The Natural History and Composition of Urinary Catheter Biofilms: Early Uropathogen Colonization with Intraluminal and Distal Predominance.

PURPOSE: We sought to determine the composition and initiation site of bacterial biofilm on indwelling urinary catheters and to track biofilm progression with time. MATERIALS AND METHODS: Indwelling urinary catheters were collected from 2 tertiary care centers following removal from patients. Indwelling time was noted and catheters were de-identified. Catheters were sectioned, stained for biofilms and analyzed by spectrophotometry and visualization. Biofilm colonization patterns were analyzed using descriptive statistical analysis and bacterial composition was determined using next generation sequencing. RESULTS: We collected and analyzed a total of 33 catheters from 26 males and 7 females with indwelling time ranging from 15 minutes to 43 days. Biofilm colonization was consistently high on the region of the balloon for all indwelling times. After week 1 the distal third of the catheter had higher biofilm colonization than the proximal third (week 2 p=0.034). At all indwelling times the intraluminal surface of the catheter had greater biofilm colonization than the outer surface. Next generation sequencing detected potential uropathogenic bacteria in all 10 analyzed samples. CONCLUSIONS: The catheter balloon, its distal aspect and its lumen were the predominant locations of biofilm comprising uropathogenic bacteria. Strategies to prevent or treat biofilm should be targeted to these areas.

PSA kinetics following primary focal cryotherapy (hemiablation) in organ-confined prostate cancer patients.

PURPOSE: We aim to evaluate prostate-specific antigen (PSA) trends in post-primary focal cryotherapy (PFC) patients. MATERIALS AND METHODS: This was an institutional review board-approved retrospective study of PFC patients from 2010 to 2015. Patients with at least one post-PFC PSA were included in the study. Biochemical recurrence (BCR) was determined using the Phoenix criteria. PSA bounce was also assessed. We analyzed rates of change of PSA over time of post-PFC between BCR and no BCR groups. PSA-derived variables were analyzed as potential predictors of BCR. RESULTS: A total of 104 PFC patients were included in our analysis. Median (range) age and follow-up time were 66 (48-82) years and 19 (6.3-38.6) months, respectively. Four (3.8%) patients experienced PSA bounce. The median percent drop in first post-PFC PSA of 80.0% was not associated with BCR (p = 0.256) and may indicate elimination of the index lesion. The rate of increase of PSA in BCR patients was significantly higher compared to patients who did not recur (median PSA velocity (PSAV): 0.15 vs 0.04 ng/ml/month, p = 0.001). Similar to PSAV (HR 9.570, 95% CI 3.725-24.592, p < 0.0001), PSA nadir ≥ 2 ng/ml [HR (hazard ratio) 1.251, 95% CI 1.100-1.422, p = 0.001] was independently associated with BCR. CONCLUSION: A significant drop in post-PFC PSA may indicate elimination of the index lesion. Patients who are likely to recur biochemically have a significantly higher PSAV compared to those who do not recur. Nadir PSA of less than 2 ng/ml may be considered the new normal PSA in focal cryotherapy (hemiablation) follow-up.

Salvage focal cryosurgery may delay use of androgen deprivation therapy in cryotherapy and radiation recurrent prostate cancer patients.

