Should obesity be associated with worse urinary continence outcomes after robotic-assisted radical prostatectomy? a propensity score matching analysis.

PURPOSE: To analyze the association between obesity and urinary incontinence rate in men submitted to robot-assisted radical prostatectomy (RARP) in a high-volume cancer center. MATERIALS AND METHODS: We reported 1.077 men who underwent RARP as the primary treatment for localized prostate cancer from 2013 to 2017. Patients were classified as non-obese (normal BMI or overweight) or obese men (BMI ≥30kg/m2). They were grouped according to the age, PSA level, D'Amico risk group, Gleason score, ASA classification, pathological stage, prostate volume, salvage/adjuvant radiotherapy, perioperative complications, and follow-up time. Urinary continence was defined as the use of no pads. For the analysis of long-term urinary continence recovery, we conducted a 1:1 propensity-score matching to control confounders. RESULTS: Among the obese patients, mean BMI was 32.8kg/m2, ranging 30 - 45.7kg/m2. Only 2% was morbidly obese. Obese presented more comorbidities and larger prostates. Median follow-up time was 15 months for the obese. Complications classified as Clavien ≥3 were reported in 5.6% of the obese and in 4.4% of the non-obese men (p=0.423). Median time for continence recovery was 4 months in both groups. In this analysis, HR was 0.989 for urinary continence recovery in obese (95%CI=0.789 - 1.240; p=0.927). CONCLUSIONS: Obese can safely undergo RARP with similar continence outcomes comparing to the non-obese men when performed by surgeons with a standardized operative technique. Future studies should perform a subgroup analysis regarding the association of obesity with other comorbidities, intending to optimize patient counseling.

Prostate Cancer Screening in Brazil: a single center experience in the public health system.

PURPOSE: Incidence and mortality of prostate cancer (PCa) are still increasing in developing countries. Limited access to the health system or more aggressive disease are potential reasons for this. Ethnic and social differences in developed countries seem to make inappropriate to extrapolate data from other centers. We aim to report the epidemiological profile of a PSA-screened population from a cancer center in Brazil. MATERIALS AND METHODS: We retrospectively selected 9.692 men enrolled in a PCa prevention program, comprising total PSA level and digital rectal examination at the first appointment, associated with complementary tests when necessary. Men aged over 40 years-old were included after shared decision-making process. Prostate biopsy (TRUS) was performed when clinically suspected for PCa. After the diagnosis, patients underwent appropriate treatment. RESULTS: TRUS was performed in 5.5% of men and PCa incidence was 2.6%. Overall ratio between number of patients who needed to be screened in order to diagnose one cancer was 38.9 patients, with 2.1 biopsies performed to diagnose a cancer. Positive predictive value (PPV) of TRUS biopsy in this strategy was 47.2%, varying from 38.5% (<50 years-old) to 60% (>80 years-old). We evidenced 70 patients (27.9%) classified as low risk tumors, 74 (29.5%) as intermediate risk, and 107 (42.6%) as high-risk disease. CONCLUSIONS: PSA-screening remains controversial in literature. In front of a huge miscegenated people and considering the big proportion of high-risk PCa, even in young men diagnosed with the disease, it is imperative to inform patients and health providers about these data particularities in Brazil.

Tissue-based molecular markers in upper tract urothelial carcinoma and their prognostic implications.

Upper tract urothelial carcinoma (UTUC) is a rare and aggressive disease that is associated with high rates of recurrence and death. Radical nephroureterectomy (RNU) with excision of the bladder cuff is considered the standard of care for high-risk UTUC, whereas kidney-sparing techniques can be indicated for select patients with low-risk disease. There is a significant lack of clinical and pathological prognostic factors for stratifying patients with regard to making treatment decisions. Incorporation of tissue-based molecular markers into prognostic tools could help accurately stratify patients for clinical decision-making in this heterogeneous disease. Although the number of studies on tissue-based markers in UTUC has risen dramatically in the past several years-many of which are based on single centers and small cohorts, with a low level of evidence-many discrepancies remain between their results. Nevertheless, certain biomarkers are promising tools, necessitating prospective multi-institution studies to validate their function.

Prognostic role of decreased E-cadherin expression in patients with upper tract urothelial carcinoma: a multi-institutional study.

