Impact of initial local therapy on survival in men later receiving chemotherapy for prostate cancer: a population-based, propensity-weighted multivariable analysis.

PURPOSE: Prostate cancer remains a common disease that is frequently treated with multimodal therapy. The goal of this study was to assess the impact of treatment of the primary tumor on survival in men who go onto receive chemotherapy for prostate cancer. METHODS: Using surveillance, epidemiology and end results (SEER)-Medicare data from 1992 to 2009, we identified a cohort of 1614 men who received chemotherapy for prostate cancer. Primary outcomes were prostate cancer-specific mortality (PCSM) and all-cause mortality (ACM). We compared survival among men who had previously undergone radical prostatectomy (RP), radiation therapy (RT), or neither of these therapies. Propensity score adjusted Cox proportional hazard models and weighted Kaplan-Meier curves were used to assess survival. RESULTS: Compared to men who received no local treatment, PCSM was lower for men who received RP ± RT (HR 0.65, p < 0.01) and for those who received RT only (HR 0.79, p < 0.05). Patients receiving neither RP nor RT demonstrated higher PCSM and ACM than those receiving treatment in a weighted time-to-event analysis. Men who received RP + RT had longer mean time from diagnosis to initiation of chemotherapy (100.7 ± 47.7 months) than men with no local treatment (48.8 ± 35.0 months, p < 0.05). CONCLUSION: In patients who go on to receive chemotherapy, treatment of the primary tumor for prostate cancer appears to confer a survival advantage over those who do not receive primary treatment. These data suggest continued importance for local treatment of prostate cancer, even in patients at high risk of failing local therapy.

Risk of end stage kidney disease after radical cystectomy according to urinary diversion type.

PURPOSE: The risk of renal insufficiency has historically been viewed as a long-term consequence of urinary diversion after radical cystectomy. However, there are little data on the long-term rate of end stage kidney disease after urinary diversion and few studies have compared end stage kidney disease rates by diversion type. In a large, population based cohort we evaluated the risk of end stage kidney disease in patients who received an ileal conduit vs continent urinary diversion after cystectomy for bladder cancer. MATERIALS AND METHODS: Using the SEER-Medicare 1992 to 2010 data set we identified 4,015 patients treated with radical cystectomy for bladder cancer, excluding those with preexisting renal disease or clinically significant preoperative hydronephrosis. The outcome of interest was end stage kidney disease stratified by diversion type. We used a Cox proportional hazard model for multivariate analysis controlling for demographic, tumor and comorbidity characteristics. RESULTS: End stage kidney disease developed in 7.2% of patients, including 84% with an ileal conduit and 16% with continent urinary diversion. Median followup was 34 months (IQR 12-73). On multivariate analysis no increased risk of end stage kidney disease was associated with continent diversion (HR 1.06, 95% CI 0.78-1.44, p = 0.71). Overall the estimated risk at 5, 10 and 15 years was 8.3% (95% CI 7.1-9.5), 16.9% (95% 14.6-19.2) and 24.4% (95% CI 20.3-28.5), respectively. CONCLUSIONS: No significant difference in the rate of end stage kidney disease was identified when comparing ileal conduits to continent urinary diversion. A significant risk of end stage kidney disease in the long term was identified in patients with post-cystectomy survival beyond 5 years.

Hepatocellular carcinoma masquerading as a large renal mass with hepatic invasion.

Large masses are evaluated with imaging to assess primary origin and tumor spread. We present the unusual case of a 53-year-old male with a 17-cm right upper quadrant mass suspected to be renal or adrenal in origin based on radiographic findings. After surgical excision, the mass was subsequently discovered to be primary hepatocellular carcinoma with direct extension to the kidney and adrenal gland. A diagnosis of chronic hepatitis B was made postoperatively. Primary hepatocellular carcinoma with direct renal extension is an exceedingly rare occurrence based on our experience and review of the published literature.

Renal Ischemia and Functional Outcomes Following Partial Nephrectomy.