INTRODUCTION: Salvage treatment options for recurrent unilateral prostate cancer (PCa) after primary radiation are limited and associated with severe complications and poor quality of life measures. Salvage focal cryotherapy (SFC) has shown success in biochemical recurrence (BCR) free survival. We aim to determine if SFC can delay use of androgen deprivation therapy (ADT) in recurrent PCa with low morbidity. METHODS: A retrospective review of patients who underwent SFC at our institution from 2007 to 2015 was performed. Patients with <2 follow-up prostate-specific antigen (PSA) values, metastatic disease, and a history of radical prostatectomy were excluded. Age at treatment, prior treatment history, PSA nadir, complications, BCR status (nadir +2 ng/ml), and follow-up data were obtained/analysed. ADT was commenced if patient experienced BCR and had a PSA doubling time <6 months or positive confirmatory biopsy or positive imaging. Cox regression and survival analysis were used to assess confounding and time to BCR respectively. RESULTS: A total of 65 patients were included and followed for a median of 26.6 (8.0-99.0) months. Thirty-one (47.7%) patients did not experience BCR. An even higher number of patients (52/65, 80.0%) are yet to receive ADT. Of those who experienced BCR [median time to BCR, 17.1 [interquartile range (IQR):11.4-23.3] months], 22/34 (64.7%) are currently carefully monitored without ADT. Survival analysis showed a biochemical recurrence-free survival of 48.1 at 1- and 3-year follow up. No patient died/experienced major complications. CONCLUSIONS: SFC may be used to delay the use of ADT. Further assessment of our findings with high-powered studies and longer follow-up is required.

Temporal trends and factors associated with systemic therapy after cytoreductive nephrectomy: an analysis of the National Cancer Database.

PURPOSE: We evaluated temporal trends in systemic therapy use in patients undergoing cytoreductive nephrectomy for metastatic renal cell carcinoma. We used data from a large national cancer registry and assessed characteristics associated with the receipt of systemic treatment. MATERIALS AND METHODS: We reviewed the NCDB to identify patients with stage IV renal cell carcinoma who underwent cytoreductive nephrectomy between 1998 and 2010. Systemic therapy was defined as immunotherapy and/or chemotherapy, including targeted agents. We evaluated associations between clinicopathological features and receipt of systemic therapy using multivariable logistic regression with generalized estimating equations. RESULTS: Of 22,409 patients with metastatic renal cell carcinoma treated with cytoreductive nephrectomy 8,830 (39%) received systemic therapy. Use of systemic therapy increased from 32% of cases in 1998 to 49% in 2010 (p < 0.001). After adjustment older patient age (71 years or greater OR 0.36, CI 0.31-0.43), increasing comorbidity count (Charlson comorbidity index 2 or greater OR 0.79, 95% CI 0.68-0.92), papillary histology (OR 0.81, 95% CI 0.71-0.93), sarcomatoid histology (OR 0.88, 95% CI 0.80-0.98), Medicaid (OR 0.61, 95% CI 0.5-0.74), Medicare (OR 0.70, 95% CI 0.62-0.79) and no insurance (OR 0.75, 95% CI 0.63-0.91) were associated with significantly decreased systemic therapy use. Male gender (OR 1.05, 95% CI 1.02-1.08) predicted an increased likelihood of systemic therapy. CONCLUSIONS: Systemic therapy in patients undergoing cytoreductive nephrectomy has increased with time, coinciding with the introduction of targeted therapies. Nevertheless, still less than half of such patients receive systemic treatment. While the etiology of the lack of treatment is likely multifactorial, the potential health policy implications of disparities in care warrant further investigation.

Coupling of prostate and thyroid cancer diagnoses in the United States.

BACKGROUND: Prostate and thyroid cancers represent two of the most overdiagnosed tumors in the US. Hypothesizing that patients diagnosed with one of these malignancies were more likely to be diagnosed with the other, we examined the coupling of diagnoses of prostate and thyroid cancer in a large US administrative dataset. METHODS: The surveillance, epidemiology, and end results (SEER) database was used to identify men diagnosed with clinically localized prostate cancer (CaP) or thyroid cancer between 1995 and 2010. SEER*stat software was used to estimate multivariable-adjusted standardized incidence ratios (SIRs) and investigate the rates of subsequent malignancy diagnosis. Additional non-urologic cancer sites were added as control groups. RESULTS: Patients with thyroid cancer were much more likely to be diagnosed with CaP than patients in the SEER control group (SIR 1.28 [95% CI 1.1-1.5]; p < 0.05). Similarly, the observed incidence of thyroid cancer was significantly higher in patients with CaP when compared with SEER controls (SIR 1.30 [95% CI 1.2-1.4]; p < 0.05). When stratified by follow-up interval, the observed thyroid cancer diagnosis rate among men with CaP was significantly higher than expected at 2-11 (SIR 1.83 [95% CI 1.4-2.4]), 12-59 (SIR 1.24 [95% CI 1.0-1.5]), and 60-119 (SIR 1.25 [95% CI 1.0-1.5]) months of follow-up. There was no increased risk of CaP or thyroid cancer diagnosis among patients with non-urologic malignancies. CONCLUSIONS: There is a significant association of diagnoses with prostate and thyroid cancer in the US. In the absence of a known biological link between these tumors, these data suggest that diagnosis patterns for prostate and thyroid malignancies are linked.