PURPOSE: To assess the role of E-cadherin as prognostic biomarker in upper tract urothelial carcinoma (UTUC) in a large multi-institutional cohort of patients. METHODS: Immunohistochemistry technique was used to evaluate E-cadherin expression in 678 patients with unilateral, sporadic UTUC treated with RNU. E-cadherin expression was considered decreased if 10 % or more cells had decreased expression (<90 %). RESULTS: Decreased E-cadherin expression was observed in 353 patients (52.1 %) and was associated with advanced pathological stage (P < 0.001), higher grade (P < 0.001), lymph node metastasis (P = 0.006), lymphovascular invasion (P < 0.001), concomitant carcinoma in situ (P < 0.001), multifocality (P = 0.004), tumor necrosis (P = 0.020) and sessile architecture (P < 0.001). Within a median follow-up of 30 months (interquartile range 15-57), 171 patients (25.4 %) experienced disease recurrence and 150 (21.9 %) died from UTUC. In univariable analyses, decreased E-cadherin expression was significantly associated with worse recurrence-free survival (P < 0.001) and cancer-specific survival CSS (P = 0.006); however, in multivariable analyses, it was not (P = 0.74 and 0.84, respectively). The lack of independent prognostic value of E-cadherin remained true in all subgroup analyses. CONCLUSION: In UTUC patients treated with RNU, decreased E-cadherin expression is associated with features of biologically and clinically aggressive disease and worse outcome in univariable, but not multivariable, analyses. If E-cadherin's association with factors of advanced disease is confirmed on UTUC biopsy specimens, it could be used to help in the clinical decision-making regarding kidney-sparing approaches and/or neo-adjuvant chemotherapy.

Predictive role of Trimprob associated with multiparametric MRI in the diagnosis of prostate cancer.

OBJECTIVES: To evaluate the predictive value of TRIMprob test to detect prostate cancer (PCa) in patients referred to prostate biopsy (PB). MATERIAL AND METHODS: Patients with PSA <10ng/mL and rectal exam without findings suggestive of prostate cancer were selected for TRIMprob evaluation. Exam was performed by a single operator through transperineal approach. Patients admitted for the study were submitted to TRIMprob and multiparametric magnetic resonance (mpMRI) and posteriorly to PB. RESULTS: In total, 77 patients were included. TRIMprob showed evidences of PCa in 25 (32.5%) and was negative in 52 patients (67.5%). The rate of detection of prostate cancer at biopsy was higher in patients with positive TRIMprob (16/25; 64.0%) than in patients with negative TRIMprob (11/52; 21.1%; p<0.001). Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of TRIMprob were respectively 61.5%, 82.0%, 64.0%, 80.3% and 74.0%. ROC curve showed the following areas under the curve values for TRIMprob, mpMRI and combination of TRIMprob + mpMRI: 0.706; 0.662 and 0.741 respectively. At combined analysis, when both TRIMprob and mpMRI were negative for prostate cancer, accuracy was 96.3% or only 1 in 27 PB was positive (3.7%). CONCLUSIONS: Trimprob had similar predictive value for PCa in patients submitted to PB as mpMRI. Combined TRIMprob and mpMRI showed higher accuracy than when performed singly.

Preoperative predictors of renal function decline after radical nephroureterectomy for upper tract urothelial carcinoma.

OBJECTIVES: To model renal function after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). To identify predictors of renal function decline after surgery, thereby allowing the identification of patients likely to be ineligible for cisplatin-based chemotherapy in the adjuvant setting. PATIENTS AND METHODS: We retrospectively identified 374 patients treated with RNU for UTUC at three centres between 1995 and 2010. Estimated glomerular filtration rate (eGFR) was calculated using Chronic Kidney Disease Epidemiology Collaboration equation before RNU and at early (1-5 months after RNU) and late (>5 months) time points after RNU. Only patients deemed eligible for cisplatin-based chemotherapy before RNU (preoperative glomerular filtration rate [GFR] ≥60 mL/min/1.73 m(2) ) were included. Multivariable analysis identified the preoperative predictors of eGFR after RNU at early postoperative and late postoperative time points. RESULTS: A total of 163 patients had an eligible early post-RNU eGFR measurement and 172 had an eligible late eGFR measurement. The median eGFR declined by 32% and did not show a significant trend toward recovery over time (P = 0.4). On multivariable analysis preoperative eGFR and patient age were significantly associated with early and late postoperative eGFR, while Charlson comorbidity index score was significantly associated with late postoperative eGFR alone. CONCLUSIONS: In patients with normal preoperative eGFR (≥60 mL/min/1.73 m(2) ), renal function decreases by one-third after RNU and does not show evidence of recovery over time. Elderly patients and those with pre-RNU eGFR closer to 60 mL/min/1.73 m(2) (lower eGFR in the present cohort) are more likely to be ineligible for adjuvant cisplatin-based chemotherapy regimens because of renal function loss after RNU.