Renal function after renal cancer surgery is a critical component of survivorship. Quantity and quality of preserved parenchyma are the most important determinants of functional recovery; type and duration of ischemia play secondary roles. Several studies evaluated surgical techniques to minimize ischemia; however, long-term outcomes and potential benefits over clamped partial nephrectomy (PN) have not been consistently demonstrated. Analysis of acute kidney injury (AKI) after PN suggest that most kidneys recover strongly even if AKI is experienced after surgery. Ongoing study is required to evaluate long-term implications of AKI after PN and further assess impact of ischemia on functional outcomes.

Use of the Modification of Diet in Renal Disease Equation for Estimating Glomerular Filtration Rate in the Urologic Literature.

PURPOSE: To evaluate the use of the modification of diet in renal disease (MDRD) equation in the urologic literature and the degree to which it is used appropriately. METHODS: Medline was queried searching the title, keywords, or abstract of seven urology journals for the exact phrases "MDRD" or "modification of diet in renal disease." Forty-seven articles published between 2004 and 2013 met the inclusion criteria and were reviewed. Each article was reviewed in its entirety and graded on the appropriateness of its use of MDRD to estimate glomerular filtration rate (GFR). Inappropriate use was defined as using the MDRD equation to make comparisons or conclusions about true renal function with the majority of estimated glomerular filtration rate (eGFR) values >60 mL/min per 1.73 m(2). RESULTS: Of the 47 articles reviewed, 17 (36%) were Grade 1 (appropriate use of MDRD), 20 (43%) were Grade 2 (inappropriate use of MDRD but not critical to claims of article), and 10 (21%) were Grade 3 (inappropriate use of MDRD). Of the Grade 3 articles, only 40% (4 of 10) acknowledged the limitations of this equation for estimating GFR. CONCLUSIONS: The majority of articles using the MDRD equation to estimate GFR did so using values where the estimate is quite unstable (eGFR >60 mL/min per 1.73 m(2)), thereby limiting the validity of the claims. Urologists should reconsider the use of MDRD for comparing estimates of GFR in patients with normal renal function in published articles.

Effect of perioperative blood transfusion on mortality for major urologic malignancies.

INTRODUCTION: Patients who undergo surgical treatment for malignancy often receive perioperative blood transfusion (PBT). We examined the association between PBT and mortality in patients who received surgical treatment of prostate, bladder, and kidney cancer. MATERIALS AND METHODS: Using the Surveillance, Epidemiology, and End Results-Medicare data set from 1992-2009, we identified 28,854 men with prostate cancer, 5462 patients with bladder cancer, and 14,379 patients with renal cell carcinoma who underwent radical prostatectomy (RP), radical cystectomy (RC), or radical (RN) or partial nephrectomy (PN) as primary therapy. Univariate and multivariate models were used to evaluate the association of PBT with cancer-specific mortality (CSM) and all-cause mortality (ACM). RESULTS: The rate of PBT in bladder and kidney cancer have been increasing over time, and PBT in prostate cancer steadily increased and peaked in 2002 and declined afterward. The median follow-up for the RP, RC, and RN/PN cohorts were 70 months, 21 months, and 39 months, respectively. In the RP cohort, PBT was associated with greater CSM (hazard ratio [HR], 1.609; 95% confidence interval [CI], 1.235-2.097; P = .0004) and ACM (HR, 1.121; 95% CI, 1.006-1.251; P = .0394). In the RC cohort, PBT was not associated with greater CSM (HR, 1.047; 95% CI, 0.917-1.195; P = .4962) or ACM (HR, 1.095; 95% CI, 0.998-1.200; P = .0547). In the nephrectomy cohort, PBT was associated with greater CSM (HR, 1.365; 95% CI, 1.167-1.597; P = .0001) and ACM (HR, 1.402; 1.273-1.544; P < .0001). CONCLUSION: PBT was associated with increased CSM and ACM for prostate and kidney cancer in a multivariate model. Although these data do not identify a causative relationship between PBT and mortality, efforts made to limit PBT in patients who undergo urologic cancer surgery can yield long-term survival benefits.