Variation in performance of candidate surgical quality measures for muscle-invasive bladder cancer by hospital type.

OBJECTIVE: To test the association between hospital type and performance of candidate quality measures for treatment of muscle-invasive bladder cancer (MIBC) using a large national tumour registry. Proposed quality measures include receipt of neoadjuvant chemotherapy, timely treatment, adequate lymph node dissection, and continent urinary diversion. PATIENTS AND METHODS: Using the National Cancer Database, patients with stage ≥II urothelial carcinoma treated with radical cystectomy (RC) from 2003 to 2010 were identified. Hospitals were grouped by type and annual RC volume: community, comprehensive low volume (CLV), comprehensive high volume (CHV), academic low volume (ALV), and academic high volume (AHV) groups. Logistic regression models were used to test the association between hospital group and performance of quality measures, adjusting for year, demographic, and clinical/pathological characteristics; generalised estimating equations were fitted to the models to adjust for clustering at the hospital level. RESULTS: In all, 23 279 patients underwent RC at community (12.4%), comprehensive (CLV 38%, CHV 5%), and academic (ALV 17%, AHV 28%) hospitals. While only 0.8% (175) of patients met all four quality criteria, 61% of patients treated at AHV hospitals met two or more quality metric indicators compared with ALV (45%), CHV (44%), CLV (38%), and community (37%) hospitals (P < 0.001). After adjustment, patients were more likely to receive two or more quality measures when treated at AHV (odds ratio [OR] 2.4, confidence interval [CI] 2.0-2.9), ALV (OR 1.3, CI 1.1-1.6), and CHV (OR 1.3, CI 1.03-1.7) hospitals compared with community hospitals. CONCLUSIONS: Patients undergoing RC at AHV hospitals were more likely to meet quality criteria. However, performance remains low across hospital types, highlighting the opportunity to improve quality of care for MIBC.

Hypoalbuminaemia is associated with mortality in patients undergoing cytoreductive nephrectomy.

OBJECTIVE: To evaluate whether poor nutrition is associated with mortality in patients undergoing cytoreductive nephrectomy (CN) for metastatic renal cell carcinoma (mRCC). PATIENTS AND METHODS: A multi-institutional review of prospective databases identified 246 patients meeting inclusion criteria who underwent CN for mRCC from 1993 to 2012. Nutritional markers evaluated were: body mass index <18.5 kg/m(2) , serum albumin <3.5 g/dL, or preoperative weight loss of ≥5% of body weight. Primary outcomes were overall (OS) and disease-specific survival (DSS). Secondary outcome was 'early mortality' defined as death at ≤6 months of surgery. Survival curves were estimated using the Kaplan-Meier product-limit method and multivariate analysis using logistic regression was used to test associations between nutritional markers and survival outcomes. RESULTS: In all, 119 patients (median follow-up 17 months) were categorised as having any abnormal nutrition parameter (48%). Hypoalbuminaemia was the only independent predictor of OS and DSS (OS: median 8 vs 23 months, P < 0.001; DSS: 11 vs 33 months, P < 0.001). On multivariate analysis, hypoalbuminaemia remained a significant predictor of death for both overall [hazard ratio (HR) 2, 95% confidence interval (CI) 1.4-2.8; P < 0.001) and disease-specific mortality (HR 2.2, 95% CI 1.4-3.3; P < 0.001). Hypoalbuminaemia was also associated with early mortality (overall: P < 0.001 and disease specific: P = 0.002). CONCLUSION: Patients with mRCC and hypoalbuminaemia undergoing CN have decreased OS and CSS, and increased risk of all-cause and disease-specific early mortality. As such, serum albumin may help risk stratify patients selected as candidates for CN. Furthermore, future work should evaluate whether nutritional depletion is a modifiable risk factor.