The impact of immunohistochemical expression of nitric oxide synthases on clinical and pathological features of renal cell carcinoma.

PURPOSE: To evaluate the immunohistochemical expression of nitric oxide synthase (NOS) types 1, 2, and 3 in intratumoral and non-neoplastic samples of renal cell carcinoma (RCC) and correlate it with the clinical and pathological features of this malignancy. METHODS: We analyzed 110 patients with RCC underwent radical nephrectomy (RN) or partial nephrectomy (PN) by streptavidin-biotin peroxidase method, tissue microarray, and digital microscopy. As endpoints, NOS expression was correlated with pathological features, overall survival (OS), and cancer-specific survival (CSS). RESULTS: Non-neoplastic samples had higher NOS3 and lower NOS 2 levels than RCC tissues. Greater expression of all NOS isoforms was associated with larger tumors. High NOS1 expression correlated with microscopic venous invasion (MVI) (p = 0.046) and lymph node metastases (p = 0.007). High NOS2 expression was linked to MVI, more RN performed, and male gender (p = 0.035, p = 0.003, and p = 0.027, respectively). High NOS3 expression correlated with lymph node metastases (p = 0.039), microlymphatic invasion (p = 0.029), invasion of the renal pelvis and ureter (p = 0.004), RN (p = 0.003), and shorter OS (58.1 vs. 79.4 % respectively, p = 0.033) by univariate analysis. DFS was not influenced by any NOS isoform. By multivariate analysis, the risk factors for death were TNM stages III and IV (hazard ratio [HR] = 4.5), high Fuhrman's grade (HR = 2.9), Karnofsky performance status ≤80 (HR = 2.5), progression (HR = 5.5), and recurrence (HR = 6.3). Stage III disease was an independent risk factor for recurrence (HR = 9.5). CONCLUSIONS: High NOS expression in RCC is associated with a poor prognosis and larger tumors. NOS3 influences OS by univariate analysis.

Renal function and oncologic outcomes of parenchymal sparing ureteral resection versus radical nephroureterectomy for upper tract urothelial carcinoma.

PURPOSE: We compared renal function and oncologic outcomes of parenchymal sparing ureteral resection with radical nephroureterectomy for the treatment of upper tract urothelial carcinoma confined to the ureter. MATERIALS AND METHODS: Review of a large institutional database identified 367 patients treated for primary upper tract urothelial carcinoma with radical nephroureterectomy or parenchymal sparing ureteral resection from 1994 to 2009. Patients with known renal pelvis tumors, muscle invasive urothelial carcinoma, prior cystectomy, contralateral upper tract urothelial carcinoma, metastatic disease or chemotherapy were excluded, leaving 120 patients for analysis. Estimated glomerular filtration rate was calculated using the Modification of Diet in Renal Disease equation. Recurrence-free, cancer specific and overall survival were estimated using Kaplan-Meier analysis. RESULTS: Radical nephroureterectomy was performed in 87 patients and parenchymal sparing ureteral resection in 33. Median age at surgery was 73 years in the radical nephroureterectomy group (IQR 64-76) vs 70 years (IQR 59-77) in the parenchymal sparing ureteral resection group (p = 0.5). The radical nephroureterectomy and parenchymal sparing ureteral resection cohorts had several disparate clinicopathological variables including preoperative hydronephrosis (80% vs 45%, p = 0.0006), stage (pT3 or greater 26% vs 9%, p = 0.01) and baseline estimated glomerular filtration rate (51 vs 63 ml/minute/1.73 m(2), p = 0.009). Patients who underwent radical nephroureterectomy experienced a significantly greater decrease in estimated glomerular filtration rate after surgery (median -7 vs 0 ml/minute/1.73 m(2), p <0.001). Median followup was 4.2 years. Of the patients 79 experienced cancer recurrence and 44 died (28 of upper tract urothelial carcinoma). There were no obvious differences in the rates of recurrence, cancer specific death or overall death by procedure type. However, due to the limited number of events we cannot exclude the possibility that there are large differences in oncologic outcomes by procedure type. CONCLUSIONS: Parenchymal sparing ureteral resection is associated with superior postoperative renal function. However, the impact on cancer control cannot be determined conclusively due to the small sample size and putative selection bias.

