Prostate cancer severity among low income, uninsured men.

PURPOSE: The proportion of American men with organ confined, low risk prostate cancer has increased significantly during the last 2 decades. Whether this trend also applies to men at the extremes of socioeconomic disadvantage remains unknown. Therefore, we evaluated trends in prostate cancer severity in an ethnically diverse cohort of low income, uninsured men served by a state funded public health program in California. MATERIALS AND METHODS: We performed a retrospective cohort study of 570 disadvantaged men enrolled in the California program from 2001 through 2006. Using routinely collected clinical variables we defined 2 measures of cancer severity as 1) the proportion of enrollees with metastases at diagnosis and 2) the proportions of men with nonmetastatic tumors whose cancers had low, intermediate or high risk features at diagnosis. We performed bivariate analyses to assess time trends in cancer severity. RESULTS: Prostate specific antigen levels at diagnosis exceeded 10 ng/ml for 51% of enrollees, 50% had a Gleason score 7 or greater and 43% had clinical T stage T2 or greater. Of disadvantaged men 19% had metastatic cancer at diagnosis and this proportion remained stable over time (p = 0.66). Among men with nonmetastatic cancers 24% had tumors with low risk features and the proportion of low risk cancers did not increase over time (p = 0.34). CONCLUSIONS: Unlike the broader United States population the proportion of disadvantaged men with organ confined, low risk prostate cancer has not been increasing. Thus, while much attention focuses on potential overdiagnosis and overtreatment of men with screen detected prostate cancer, our findings suggest that for low income, uninsured men, underdetection and undertreatment remain significant concerns.

Robot-assisted Laparoscopic Retroperitoneal Lymph Node Dissection for Testicular Cancer: Evolution of the Technique.

BACKGROUND: Retroperitoneal lymph node dissection (RPLND) is an accepted staging and treatment option for nonseminomatous germ cell tumor. Robotic surgery offers technical advantages and is being increasingly used in urologic procedures. OBJECTIVE: To determine the feasibility and safety of robotic surgery for RPLND. DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of robotic (R)-RPLND performed by a single surgeon from April 2008 to October 2014 using two approaches was performed. In total, 20 procedures in 19 patients were evaluated. Eleven men had clinical stage (CS) I disease, six had CS II, one of whom had prior chemotherapy, and two had CS III disease and had also undergone previous chemotherapy. SURGICAL PROCEDURE: A lateral robotic approach was initially used; however, a supine robotic approach was developed to allow for bilateral dissection in one setting without repositioning. Template dissection with nerve sparing was performed for CS I patients and full bilateral dissection for patients with CS II or higher disease and for those who had active disease according to intraoperative frozen section results. OUTCOME MEASUREMENTS: Mean operative time, estimated blood loss, hospital stay, and lymph node count were retrospectively reviewed, as was the presence of recurrence or the need for adjuvant therapy over median follow-up of 49 mo (interquartile range [IQR] 37.4-70.5). Intraoperative and postoperative complications were also reviewed. RESULTS AND LIMITATIONS: R-RPLND was performed successfully in 20 procedures in 19 patients; 11 were performed from a lateral approach and nine from a supine approach. The median operating time (available for 19 of 20 cases) was 293min (IQR 257.5-317). Median estimated blood loss and length of stay were 50ml (IQR 50-100) and 1 d (IQR 1-2), respectively. Some 70% (14/20) of patients were discharged after one night. The median lymph node yield was 19.5 (IQR 13.8-27. 3). Eleven patients had pathologic stage I disease, and eight had residual disease on pathology. There was one ureteral transection that was repaired robotically at the time of surgery with no long-term sequelae. There were no open conversions or transfusions. Two patients had ejaculatory dysfunction following bilateral RPLND. There has been no evidence of retroperitoneal disease recurrence during the follow-up period. Limitations include the retrospective nature of the study and the single surgeon experience. CONCLUSIONS: R-RPLND can be successfully performed and provides improved visualization and dexterity over conventional laparoscopy. Patients experience significantly reduced morbidity and the nodal yield is comparable to open surgical techniques. PATIENT SUMMARY: We studied our experience with robot-assisted removal of lymph nodes from the abdomen among men with testicular cancer. This method was found to be safe and effective with a very short hospital stay.

Effect of a low-fat fish oil diet on proinflammatory eicosanoids and cell-cycle progression score in men undergoing radical prostatectomy.