Care transitions between hospitals are associated with treatment delay for patients with muscle invasive bladder cancer.

PURPOSE: Hypothesizing that changing hospitals between diagnosis and definitive therapy (care transition) may delay timely treatment, we identified the association between care transitions and a treatment delay of 3 months or greater in patients with muscle invasive bladder cancer. MATERIALS AND METHODS: Using the National Cancer Database we identified all patients with stage II or greater urothelial carcinoma treated from 2003 to 2010. Care transition was defined as a change in hospital from diagnosis to definitive treatment course, that is diagnosis to radical cystectomy or the start of neoadjuvant chemotherapy. Logistic regression models were used to test the association between care transition and treatment delay. RESULTS: Of 22,251 patients 14.2% experienced a treatment delay of 3 months or greater and this proportion increased with time (13.5% in 2003 to 2006 vs 14.8% in 2007 to 2010, p = 0.01). Of patients who underwent a care transition 19.4% experienced a delay to definitive treatment compared to 10.7% diagnosed and treated at the same hospital (p <0.001). The proportion of patients with a care transition increased during the study period (37.4% in 2003 to 2006 vs 42.3% in 2007 to 2010, p <0.001). After adjustment patients were more likely to experience a treatment delay when undergoing a care transition (OR 2.0, 95% CI 1.8-2.2). CONCLUSIONS: Patients with muscle invasive bladder cancer who underwent a care transition were more likely to experience a treatment delay of 3 months or greater. Strategies to expedite care transitions at the time of hospital referral may improve quality of care.

Nephron-sparing management vs radical nephroureterectomy for low- or moderate-grade, low-stage upper tract urothelial carcinoma.

OBJECTIVE: To compare overall and cancer-specific outcomes between patients with upper tract urothelial carcinoma (UTUC) managed with either radical nephroureterectomy (RNU) or nephron-sparing measures (NSM) using a large population-based dataset. PATIENTS AND METHODS: Using Surveillance, Epidemiology, and End Results (SEER) data, patients diagnosed with low- or moderate-grade, localised non-invasive UTUC were stratified into two groups: those treated with RNU or NSM (observation, endoscopic ablation, or segmental ureterectomy). Cancer-specific mortality (CSM) and other-cause mortality (OCM) rates were determined using cumulative incidence estimators. Adjusting for clinical and pathological characteristics, the associations between surgical type, all-cause mortality and CSM were tested using Cox regressions and Fine and Gray regressions, respectively. RESULTS: Of 1227 patients [mean (sd) age 70.2 (11.00) years, 63.2% male] meeting inclusion criteria, 907 (73.9%) and 320 (26.1%) patients underwent RNU and NSM for low- or moderate-grade, low-stage UTUC from 1992 to 2008. Patients undergoing NSM were older (mean age 71.6 vs 69.7 years, P < 0.01) with a greater proportion of well-differentiated tumours (26.3% vs 18.0%, P = 0.001). While there were differences in OCM between the groups (P < 0.01), CSM trends were equivalent. After adjustment, RNU treatment was associated with improved non-cancer cause survival [hazard ratio (HR) 0.78, confidence interval [CI] 0.64-0.94) while no association with CSM was demonstrable (HR 0.89, CI 0.63-1.26). CONCLUSIONS: Patients with low- or moderate-grade, low-stage UTUC managed through NSM are older and are more likely to die of other causes, but they have similar CSM rates to those patients managed with RNU. These data may be useful when counselling patients with UTUC with significant competing comorbidities.