Bilateral testicular germ cell tumours: a systematic review.

What's known on the subject? and What does the study add? Bilateral testicular germ cell tumours (BTGCTs) are rare neoplasms. Most previously published studies consist of case reports or small retrospective case series. Little is known about their epidemiological and clinicopathological characteristics. BTGCT corresponded to 1.82% of testicular tumours. Metachronous disease was about twice as frequent as synchronous disease. The primary tumour histology, chemotherapy use and the interval between metachronous tumours influenced the histology of the second tumour. Overall, synchronous tumours were associated with more advanced disease and presented less favourable survival rates than metachronous tumours. Testicular cancer is the most common tumour in young men. It is known that a second primary contralateral testis tumour may occur in up to 5% of men with a proior tumour. About 35% of these men present with synchronous tumours, and 65% present with metachronous tumours. However there is little data about bilateral testicular germ cell tumours (BTGCT) in the literature and the most published articles are case reports on a small series of men, which makes it difficult to draw conclusions about therapeutic strategies for the treatment of BTGCTs. In fact, current guidelines for the treatment of testicular cancer contain little information related to bilateral disease. Therefore, the aim of our study is to provide a broad overview of BTGCT and to update data focusing on incidence, pathological features, and clinical outcomes of men with BTGCTs. Thus, an extensive review containing 94 studies and more than 50,000 patients was conducted.

Combining imaging and ureteroscopy variables in a preoperative multivariable model for prediction of muscle-invasive and non-organ confined disease in patients with upper tract urothelial carcinoma.

OBJECTIVE: To create a preoperative multivariable model to identify patients at risk of muscle-invasive (pT2+) upper tract urothelial carcinoma (UTUC) and/or non-organ confined (pT3+ or N+) UTUC (NOC-UTUC) who potentially could benefit from radical nephroureterectomy (RNU), neoadjuvant chemotherapy and/or an extended lymph node dissection. PATIENTS AND METHODS: We retrospectively analysed data from 324 consecutive patients treated with RNU between 1995 and 2008 at a tertiary cancer centre. Patients with muscle-invasive bladder cancer were excluded, resulting in 274 patients for analysis. Logistic regression models were used to predict pT2+ and NOC-UTUC. Pre-specified predictors included local invasion (i.e. parenchymal, renal sinus fat, or periureteric) on imaging, hydronephrosis on imaging, high-grade tumours on ureteroscopy, and tumour location on ureteroscopy. Predictive accuracy was measured by the area under the curve (AUC). RESULTS: The median follow-up for patients without disease recurrence or death was 4.2 years. Overall, 49% of the patients had pT2+, and 30% had NOC-UTUC at the time of RNU. In the multivariable analysis, only local invasion on imaging and ureteroscopy high grade were significantly associated with pathological stage. AUC to predict pT2+ and NOC-UTUC were 0.71 and 0.70, respectively. CONCLUSIONS: We designed a preoperative prediction model for pT2+ and NOC-UTUC, based on readily available imaging and ureteroscopic grade. Further research is needed to determine whether use of this prediction model to select patients for conservative management vs RNU, neoadjuvant chemotherapy, and/or extended lymphadenectomy will improve patient outcomes.

Systematic classification and prediction of complications after nephrectomy in patients with metastatic renal cell carcinoma (RCC).

