590 was found to activate hydrolysis of Abeta significantly, while having no effect on insulin, demonstrating that chemical modulation of IDE can be both bidirectional and highly substrate selective. Our findings resolve a long-standing riddle about the basic enzymology of IDE with important implications for the etiology of DM2 and AD. Moreover, this work uncovers key details about the mechanistic basis of the unusual substrate selectivity of IDE that may aid the development of pharmacological agents or IDE mutants with therapeutic value.

Postoperative penile prosthesis pain: is it worse in diabetic patients?

Inflatable penile prosthesis (IPP) surgery is an effective, safe and satisfactory treatment option for medication-refractory erectile dysfunction. Postoperative complications include infection, mechanical failure, erosion, and pain. Current literature suggests the need for a better approach to postoperative pain management after IPP surgery. Clinical studies have demonstrated that postoperative pain is different in diabetic patients. We sought to determine if there is a difference in pain after IPP placement in diabetics. This is a single-institution retrospective review. The main outcome measure was the number of 30-day postoperative visits for pain. The secondary outcome included differences in how pain was managed. The top HbA1c quartile was compared with the other HbA1c quartiles. Diabetes was present in 92 (54.4%) patients and 96% of these had HbA1c > 8. Significant postoperative pain was more common in patients with HbA1c > 8 (41% vs 13%, p = 0.047) and resulted in more unplanned visits (27% vs 11%, p = 0.042). Patients with HbA1c > 8 with significant postoperative pain were more likely to be managed with opioids and gabapentin (30% vs 14%, p = 0.05). There were no statistical differences in age between diabetics and non-diabetics (mean 59 vs 61, p = 0.193). Hispanic and African-American patients represented 87% of the poorly controlled diabetics compared with only 13% of white patients (p < 0.001). Poorly controlled diabetics had more medical comorbidities (p < 0.001). On logistic regression, a HbA1c > 8 was predictive of an unplanned visit for pain with an OR of 2.83 (p = 0.04). Significant pain after IPP surgery was higher in diabetics with HbA1c > 8, which resulted in more unplanned 30-day postoperative visits. Patients with significant postoperative pain were managed with a combination of opioids and gabapentin. Future studies are required to optimize pain management in diabetics following IPP placement.

Estimating the rate and reasons of clinical trial failure in urologic oncology.

OBJECTIVES: Clinical trials are pillars of modern clinical evidence generation. However, the clinical trial enterprise can be inefficient, and trials often fail before their planned endpoint is reached. We sought to estimate how often urologic oncology trials fail, why trials fail, and associations with trial failure. METHODS: We queried phase 2/3 urologic clinical trial data from ClinicalTrials.gov registered between 2007 and 2019, with status marked as active, completed, or terminated. We extracted relevant trial data, including anticipated and actual accrual, from trial records and ClinicalTrials.gov archives. We manually coded reasons given in the "why stopped" free text field for trial failure into categories (poor accrual, interim results, toxicity/adverse events, study agent unavailable, canceled by the sponsor, inadequate budget, logistics, trial no longer needed, principal investigator left, no reason given, or other). We considered trials terminated for safety or efficacy to be completed trials. Trials marked as terminated for other reasons were considered failed trials. We then estimated the rate of trial failure using competing risks methods. Finally, we assessed associations with trial failure using a Cox proportional hazards model. RESULTS: A total of 1,869 urologic oncology trials were included. Of these, 225 (12.0%) failed, and 51 (2.7%) were terminated for "good" reasons (e.g., toxicity, efficacy). Of the 225 failed trials, 122 (54%) failed due to poor accrual. Failed trials had a lower anticipated accrual than successfully completed trials (55 vs. 63 patients, P<0.001). A total of 6,832 patients were actually accrued to failed trials. The 10-year estimated risk of trial failure was 17% (95% CI 15%-22%). Single center trials, phase 3 trials, drug trials, and trials with exclusively USA sites were more likely to fail. CONCLUSION: We estimate that 17%, or roughly 1 in 6, of urologic oncology trials fail, most frequently for poor accrual. Further investigations are needed into systemic, trial, and site-specific factors that may impact accrual and successful trial completion.

Pain Management in Penile Prosthetic Surgery: A Review of the Literature.

INTRODUCTION: The literature on perioperative pain control and management in inflatable penile prosthesis placement is not firmly established. Because inflatable penile prosthesis placement is an elective procedure, pain can be one of the many issues that influence patient decision making. Pain control also presents a unique challenge to providers in an era of widespread opiate abuse. AIM: To review published data on pain management before, during, and after penile prosthetic surgery. METHODS: Peer-reviewed literature and conference abstracts were analyzed for all relevant publications related to this issue. RESULTS: The past several decades have seen a shift from general to local anesthesia for penile prosthetic surgery. This has been well characterized and is seen as successful with different local anesthetic options and techniques. To date, only one study has provided follow-up for longer than 1 week regarding postoperative pain management for prosthetic surgery. CONCLUSION: Perioperative pain management for the patient receiving a penile prosthetic is well characterized; postoperative pain management is not. Although periprocedural local anesthesia has been well described for penile prosthesis surgery, a standardized postoperative pain management plan does not exist. This review highlights the need for further characterization of postoperative pain and the subsequent development of an algorithmic approach for management. Reinstatler L, Shee K, Gross MS. Pain Management in Penile Prosthetic Surgery: A Review of the Literature. Sex Med Rev 2018;6:162-169.

