Safety and effectiveness of the radium-223-taxane treatment sequence in patients with metastatic castration-resistant prostate cancer in a global observational study (REASSURE).

BACKGROUND: Radium-223 and taxane chemotherapy each improve survival of patients with metastatic castration-resistant prostate cancer (mCRPC). Whether the radium-223-taxane sequence could extend survival without cumulative toxicity was explored. METHODS: The global, prospective, observational REASSURE study (NCT02141438) assessed real-world safety and effectiveness of radium-223 in patients with mCRPC. Using data from the prespecified second interim analysis (data cutoff, March 20, 2019), hematologic events and overall survival (OS) were evaluated in patients who were chemotherapy-naive at radium-223 initiation and subsequently received taxane chemotherapy starting ≤90 days ("immediate") or >90 days ("delayed") after the last radium-223 dose. RESULTS: Following radium-223 therapy, 182 patients received docetaxel (172 [95%]) and/or cabazitaxel (44 [24%]); 34 patients (19%) received both. Seventy-three patients (40%) received immediate chemotherapy and 109 patients (60%) received delayed chemotherapy. Median time from last radium-223 dose to first taxane cycle was 3.6 months (range, 0.3-28.4). Median duration of first taxane was 3.7 months (range, 0-22.0). Fourteen patients (10 in the immediate and four in the delayed subgroup) had grade 3/4 hematologic events during taxane chemotherapy, including neutropenia in two patients in the delayed subgroup and thrombocytopenia in one patient in each subgroup. Median OS was 24.3 months from radium-223 initiation and 11.8 months from start of taxane therapy. CONCLUSIONS: In real-world clinical practice settings, a heterogeneous population of patients who received sequential radium-223-taxane therapy had a low incidence of hematologic events, with a median survival of 1 year from taxane initiation. Thus, taxane chemotherapy is a feasible option for those who progress after radium-223. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02141438. PLAIN LANGUAGE SUMMARY: Radium-223 and chemotherapy are treatment options for metastatic prostate cancer, which increase survival but may affect production of blood cells as a side effect. We wanted to know what would happen if patients received chemotherapy after radium-223. Among the 182 men treated with radium-223 who went on to receive chemotherapy, only two men had severe side effects affecting white blood cell production (neutropenia) during chemotherapy. On average, the 182 men lived for 2 years after starting radium-223 and 1 year after starting chemotherapy. In conclusion, patients may benefit from chemotherapy after radium-223 treatment without increasing the risk of side effects.

Contemporary prostate cancer treatment choices in multidisciplinary clinics referenced to national trends.

BACKGROUND: The purpose of this study was to assess treatment choices among men with prostate cancer who presented at The University of Texas MD Anderson Cancer Center multidisciplinary (MultiD) clinic compared with nationwide trends. METHODS: In total, 4451 men with prostate cancer who presented at the MultiD clinic from 2004 to 2016 were analyzed. To assess nationwide trends, the authors analyzed 392,710 men with prostate cancer who were diagnosed between 2004 and 2015 from the Surveillance, Epidemiology, and End Results (SEER) database. The primary endpoint was treatment choice as a function of pretreatment demographics. RESULTS: Univariate analyses revealed similar treatment trends in the MultiD and SEER cohorts. The use of procedural forms of definitive therapy decreased with age, including brachytherapy and prostatectomy (all P < .05). Later year of diagnosis/clinic visit was associated with decreased use of definitive treatments, whereas higher risk grouping was associated with increased use (all P < .001). Patients with low-risk disease treated at the MultiD clinic were more likely to receive nondefinitive therapy than patients in SEER, whereas the opposite trend was observed for patients with high-risk disease, with a substantial portion of high-risk patients in SEER not receiving definitive therapy. In the MultiD clinic, African American men with intermediate-risk and high-risk disease were more likely to receive definitive therapy than white men, but for SEER the opposite was true. CONCLUSIONS: Presentation at a MultiD clinic facilitates the appropriate disposition of patients with low-risk disease to nondefinitive strategies of patients with high-risk disease to definitive treatment, and it may obviate the influence of race.

Active Surveillance as Initial Management of Newly Diagnosed Prostate Cancer: Data from the PURC.