UNLABELLED: Study Type - Harm (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Radical nephrectomy for patients with metastatic renal cell carcinoma results in greater rates of morbidity than for those with less advanced disease. This study systematically characterizes complications associated with nephrectomy for metastatic RCC and identifies patient and disease characteristics that are associated with a greater risk of developing complications. Overall complications were relatively frequent, but major complications (grade 3 or greater) were rare. Increasing age and worsening performance status were associated with increased probability of complications. When complications were sustained, patients were less likely to receive systemic therapy in a timely fashion. These observations may influence the timing or patient selection for surgery or systemic therapy. OBJECTIVE: • To evaluate and identify factors predictive for morbidity after radical nephrectomy in patients with metastatic renal cell carcinoma (mRCC). PATIENTS AND METHODS: • We identified patients with mRCC who underwent nephrectomy at Memorial Sloan-Kettering Cancer Center (MSKCC) between 1989 and 2009. • Postoperative complications were characterised using a modified version of the Clavien-Dindo classification system. • Patient and disease characteristics, including a previously validated MSKCC risk-stratification system using calcium, haemoglobin (Hb), lactate dehydrogenase, and Karnofsky Performance Status (KPS), were evaluated as predictors of postoperative complications using univariate and multivariable logistic regression models. • The area under the receiver operating characteristic curve (AUC) was calculated for each model to assess predictive accuracy and corrected for overfit using 10-fold cross validation. RESULTS: • Over the study period, 195 patients with mRCC underwent nephrectomy; 53 (27%) developed grade ≥ 2 complications within 8 weeks of surgery. • Pulmonary, thromboembolic events and anaemia requiring transfusion were the most common types of complications after nephrectomy in the metastatic setting. • In univariate analysis, age, low albumin, low KPS, high corrected serum calcium, low serum Hb, and unfavourable MSKCC risk score were predictive of complications. • Patients who sustained postoperative complications were less likely to receive systemic therapy within 56 days (odds ratio [OR] 0.32; 95% confidence interval [CI] 0.12-0.86; P= 0.024). • A multivariable model containing KPS (OR 14.5; 95%CI 4.34-48.6; P < 0.001) and age (OR 1.04; 95%CI 1.01-1.08; P= 0.014) showed the greatest predictive accuracy (corrected AUC 0.72; 95%CI 0.63-0.80) for postoperative complications. CONCLUSIONS: • Postoperative complications after radical nephrectomy in the setting of mRCC are common and occur frequently in older patients and those with worse KPS. • These complications are important because they may delay or deny receipt of subsequent systemic therapy.

Epidemiology of Urological Cancers in Brazil: Trends in Mortality Rates Over More Than Two Decades.

BACKGROUND: Considering the socioeconomic disparities and inequalities observed in the healthcare resources among the Brazilian regions, we aimed to analyze the mortality trends of urological cancers in Brazil to identify areas with differential risks. METHODS: Deaths related to prostate (PCa), bladder (BCa), kidney (KC), penile (PeC), and testis (TCa) cancers from 1996 to 2019 were retrieved from the Mortality Information System database (Brazil). Geographic and temporal patterns were analyzed using age-standardized mortality rates (ASMRs). A joinpoint regression model was used to identify changes in the trends and calculate the average annual percentage change (AAPC) for each region. RESULTS: In Brazil, the ASMRs (per 100,000 persons/year) were 11.76 for PCa; 1.37, BCa; 1.13, KC; 0.33, and PeC; 0.26, TCa over the period. Increasing mortality trends were registered for BCa (AAPC = 0.45 in men; 0.57 in women), KC (AAPC = 2.03 in men), PeC (AAPC = 1.01), and TCa (AAPC = 2.06). The PCa mortality presented a significant reduction after 2006. The Northeast and North regions showed the highest increases in the PCa mortality. The South registered the highest ASMRs for BCa and KC, but the highest increasing trends occurred in the men from the Northeast. The North presented the highest ASMR for PeC, while the South registered the highest ASMR for TCa. CONCLUSION: Differences among regions may be partly explained by disparities in the healthcare systems. Over the study period, the North and Northeast regions presented more discrepant mortality rates. Efforts should be made to ensure access to the healthcare resources for people at risk, particularly in these regions.

Selective arterial embolization for pseudoaneurysms and arteriovenous fistula of renal artery branches following partial nephrectomy.

PURPOSE: We describe the presentation, endovascular management and functional outcomes of 15 patients with renal arterial pseudoaneurysm following open and laparoscopic partial nephrectomy. MATERIALS AND METHODS: An institutional review board approved, Health Insurance Portability and Accountability Act compliant retrospective review of a prospectively maintained database revealed that 7 of 1,160 patients who underwent open partial nephrectomy and 8 of 301 treated with laparoscopic partial nephrectomy were diagnosed with a pseudoaneurysm of a renal artery branch between 2003 and 2010. Some cases were associated with arteriovenous fistula. RESULTS: Diagnosis of pseudoaneurysm was made a median of 14 days after surgery. Gross hematuria was the most frequent symptom. Median estimated glomerular filtration rate measurements at the preoperative evaluation, postoperatively, on the day the vascular lesion was diagnosed, after embolization and at the last followup were 62, 55, 55, 56 and 58 ml/minute/1.73 m(2), respectively. Median followup was 7.8 months. All patients underwent angiography and superselective coil embolization of 1 or more pseudoaneurysms with or without arteriovenous fistula. Eleven patients had immediate cessation of symptoms while 4 had persistent gross hematuria after the procedure. Of these 4 patients 2 were treated with bedside care, 1 required repeat embolization with thrombin, which was successful, and the remaining patient had coagulopathy and underwent radical nephrectomy for persistent bleeding. CONCLUSIONS: Pseudoaneurysms and arteriovenous fistulas of the renal artery are rare complications of partial nephrectomy. Presentation is often delayed. Superselective coil embolization is a safe, minimally invasive treatment option that usually solves the clinical problem and preserves renal function.