We previously reported that a 4- to 6-week low-fat fish oil (LFFO) diet did not affect serum insulin-like growth factor (IGF)-1 levels (primary outcome) but resulted in lower omega-6 to omega-3 fatty acid ratios in prostate tissue and lower prostate cancer proliferation (Ki67) as compared with a Western diet. In this post hoc analysis, the effect of the LFFO intervention on serum pro-inflammatory eicosanoids, leukotriene B4 (LTB4) and 15-S-hydroxyeicosatetraenoic acid [15(S)-HETE], and the cell-cycle progression (CCP) score were investigated. Serum fatty acids and eicosanoids were measured by gas chromatography and ELISA. CCP score was determined by quantitative real-time reverse transcriptase PCR (RT-PCR). Associations between serum eicosanoids, Ki67, and CCP score were evaluated using partial correlation analyses. BLT1 (LTB4 receptor) expression was determined in prostate cancer cell lines and prostatectomy specimens. Serum omega-6 fatty acids and 15(S)-HETE levels were significantly reduced, and serum omega-3 levels were increased in the LFFO group relative to the Western diet group, whereas there was no change in LTB4 levels. The CCP score was significantly lower in the LFFO compared with the Western diet group. The 15(S)-HETE change correlated with tissue Ki67 (R = 0.48; P < 0.01) but not with CCP score. The LTB4 change correlated with the CCP score (r = 0.4; P = 0.02) but not with Ki67. The LTB4 receptor BLT1 was detected in prostate cancer cell lines and human prostate cancer specimens. In conclusion, an LFFO diet resulted in decreased 15(S)-HETE levels and lower CCP score relative to a Western diet. Further studies are warranted to determine whether the LFFO diet antiproliferative effects are mediated through the LTB4/BLT1 and 15(S)-HETE pathways.

Technique and outcomes of robot-assisted retroperitoneoscopic partial nephrectomy: a multicenter study.

BACKGROUND: Robot-assisted retroperitoneoscopic partial nephrectomy (RARPN) may be used for posterior renal masses or with prior abdominal surgery; however, there is relatively less familiarity with RARPN. OBJECTIVE: To demonstrate RARPN technique and outcomes. DESIGN, SETTING, AND PARTICIPANTS: A retrospective multicenter study of 227 consecutive RARPNs was performed at the Swedish Medical Center, the University of Michigan, and the University of California, Los Angeles, from 2006 to 2013. SURGICAL PROCEDURE: RARPN. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We assessed positive margins and cancer recurrence. Stepwise regression was used to examine factors associated with complications, estimated blood loss (EBL), warm ischemia time (WIT), operative time (OT), and length of stay (LOS). RESULTS AND LIMITATIONS: The median age was 60 yr (interquartile range [IQR]: 52-66), and the median body mass index (BMI) was 28.2 kg/m(2) (IQR: 25.6-32.6). Median maximum tumor diameter was 2.3 cm (IQR: 1.7-3.1). Median OT and WIT were 165 min (IQR: 134-200) and 19 min (IQR: 16-24), respectively; median EBL was 75 ml (IQR: 50-150), and median LOS was 2 d (IQR: 1-3). Twenty-eight subjects (12.3%) experienced complications, three (1.3%) had urine leaks, and three (1.3%) had pseudoaneurysms that required reintervention. There was one conversion to radical nephrectomy and three transfusions. Overall, 143 clear cell carcinomas (62.6%) composed most of the histology with eight positive margins (3.5%) and two recurrences (0.9%) with a median follow-up of 2.7 yr. In adjusted analyses, intersurgeon variation was associated with complications (odds ratio [OR]: 3.66; 95% confidence interval, 1.31-10.27; p = 0.014) and WIT (parameter estimate [PE; plus or minus standard error]: 4.84 ± 2.14; p = 0.025). Higher surgeon volume was associated with shorter WIT (PE: -0.06 ± 0.02; p = 0.002). Higher BMI was associated with longer OT (PE: 2.09 ± 0.56; p < 0.001). Longer OT was associated with longer LOS (PE: 0.01 ± 0.01; p = 0.002). Finally, there was a trend for intersurgeon variation in OT (PE: 18.5 ± 10.3; p = 0.075). CONCLUSIONS: RARPN has acceptable morbidity and oncologic outcomes, despite intersurgeon variation in WIT and complications. Greater experience is associated with shorter WIT. PATIENT SUMMARY: Robot-assisted retroperitoneoscopic partial nephrectomy has acceptable morbidity and oncologic outcomes, and there is intersurgeon variation in warm ischemia time and complications.