Comparison of prostate cancer diagnosis in patients receiving unrelated urological and non-urological cancer care.

OBJECTIVE: To evaluate prostate cancer diagnosis rates and survival outcomes in patients receiving unrelated (non-prostate) urological care with those in patients receiving non-urological care. MATERIALS AND METHODS: We conducted a population-based study using the Surveillance Epidemiology and End Results (SEER) database to identify men who underwent surgical treatment of renal cell carcinoma (RCC; n = 18,188) and colorectal carcinoma (CRC; n = 45,093) between 1992 and 2008. Using SEER*stat software to estimate standardized incidence ratios (SIRs), we investigated rates of prostate cancer diagnosis in patients with RCC and patients with CRC. Adjusting for patient age, race and year of diagnosis on multivariate analysis, we used Cox and Fine and Gray proportional hazards regressions to evaluate overall and disease-specific survival endpoints. RESULTS: The observed incidence of prostate cancer was higher in both the patients with RCC and those with CRC: SIR = 1.36 (95% confidence interval [CI] 1.27-1.46) vs 1.06 (95% CI 1.02-1.11). Adjusted prostate cancer SIRs were 30% higher (P < 0.001) in patients with RCC. Overall (hazard ratio = 1.13, P < 0.001) and primary cancer-adjusted mortalities (sub-distribution Hazard Ratio (sHR) = 1.17, P < 0.001) were higher in patients with RCC with no significant difference in prostate cancer-specific mortality (sHR = 0.827, P = 0.391). CONCLUSION: Rates of prostate cancer diagnosis were higher in patients with RCC (a cohort with unrelated urological cancer care) than in those with CRC. Despite higher overall mortality in patients with RCC, prostate cancer-specific survival was similar in both groups. Opportunities may exist to better target prostate cancer screening in patients who receive non-prostate-related urological care. Furthermore, urologists should not feel obligated to perform prostate-specific antigen screening for all patients receiving non-prostate-related urological care.

Mapping the cytokine profile of painful bladder syndrome/interstitial cystitis in human bladder and urine specimens.

PURPOSE: This study investigated the cytokine profile in bladder tissue and urine of painful bladder syndrome/interstitial cystitis (PBS/IC) patients. METHODS: Multiplex analysis of 23 cytokines was performed with a multiple antigen bead assay (Luminex 100 IS) on cold cup bladder biopsy and urine specimens collected during cystoscopy with hydrodistention (HD) under general anesthesia from 10 PBS/IC patients (ICS definition). Collected tissue specimens and urine from pre-HD and post-HD (mean 27 days) were compared to banked urine and tissue specimens (n = 10) collected from control subjects without PBS/IC symptoms. RESULTS: Univariate comparison of bladder tissue levels found significant elevation of IL-16, IL-18, CTACK, ICAM-1, MCP-3, SCGFß, TRAIL, and VCAM-1 in PBS/IC relative to controls. Multivariate analysis revealed VCAM-1 and ICAM-1 were responsible for the discrimination of both tissue and urine of PBS/IC from controls. Urine levels of MCP-3 and TRAIL were significantly reduced a month after HD in concert with improvement in standardized measures of clinical symptoms (pain, urgency, and frequency (PUF) overall score [mean 25.8 ± 5.5 vs. 20.3 ± 7, p = 0.04] and symptom score [mean 18.2 ± 3.2 vs. 12.2 ± 5.9; p = 0.009]). Post-HD urine levels of MCSF(r = 0.88; p = 0.003), MCP-3 (r = 0.81; p = 0.01), SDF1α (r = 0.82; p = 0.01), and IL-18 (r = 0.64; p = 0.08) positively correlated with improved symptom scores. CONCLUSIONS: These results indicate significant elevation of cytokines in PBS/IC bladder tissue relative to controls. Significant reduction in post-HD urine levels of MCP-3 and TRAIL relative to pre-HD in PBS/IC was associated with clinical improvement (as measured by PBS/IC symptom scores) to qualify them as biomarker candidates.