Solitary, isolated metastatic disease to the kidney: Memorial Sloan-Kettering Cancer Center experience.

OBJECTIVE: • To analyse the clinical characteristics and outcomes of patients who underwent nephrectomy for solitary, isolated metastatic disease to the kidney. PATIENTS AND METHODS: • From July 1989 to July 2009, we identified 13 patients who underwent nephrectomy for solitary metastasis to the kidney. Patients' demographics, intra-operative variables and outcomes are reported. RESULTS: • The median age at nephrectomy was 52 years (range 33-79). Eleven patients (85%) had an incidentally discovered renal mass, whereas two patients (15%) presented with gross haematuria. • Median time from initial surgery at the primary site to development of metastatic disease to the kidney was 63 months (range 9-136). No patient had evidence of disease at other sites at the time of nephrectomy. In seven patients (54%), the kidney was the first site of recurrence. • The most common primary site was the lung in five patients (38%), followed by the colon in two (15%), chest wall in two (15%) and bone, brain, breast and salivary gland in one patient each (8%). • Of the 14 procedures performed, eight (57%) were partial nephrectomy (PN) and six (43%) were radical nephrectomy (RN). • Four patients died after progression from the primary tumour, all within 2 years of nephrectomy. One patient with a primary chondrosarcoma had no evidence of disease at last follow-up and died from other causes 50 months after nephrectomy. The median follow-up for the eight patients who were alive at last follow-up was 30 months after nephrectomy. Four of these patients had no evidence of disease and four patients were alive with metastatic disease. CONCLUSION: • Kidney involvement by metastatic disease can occur as isolated solitary lesions. Some patients will also have the kidney as the first and only site of metastatic involvement. The presence of an isolated renal metastasis should not be considered an end-stage disease, and nephrectomy can be offered for highly selected patients as a therapeutic option.

Impact of smoking on outcomes after intravesical bacillus Calmette-Guérin therapy for urothelial carcinoma not invading muscle of the bladder.

UNLABELLED: Study Type - Prognosis (case series). LEVEL OF EVIDENCE: 4. What's known on the subject? and What does the study add? The main goal of a prostate biopsy is to identify clinically relevant prostate cancer with the lowest possible morbidity from the procedure. Through time many have tried different variations in the procedure in an attempt to find the optimal methodology for performing prostate biopsies. These changes include better equipment in helping optimize cancer localizing, varying the number of cores in efforts to improve cancer detection and sampling various areas of the prostate to find cancer that may be hiding. To our knowledge we are the first to describe performing prostate biopsies with keeping the sampling size constant and varying the number of cores based on the size of the prostate. The study adds a variation in the current techniques used for prostate biopsies. In certain situations using a standard number of cores makes obtaining proper sampling of a prostate difficult. We propose a methodology in performing prostate biopsies that will allow for standardization of the tissue per core analyzed thus allowing for an improved sampling of the prostate. OBJECTIVE: To determine the influence of smoking on the outcomes of patient with urothelial carcinoma of the bladder (UCB) not invading muscle treated with BCG therapy. MATERIALS AND METHODS: A retrospective chart review was conducted on 623 consecutive patients treated with BCG therapy for high-grade Ta (n= 219; 35.2%), T1 (n= 215; 34.5%) and/or carcinoma in situ (n= 189; 30.3%). Cigarette smoking status was categorized as (smokers vs non-smokers) and as (current smokers vs past smokers vs never smokers). In addition, we analyzed the time since smoking cessation as a continuous and categorical variable (smoking cessation after diagnosis vs 0.1-10 years before diagnosis vs more than 10 years before diagnosis). Association with outcomes was examined by univariate and multivariable analyses, adjusting for the effects of age, gender, stage and grade. RESULTS: The study cohort consisted of 423 males (67.9%) and 200 females (32.1%). Overall, 386 patients (62.0%) were past smokers, 97 (15.6%) were current smokers and 140 (22.5%) had never smoked. In both univariate and multivariable analyses, smoking status by any definition was not associated with the response to BCG therapy, disease recurrence, progression, all-cause mortality or UCB-specific mortality. TUR grade was significantly associated with disease progression. TUR stage and BCG response at 6 months were significantly associated with disease recurrence, progression, all-cause mortality and UCB-specific mortality. CONCLUSIONS: Smoking does not appear to affect the response to BCG therapy or long-term oncological outcomes.