Characterization and outcomes of local treatment for primary bladder lymphoma: A population-based cohort analysis.

INTRODUCTION: Primary bladder lymphoma (PBL) is rare, representing 0.2% of extranodal lymphoma and less than 1% of all tumors originating in the bladder. Since the initial description of the disease, low-grade mucosa-associated lymphoid tissue (MALT) lymphoma has been reported as the most common subtype while high-grade disease was thought to represent only 20% of the reported cases. MATERIALS AND METHODS: One hundred and ninety five patients with PBL from the Surveillance, Epidemiology, and End Results (SEER) registry from 1998-2010 were reviewed. Tumors were classified as high or low grade based on histologic subtype of lymphoma based on revised European-American Lymphoma classification system. Socio-demographic and clinical variables were reported, as well as survival outcome analyses using the Kaplan-Meier method and log-rank test. Cox proportional hazard analysis was used to generate hazard ratios for risk factors associated with mortality. RESULTS: Eighty-three patients (42.6%) with low-grade and 112 patients (57.4%) with high-grade bladder lymphoma were studied. There were no differences between the low and high-grade groups for socio-demographic or clinical variables. Median overall survival or patients with low-grade disease was 38 months versus 15 months for patients with high-grade disease (p< 0.001). Analysis demonstrated worse survival outcomes for patients with high-grade disease compared to low-grade disease (p< 0.001). On multivariable analysis, increasing age and high-grade disease were associated with worse disease specific mortality (p< 0.001). CONCLUSION: Patient with high-grade primary bladder lymphoma had worse survival outcomes compared to those with low-grade disease. While transurethral resection provides tissue for diagnosis, immunotherapy/chemotherapy remains the mainstay of treatment for bladder lymphoma. Consolidation chemotherapy has been recommended in young patients not achieving complete remission with immunotherapy/chemotherapy.

Ensuring Evidence-Based Practice: A Study of Factors Associated with Nonuse of American Urological Association Guidelines.

INTRODUCTION: Evidence-based guidelines are published by the AUA (American Urological Association) to improve the quality and consistency of urological care. The 2014 AUA Census reported a unique field regarding provider utilization of AUA Guidelines. We sought to identify factors associated with nonuse of AUA Guidelines to understand how education and dissemination of these guidelines might be improved. METHODS: Using 2014 AUA Census data providers were stratified based on self-reported use or nonuse of AUA Guidelines. Bivariate analyses and multivariable logistic regression analysis were performed to identify factors associated with nonuse. Post-stratification weights were applied to calculate national estimates with SAS®, version 9.4. RESULTS: The 2,202 survey respondents represented 11,680 practicing urologists. AUA guideline use was reported by 95.0% of the weighted population. There was no significant difference in utilization based on gender, race, country of origin, practice type or fellowship completion. After controlling for other variables urologists who reported practicing in a rural area were more likely to be nonusers (OR 1.06, 95% CI 1.03-1.09). Additionally, urologists who had been practicing longer were less likely to utilize guidelines compared with those earlier in the career (practicing 10 to 20 years OR 1.15, 95% CI 1.10-1.21 and more than 20 years OR 1.13, 95% CI 1.09-1.18, p <0.05). CONCLUSIONS: Despite continued publication and dissemination of AUA Guidelines about 5% of urologists do not utilize guidelines. Later career status and rural geography were associated with nonuse. These data may inform efforts to improve dissemination and education regarding evidence-based practice.

Secular Trends in Prostate Biopsy Criteria and Outcomes: The Dartmouth Experience.

OBJECTIVE: To evaluate trends in prostate biopsy and cancer diagnosis at a center with conservative screening practices in the pre- and post-2012 era. More restrictive prostate-specific antigen (PSA) screening guidelines have led to lower rates of screening, biopsy, and diagnosis of prostate cancer. It is not clear, however, how regions with low baseline screening rates (the Lebanon, New Hampshire hospital referral region centered on Dartmouth-Hitchcock Medical Center had the lowest rate of screening among Medicare patients in 2012) have responded to these guidelines. METHODS: We retrospectively analyzed patients who underwent prostate biopsy from January 2011 to March 2016. Demographic and clinical characteristics were analyzed by time. Multivariable analysis assessed for factors associated with higher grade cancer. RESULTS: There were 614 prostate biopsies were performed. PSA at biopsy increased with time (7.2 in 2011 vs 10.1 in 2015, P = .0085); age did not. There was a stable proportion of benign findings; proportions of low-grade disease decreased, whereas intermediate- and high-grade disease increased (2011 vs 2015: 21.1% vs 10.8% Gleason 3 + 3, 32.9% vs 43.3% ≥ Gleason 3 + 4, P = .0454). Factors predictive of higher grade disease included abnormal digital examination (odds ratio [OR] 2.19, P = .0076), higher PSA (OR 1.09, P = .0040), and later biopsy date (OR 1.01, P = .0469). CONCLUSION: In an environment of conservative baseline screening practices, there has been a shift in prostate biopsy criteria and outcomes, namely a rising PSA threshold for biopsy and a 50% decrease in the diagnosis of low-grade disease. Additional study is needed to ensure these trends are favorably impacting the quality of care.