Racial disparities in access to care for men in a public assistance program for prostate cancer.

California's IMPACT program provides all its enrollees with health insurance and social service resources. We hypothesized that racial/ethnic disparities in access to care might be attenuated among men served by this program. Our objective was to evaluate racial/ethnic differences in health services utilization and patient-reported health care outcomes among disadvantaged men in a prostate cancer public-assistance program, and to identify modifiable factors that might explain persistent disparities in this health care setting. We performed a retrospective cohort study of 357 low-income men enrolled in IMPACT from 2001 through 2005. We evaluated realized access to care with two health services utilization measures: (1) use of emergency department care without hospitalization and, (2) frequency of prostate-specific antigen testing. We also measured two patient-experience outcomes: (1) satisfaction with care received from IMPACT, and (2) confidence in IMPACT care providers. We observed significant bivariate associations between race/ethnicity and patient-experience outcomes (P<0.05), but not utilization measures. In multivariable models, Hispanic men were more likely than white men to report complete satisfaction with health care received in IMPACT (adjusted OR=5.15, 95% CI 1.17-22.6); however, the association between race/ethnicity and satisfaction was not statistically significant (P=0.11). Language preference and self-efficacy in patient-physician interactions are potentially-modifiable predictors of patient-experience outcomes. We observed no racial/ethnic disparities in health services utilization among disadvantaged men served by a disease-specific public assistance program. The greater satisfaction and confidence among Hispanic men are explained by modifiable variables that suggest avenues for improvement.

Use of haemostatic agents and glues during laparoscopic partial nephrectomy: a multi-institutional survey from the United States and Europe of 1347 cases.

OBJECTIVES: Laparoscopic partial nephrectomy (LPN) is a technically challenging procedure for the management of renal tumours. Major complications of LPN include bleeding and urine leakage. Haemostatic agents (HAs) and/or glues may reduce haemorrhage and urine leakage. We sought to examine the current practice patterns for urologists performing LPN with regard to HA use and its relationship with bleeding and urine leakage. MATERIALS AND METHODS: A survey was sent via e-mail to urologists currently performing LPN in centres in the United States and Europe. We queried the indications for HA/glue usage, type of HAs/glues used, and whether concomitant suturing/bolstering was performed. In addition, the total number of LPNs performed, laparoscopic tools used to resect the tumour, tumour size, and tumour position were queried. RESULTS: Surveys suitable for analysis were received from 18 centres (n=1347 cases). HAs and/or glues were used in 1042 (77.4%) cases. Mean tumour size was 2.8cm, with 79% of the tumours being defined as exophytic and 21% deep. The HAs and glues used included gelatin matrix thrombin (FloSeal), fibrin gel (Tisseel), bovine serum albumin (BioGlue), cyanoacrylate glue (Glubran), oxidized regenerated cellulose (Surgicel), or combinations of these. Sixteen centres performed concomitant suturing/bolstering. The overall postoperative bleeding requiring transfusion and urine leakage rates were 2.7% and 1.9%, respectively. CONCLUSIONS: The use of HAs and/or glues is routine in most centres performing LPN. The overall haemorrhage and urine leakage rates are low following LPN. More studies are needed to assess the potential role of HAs and/or glues in LPN.

Characterization of the human glycerol kinase promoter: identification of a functional HNF-4alpha binding site and evidence for transcriptional activation.

Glycerol kinase (GK) is an enzyme at the interface of carbohydrate and fat metabolism. Mutations in the GK gene result in a rare inborn error of metabolism, GK deficiency (GKD), and at least one of these mutations (N288D) is associated with insulin resistance and diabetes mellitus. In an attempt to identify potential modifiers of the GKD phenotype, and to elucidate better the relationship between GKD and diabetes mellitus, we investigated the GK promoter. We examined the GK promoter using in silico methods, transient transfections of GK promoter-luciferase constructs in HepG2 hepatocellular carcinoma cells, and gel shift assays using liver nuclear extracts. We determined that the first 100 bp of the GK 5(') upstream region was sufficient for basal levels of transcription and that there was a functional HNF-4alpha binding site in the first 500 bp of the 5(') upstream region that was important for increased levels of GK expression in vitro. The involvement of both GK and HNF-4alpha in the etiology of diabetes mellitus is intriguing, and we speculate that HNF-4alpha represents a potential modifier of the GKD phenotype.