Pelvimetric dimensions do not impact upon nerve sparing or erectile function recovery in patients undergoing radical retropubic prostatectomy.

INTRODUCTION: The impact of unfavorable pelvic anatomy on the likelihood of having a nerve sparing radical retropubic prostatectomy (RRP) and the potential correlation between pelvic dimensions and recovery of erectile function (EF) after RRP have not been previously evaluated. AIM: To determine the impact of different pelvic bony and soft tissue dimensions as well as apical prostate depth on the likelihood of performing bilateral nerve sparing and on recovery of EF after RP. METHODS: Between November 2001 and June 2007, 644 potent men undergoing RRP had preoperative MRI where pelvimetry was performed with bilateral nerve sparing in 504 men. Outcomes including varying degrees of recovery of EF (level 1: normal; level 2: partial erections routinely sufficient for intercourse; level 3: partial erections occasionally sufficient for intercourse) were assessed. Median follow-up was 44.1 (interquartile range: 29.2, 65.3) months. We evaluated independent predictors of performing a bilateral nerve sparing procedure and of recovery of EF using multivariable Cox proportional hazards methods. MAIN OUTCOME MEASURES: Likelihood of performing bilateral nerve sparing as well as recovery of EF after RRP. RESULTS: Patients with higher clinical stage and biopsy Gleason score are less likely to undergo bilateral nerve sparing. Surgeon is also a factor in the likelihood of having bilateral nerve sparing RRP. On multivariate Cox regression analysis, factors predictive of recovery of EF were age, pretreatment erectile function, surgeon, and modified Charlson score. None of the pelvimetric dimensions were significant predictors of any degree of recovery of EF. However, the study is limited by its retrospective nature and by being based on MRI evaluations useful for cancer staging rather than anatomical evaluation of pelvimetric dimensions. CONCLUSIONS: We did not find unfavorable pelvic anatomy to impact the likelihood of performing a nerve sparing procedure or to be predictive of any degree of recovery of EF after RRP.

Gender differences in radical nephroureterectomy for upper tract urothelial carcinoma.

PURPOSE: Women have been associated with adverse outcomes after radical cystectomy for lower tract urothelial carcinoma. We evaluated the prognostic value of gender in an international cohort of patients treated with radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). METHODS: We retrospectively studied 754 patients treated with RNU for UTUC without neoadjuvant chemotherapy at nine centers located in Asia, Canada, and Europe. Univariable and multivariable Cox regression analyses were used to address recurrence-free (RFS) and cancer-specific survival (CSS) estimates. Median follow-up was 40 months (interquartile range: 18-75). RESULTS: The majority of patients was of men (516, 68.4%). Women were older than men at the time of RNU (median: 69.2 vs. 66.5 years; P = 0.0003). Women were less likely to have high-grade disease, undergo lymph node dissection, and to receive adjuvant chemotherapy. Gender was not associated with pathologic stage, lymph node metastasis, lymphovascular invasion, concomitant CIS, tumor architecture, or tumor necrosis. On univariable Cox regression analyses, there was no association between gender and cancer recurrence (P = 0.76) or cancer-specific mortality (P = 0.30). On multivariable Cox regression analyses that adjusted for the effects of clinicopathologic features, gender was not associated with disease recurrence (P = 0.47) or cancer-specific survival (P = 0.15). CONCLUSIONS: We found no difference in histopathologic features and outcomes between men and women treated with RNU for UTUC. Nevertheless, epidemiologic and mechanistic molecular studies should be encouraged to design, analyze, and report gender-specific associations to aid in our understanding of gender impact on UTUC incidence, progression, and metastasis.

Pelvic Pseudoaneurysm as a Cause of Severe Hematuria After Robotic-assisted Radical Prostatectomy.