PURPOSE: We describe contemporary active surveillance utilization and variation in a regional prostate cancer collaborative. We identified demographic and disease specific factors associated with active surveillance in men with newly diagnosed prostate cancer. MATERIALS AND METHODS: We analyzed data from the PURC (Pennsylvania Urologic Regional Collaborative), a cooperative effort of urology practices in southeastern Pennsylvania and New Jersey. We determined the rates of active surveillance among men with newly diagnosed NCCN® (National Comprehensive Cancer Network®) very low, low or intermediate prostate cancer and compared the rates among participating practices and providers. Univariate and multivariable analyses were used to identify factors associated with active surveillance utilization. RESULTS: A total of 1,880 men met inclusion criteria. Of the men with NCCN very low or low risk prostate cancer 57.4% underwent active surveillance as the initial management strategy. Increasing age was significantly associated with active surveillance (p <0.001) while adverse clinicopathological variables were associated with decreased active surveillance use. Substantial variation in active surveillance utilization was observed among practices and providers. CONCLUSIONS: More than 50% of men with low risk disease in the PURC collaborative were treated with active surveillance. However, substantial variation in active surveillance rates were observed among practices and providers in academic and community settings. Advanced age and favorable clinicopathological factors were strongly associated with active surveillance. Analysis of regional collaboratives such as the PURC may allow for the development of strategies to better standardize treatment in men with prostate cancer and offer active surveillance in a more uniform and systematic fashion.

Surgical Apgar Score predicts an increased risk of major complications and death after renal mass excision.

PURPOSE: Tailoring perioperative management to minimize the postoperative complication rates depends on reliable prognostication of patients most at risk. The Surgical Apgar Score is an objective measure of the operative course validated to predict major complications and death after general/vascular surgery. We assessed the ability of the Surgical Apgar Score to identify patients most at risk for postoperative morbidity and mortality after renal mass excision. MATERIALS AND METHODS: Data for 886 patients undergoing renal mass excision via radical or partial nephrectomy from 2010 to 2013 were extracted from a prospectively collected database. The Surgical Apgar Score was calculated using electronic anesthesia records. Major postoperative complications, readmission and reoperation within 30 days of surgery as well as 90-day mortality were examined. RESULTS: Overall 13.2% of patients experienced major postoperative complications at 30 days. Clavien grade I, II, III, IV and V complications were experienced by 1.7%, 2.9%, 5.8%, 1.9% and 0.9%, respectively. The 90-day all cause mortality rate was 1.4%. The Surgical Apgar Score was significantly lower in patients experiencing major complications (mean 7.3 vs 7.8, p=0.004) and death (6.3 vs 7.7, p=0.03). Patients with a Surgical Apgar Score of 4 or less were 3.7 times more likely to experience a major complication (p=0.01) and 24 times more likely to die within 90 days of surgery (p=0.0007) compared to patients with a Surgical Apgar Score greater than 8. CONCLUSIONS: The Surgical Apgar Score is an easily collected metric that can identify patients at higher risk for major complications and death after renal mass excision. A prospective trial to help further delineate the optimal use of this tool in an adjusted perioperative management approach with patients undergoing renal mass excision is warranted.

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.

Is radical nephrectomy a legitimate therapeutic option in patients with renal masses amenable to nephron-sparing surgery?

The decision to perform a radical nephrectomy (RN) or a partial nephrectomy (PN), not unlike most decisions in clinical practice, ultimately hinges on the balance of risk. Do the higher risks of a more complex surgery (PN) justify the theoretical benefits of kidney tissue preservation? Data suggest that for patients with an anatomically complex renal mass and a normal contralateral kidney, for whom additional surgical intensity may be risky, such as the elderly and comorbid, RN presents a robust treatment option. Nevertheless, PN, especially for small and anatomically simple renal masses in young patients without comorbidities should remain the surgical reference standard, as preservation of renal tissue can serve as an 'insurance policy' not only against future renal functional decline, but also against the possibility of tumour development in the contralateral kidney. In the present review, we outline the ongoing debate between the role of RN and PN in treatment of the enhancing renal mass.

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.

Prostate biopsy perineural invasion is not independently associated with positive surgical margins following radical retropubic prostatectomy.