Clinical Disparities for Minorities and Foreign-Born Men With Undescended Versus Descended Testicular Germ Cell Tumors.

BACKGROUND: Few reports have been published regarding the outcomes of patients who develop an undescended testicular malignancy (UTM). Our objective was to analyze the sociodemographic and survival outcomes of patients with UTM and those of with descended testicular malignancy (DTM). PATIENTS AND METHODS: All 17 registries constituting the Surveillance, Epidemiology, and End Results (SEER) database were analyzed from 1988 to 2008. Patients with a descended or undescended testis and a diagnosis of nonseminomatous or seminomatous testicular cancer were identified. Descriptive statistical data and multivariate analysis were used to identify the predictors of a UTM diagnosis. The primary outcomes were overall and disease-specific survival. RESULTS: The study cohort included 10,159 men (95.3%) with DTM and 496 (4.7%) with UTM. Patients with UTM were more likely to be older, married, and a minority or foreign born and to have seminoma, a higher rate of node positivity, and a higher SEER stage compared with patients with DTM. The median survival time for patients with UTM was longer than that for patients with to DTM (83.1 vs. 72.5 months; P = .0001), although no difference was found in cancer-specific mortality (P = .34). CONCLUSION: Patients with UTM are more likely to be a minority or foreign born, highlighting a previously unrecognized healthcare disparity that might represent a lack of diagnosis and access to care.

Multiple Discordant Histology After Nephrectomy: Descriptive Analysis and Outcomes.

BACKGROUND: While RCC is the most common primary renal neoplasm, few cases of ipsilateral renal lesions of different RCC histologic subtypes have been described. The objective of this study was to evaluate our experience with synchronous, histologically unique, primary renal neoplasms within the same kidney. PATIENTS AND METHODS: We retrospectively analyzed 2 institutional nephrectomy databases from 2000 to 2013. The study cohort comprised 15 patients with multiple, discordant renal histology after partial or radical nephrectomy. Demographic data, immunohistochemical analysis, and clinical course were assessed and analyzed. RESULTS: Eight patients (53%) were black, 10 (60%) were male, and 5 (36%) were tobacco users. Median follow-up time was 13 months (range, 1-62 months), and 9 patients (56%) underwent radical nephrectomy. Among 36 tumors, the median tumor size was 2.3 cm (range, 0.4-9 cm). The most common combination of discordant tumor histology among patients with ≥ 2 tumors was clear-cell (cc) renal-cell carcinoma (RCC) with chromophobe RCC (3 cases, 19%). In 3 patients (19%), a single tumor was noted to have 2 distinct patterns; all patients had ccRCC with papillary RCC. Three (20%) of 15 patients developed metastatic disease. The median cancer-free survival time for patients with metastasis was 2 months. CONCLUSION: Multiple, discordant renal pathology represents a rarely reported entity in patients receiving nephrectomy. We introduce the largest cohort of synchronous renal tumors, of which ccRCC/chromophobe RCC was the most common pairing.

Female, Black, and Unmarried Patients Are More Likely to Present With Metastatic Bladder Urothelial Carcinoma.

BACKGROUND: Although there are well-established risk factors for the diagnosis of bladder cancer, there is no consensus regarding risk factors for presentation of advanced or metastatic disease at diagnosis. The objective of this study was to identify the demographic and clinical factors associated with metastasis at diagnosis in patients with bladder urothelial carcinoma. PATIENTS AND METHODS: Patients diagnosed with bladder urothelial carcinoma from 2004 to 2010 were identified in the Surveillance, Epidemiology, and End Results (SEER) database (n = 108,417). The primary outcome was metastatic disease at the time of diagnosis. Demographic and socioeconomic variables were analyzed, and multivariable logistic regression models were performed to generate odds ratios (OR) for factors associated with metastasis at diagnosis. RESULTS: Of patients with bladder cancer, 3018 (2.8%) had metastasis at diagnosis and 105,399 (97.2%) had nonmetastatic disease. Patients with metastatic disease at diagnosis were more frequently female (29.6% vs. 23.6%, P < .001), black (9.4% vs. 5.0%, P < .001), and unmarried (44.1% vs. 32.5%, P < .001) compared to patients with nonmetastatic disease. On multivariable analysis, the following characteristics were confirmed to be independently associated with metastatic disease at diagnosis: female gender (vs. male, OR 1.21), black race (vs. white, OR 1.71), unmarried (vs. married, OR 1.46), unemployed (OR 1.02), and foreign-born status (OR 1.01). CONCLUSION: Female gender, black race, unmarried, unemployed, and foreign-born status are independently associated with metastasis at diagnosis for bladder urothelial carcinoma. All clinicians should be aware of these potential health care disparities in order to involve social services and other support mechanisms in efforts to improve early care.