OBJECTIVE: To alert the medical society regarding that hematuria after radical prostatectomy can be caused by pelvic pseudoaneurysm. METHODS: Case report of a 61-year-old male underwent extraperitoneal robotic-assisted radical prostatectomy. He was readmitted on the 15th POD due to gross hematuria with resolution after bladder irrigation. It returned on the 21st POD. RESULTS: The CT angiography evidenced the pseudoaneurysm of the left internal iliac artery. Selective embolization was effectively performed, with no additional bleeding or pelvic ischemia. Endovascular therapy is the preferred method of treatment. CONCLUSION: The pelvic pseudoaneurysm is a rare, but serious complication that can cause severe bleeding. In our experience, we had 3 cases of persistent hematuria caused by pelvic pseudoaneurysm after 1810 robotic-assisted radical prostatectomy.

Cost-effectiveness analysis of robotic-assisted versus retropubic radical prostatectomy: a single cancer center experience.

Prostate cancer (PCa) treatment has been greatly impacted by the robotic surgery. The economics literature about PCa is scarce. We aim to carry-out cost-effectiveness and cost-utility analyses of the robotic-assisted radical prostatectomy (RALP) using the "time-driven activity-based cost" methodology. Patients who underwent radical prostatectomy in 2013 were retrospectively analyzed in a cancer center over a 5-year period. Fifty-six patients underwent RALP and 149 patients underwent retropubic radical prostatectomy (RRP). The amounts were subject to a 5% discount as correction of monetary value considering time elapsed. Calculation of the Incremental Cost-Effectiveness Ratios (ICER) related to events avoided and the Incremental Cost-Utility Ratio (ICUR) related to "QALY saved" were performed. QALY was performed using values of utility and "disutility" weights from the "Cost-Effectiveness Analysis Registry". Hypothetical cohorts were simulated with 1000 patients in each group, based on the treatment outcomes. Total and average costs were R$1,903,671.93, and R$12,776.32 for the RRP group, and R$1,373,987.26, and R$24,535.49 for the RALP group, respectively. The costs to treat the hypothetical cohorts were R$10,010,582.35 for RRP, and R$19,224,195.90 for RALP. ICER calculation evidenced R$9,213,613.55 of difference between groups. ICUR was R$ 22,690.83 per QALY saved. Limitations were the lack of cost-effectiveness analyses related to re-hospitalization rates and complications, single center perspective, and currency-translation differences. Medical fees were not included. RALP showed advantages in cost-effectiveness and cost-utility over RRP in the long term. Despite the increased costs to the introduction of robotic technology, its adoption should be encouraged due to the gains.

Cost-Effectiveness Analysis of Prostate Cancer Screening in Brazil.

INTRODUCTION: Prostate cancer is one of the most common malignancies among men worldwide. Prostate-specific antigen (PSA) screening shows uncertain benefits and harms from clinical and economic perspectives, resulting in an important impact on healthcare systems. Because of nonstandardized studies and substantial differences among populations, data are still inconclusive. OBJECTIVE: The objective of this study was to carry out long-term cost-effectiveness and cost-utility analysis on the PSA-screened population from the service provider's perspective in the Brazilian population. METHODS: We performed a cost-effectiveness and cost-utility analysis using clinical outcomes obtained from 9692 men enrolled in the PSA screening program. Prostate cancer treatments, 5-year follow-up outcomes, and all related costs were examined. Data were compared with a nonscreened prostate cancer population to calculate incremental cost-effectiveness ratio (ICER) and incremental cost-utility ratio (ICUR). ICER and ICUR were compared with the Brazilian-established willingness-to-pay (WTP) threshold (WTP = R$ 114 026.55). RESULTS: A total of 251 of 9692 men had a diagnosis of prostate cancer (2.6%), of which 90% had localized disease. Two hundred and five patients were treated as follows: surgery (45.37%); radiation therapy (11.22%); radiation plus androgen deprivation therapy (21.95%); active surveillance (13.17%); exclusive androgen deprivation therapy (7.32%); and watchful waiting (0.98%). Two simulated cohorts were compared based on screening and nonscreening groups. Values obtained were-ICER of R$ 44 491.39 per life saved and ICUR of R$ 10 851.56 per quality-adjusted life year (QALY) gained-below the Brazilian WTP threshold and showed cost-effectiveness and cost-utility advantages. CONCLUSION: According to the Brazilian WTP, PSA screening is a cost-effective policy from a hospital and long-term perspective and should have more standardized studies developed in different populations and economies.