Contemporary techniques and outcomes of robotic assisted radical cystectomy with intracorporeal urinary diversion.

The open approach to radical cystectomy continues to be accompanied by significant morbidity despite enhanced recovery protocols (ERP). Robotic assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) has become an increasingly popular technique for removal of aggressive bladder cancer and subsequent urinary diversion. Randomized clinical trials comparing the robotic and open techniques address the uncertainty surrounding oncological efficacy of the RARC and show that RARC is at least comparable to open radical cystectomy (ORC) in terms of oncologic adequacy and survival. Although RARC with ICUD is a technically challenging procedure, surgeons have noted ergonomic advantages while patients experience less blood loss and quicker time to recovery and to adjuvant chemotherapy (AC), if necessary. Even with these benefits, there is a paucity of data describing outcomes of ICUD. For those surgeons who have switched to ICUD, priority remains standardization of a protocol for the reconstructive component and for a safe transition from extracorporeal urinary diversion (ECUD) to ICUD. Additionally, there is a need for evidence of reduced financial toxicity for the patient, as well as more comprehensive cost-effectiveness analyses. The literature from this review represents 10 years of accumulating data on techniques and outcomes of RARC with ICUD.

Pathologic measures of quality compare favorably in patients undergoing robot-assisted radical cystectomy to open cystectomy cohorts: a National Cancer Database analysis.

This study aims to assess the impact of facility characteristics on measures of surgical quality (positive surgical margin rates and lymph-node yield) in patients undergoing robot-assisted (RARC) versus open (ORC) radical cystectomy using the National Cancer Database. Patients who received RC between the years of 2010-2013 were stratified according to surgery type (ORC vs. RARC), and corresponding patient and facility-level variables (facility type and volume) were assessed. Logistic regression models for procedure type, positive surgical margins (PSMs), and LN dissection (LND) rates were estimated. Radical cystectomies (ORC = 13,236, RARC = 3687) were performed more often in academic centers (58.3%) compared to community centers (31.6%). As facility volume increased, centers performed more LNDs during ORCs (p = 0.03) and the number of nodes retrieved increased in both ORC and RARC (ORC p < 0.001; RARC p < 0.0001). Increased facility volume also resulted in significantly fewer PSMs within the RARC cohort (p = 0.01). Comparison of ORC and RARC within each facility type cohort identified improved pathological metrics for RARC with fewer PSMs (p = 0.001) as well as increased LNDs (p < 0.0001) and median number of LNs retrieved (p < 0.0001), which suggests that RARC may facilitate comparative outcomes in community centers and academic centers. Overall, higher facility volume and robot-assisted surgery resulted in more favorable pathologic metrics compared to lower facility volume and ORC.

Endourological management of pediatric stone disease: present status.

PURPOSE: The incidence of nephrolithiasis in the pediatric population has been steadily increasing. The miniaturization of endoscopic instruments and improvement in imaging modalities have facilitated safe and effective endourological treatment in this patient population. We reviewed the current status of pediatric stone disease management. MATERIALS AND METHODS: A comprehensive literature review was performed using MEDLINE/PubMed to evaluate the indications, techniques, complications and efficacy of endourological stone management in children. RESULTS: In the 1980s shock wave lithotripsy revolutionized stone management in children, becoming the procedure of choice for treating upper tract calculi less than 1.5 cm. Percutaneous nephrolithotomy has replaced open surgical techniques for the treatment of stone burdens greater than 1.5 cm with efficacy and complication rates mirroring those in the adult population. However, at an increasing number of centers ureteroscopy is now being performed in cases that previously would have been treated with shock wave lithotripsy or percutaneous nephrolithotomy. Results from recent retrospective series demonstrate that stone-free rates and complication rates with ureteroscopy are comparable to percutaneous nephrolithotomy and shock wave lithotripsy. Although concerns remain with all endoscopic techniques in children regarding damage to the urinary tract and renal development, neither short-term nor long-term adverse effects have been consistently reported. CONCLUSIONS: Shock wave lithotripsy, percutaneous nephrolithotomy and ureteroscopy are highly effective endourological techniques to treat stone disease in the pediatric population. A lack of prospective randomized trials comparing treatment modalities coupled with a vast disparity in the access to resources worldwide continues to individualize rather than standardize stone treatment in children.

Estimating postoperative mortality and morbidity risk of radical cystectomy with continent diversion using predictor equations.

PURPOSE: The POSSUM (Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity) and Portsmouth POSSUM predictor equations are scoring systems validated in the general surgery literature that estimate postoperative morbidity and mortality risk. We tested the validity of POSSUM and Portsmouth POSSUM in patients undergoing radical cystectomy with continent diversion. MATERIALS AND METHODS: We retrospectively reviewed physiological parameters, operative parameters, and 30-day morbidity and mortality in 102 patients who underwent radical cystectomy with continent orthotopic diversion, as done by a single surgeon. Predicted morbidity and mortality were calculated using the POSSUM and Portsmouth POSSUM equations. Patients were stratified into risk groups, and observed and predicted outcomes were compared. The accuracy of predictions was assessed using binomial and chi-square analysis. RESULTS: Observed mortality and morbidity rates were 2.9% and 34.3%, respectively. Predicted morbidity using POSSUM analysis was 46 compared to the 35 observed in our series (p = 0.01). Compared to 3 observed deaths predicted mortality using POSSUM and Portsmouth POSSUM analysis was 13 and 5 (p = 0.002 and 0.30, respectively). There was a significant lack of fit for the POSSUM model to predict morbidity and mortality (p <0.05). However, the mortality risk estimated by Portsmouth POSSUM was not significantly different from the observed mortality rate in our cohort. CONCLUSIONS: In our series the POSSUM equation over predicted morbidity and mortality, and was unsuitable for a comparative audit of patients who underwent radical cystectomy with continent diversion. The Portsmouth POSSUM equation allowed satisfactory prediction of mortality in our cohort and should be evaluated further in larger series.

Case report of significant bleeding associated with prostate brachytherapy.

Prostate brachytherapy is a minimally invasive option in treating prostate cancer, usually with little risk of surgical morbidity. This reports a case of significant bleeding associated with the procedure of prostate brachytherapy.

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

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

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

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

When is prior ureteral stent placement necessary to access the upper urinary tract in prepubertal children?

PURPOSE: We studied the possibility that age, height, weight and body mass index could be used to predict the likelihood of successful ureteroscopic access to the upper urinary tract without previous stent placement in prepubertal children. MATERIALS AND METHODS: We retrospectively reviewed all ureteroscopic procedures for upper tract calculi in prepubertal children from 2003 to 2007. We compared age, height, weight and body mass index in patients who underwent successful primary flexible ureteroscopic access and in those who required initial stent placement to perform ureteroscopy. RESULTS: Successful primary ureteroscopic access to the upper tract was achieved in 18 of 30 patients (60%). There was no difference in mean age (9.9 vs 9.5 years, p = 0.8), height (132 vs 128 cm, p = 0.6), weight (37 vs 36 kg, p = 0.86) or body mass index (19.3 vs 20.5 kg/m(2), p = 0.55) between patients with successful vs unsuccessful upper tract access. Locations that prevented access to the upper urinary tract were evenly distributed among the ureteral orifice, iliac vessels and ureteropelvic junction. CONCLUSIONS: Age, height, weight and body mass index could not predict the likelihood of successful ureteroscopic access to the upper tract. Placement of a ureteral stent for passive ureteral dilation is not necessary for successful ureteroscopic access to the renal pelvis in prepubertal children. An initial attempt at ureteroscopy, with placement of a ureteral stent if upper tract access is unsuccessful, decreases the number of procedures while maintaining a low complication rate.