PURPOSE: Perineural invasion (PNI) in prostate cancer has been associated with poor prognosis. We sought to determine whether biopsy and radical prostatectomy (RP) PNI are associated with adverse outcomes. A secondary objective was to determine whether prostate biopsy PNI should alter surgical technique. METHODS: Patients were categorized by PNI on biopsy and RP specimens. Associations between PNI, clinicopathologic characteristics, and biochemical recurrence (BCR) rates were assessed. RESULTS: A total of 2,500 patients undergoing open RP by a single-surgeon from 1999 to 2011 were analyzed. In unadjusted univariate analyses, biopsy PNI was significantly associated with Gleason score, clinical stage, positive surgical margins, extraprostatic extension (EPE), seminal vesicle invasion (SVI), positive lymph nodes, and BCR (p < 0.001). On multivariate analysis, EPE (p < 0.001), and SVI (p = 0.022) remained associated with biopsy PNI. Biopsy PNI was not associated with positive margins at RP (OR 1.3, 95 % CI 0.92-1.9). The presence of PNI in the final RP specimen conferred a greater than 4 times increased odds of positive margin (OR 4.6, 95 % CI 2.30-9.22; p < 0.0001). Men with PNI on biopsy were 1.5 times more likely to experience BCR (OR 1.5, 1.06-2.01). PNI on biopsy or RP specimens was not associated with overall survival. CONCLUSIONS: In men undergoing open RP for clinically localized prostate adenocarcinoma, biopsy PNI is associated with an increased risk of BCR. PNI on prostate biopsy was not associated with positive surgical margins after adjusting for related co-variables. The presence of PNI on prostate biopsy should not preclude utilization of a nerve-sparing approach.

Perioperative strategies to reduce postoperative complications after radical cystectomy.

Radical cystectomy with creation of urinary diversion is the standard treatment for muscle-invasive urothelial carcinoma of the bladder. Despite advances in perioperative care, radical cystectomy is associated with significant morbidity. Reduction in perioperative morbidity and mortality remains a primary focus of bladder cancer outcome improvement. A number of evidence-based approaches to perioperative care have been proposed to reduce the overall burden of complications associated with radical cystectomy. Herein, we highlight and review recent and evolving evidence-based strategies to minimize the morbidity associated with surgical management of muscle-invasive bladder cancer.

The burden of overtreatment: comparison of toxicity between single and combined modality radiation therapy among low risk prostate cancer patients.

INTRODUCTION: To compare radiation related toxicities among men with low risk prostate cancer treated with single or multimodal radiation therapy. MATERIALS AND METHODS: The SEER-Medicare linked database was used to assess the relationship between treatment type and toxicity among men with low risk prostate cancer treated with brachytherapy (BT), external beam radiation therapy (EBRT), or combined therapy between 2004 and 2007. Inverse probability of treatment weighting was utilized to minimize selection bias and control for confounding. Multivariate logistic regression models were used to explore the relationship between treatment and outcomes. RESULTS: Overall 1915 (43.9%), 1893 (43.4%), and 555 (12.7%) patients were treated with EBRT, BT, and combined therapy, respectively. In univariate analyses, combined modality radiation was more toxic than BT alone for GU incontinence (56.76% versus 49.08%), GU obstruction (21.26% versus 19.70%), and erectile dysfunction (22.52% versus 22.24%) (p < 0.01, all comparisons). Compared to EBRT alone, combined modality radiation was more toxic for GI bleeding (7.21% versus 6.21%), GU incontinence (56.76% versus 29.24%), GU obstruction (21.26% versus 14.15%), and erectile dysfunction (22.52% versus 15.35%) (p < 0.01, all comparisons). Among the most frequent radiation toxicity events, the probability of treatment associated toxicity was highest for patients receiving combined modality treatment and lowest for the group treated with EBRT. After multivariate adjustment, EBRT alone demonstrated protective effects against GU obstruction (OR 0.56 [CI 0.50-0.63]), GI bleeding (OR 0.57 [CI 0.48-0.67]), GU incontinence (OR 0.39 [CI 0.36-0.43]), and erectile dysfunction (OR 0.68 [CI 0.61-0.76]) when compared to combined therapy. CONCLUSIONS: The use of combined modality radiation therapy in low risk prostate cancer patients is discordant with clinical guidelines and associated with a significantly increased burden of associated toxicity when compared to EBRT monotherapy. Prudent patient selection and judicious use of combined therapy among men with low risk prostate cancer represents a targetable area to reduce the burden of overtreatment.

Impact of folate intake on prostate cancer recurrence following definitive therapy: data from CaPSURE™.

PURPOSE: A randomized, placebo controlled clinical trial of folic acid supplementation for the chemoprevention of colorectal adenoma revealed an increased incidence of prostate cancer in the treatment group. Limited data exist on postdiagnostic folate/folic acid intake and the risk of prostate cancer progression. We prospectively examined the association between postdiagnostic folate consumption and the risk of prostate cancer recurrence after radical prostatectomy, external beam radiation therapy and brachytherapy. MATERIALS AND METHODS: This study was done in 1,153 men treated with radical prostatectomy, external beam radiation therapy and brachytherapy who had clinical stage T1-T2c prostate adenocarcinoma and participated in the CaPSURE Diet and Lifestyle substudy by completing the semiquantitative Food Frequency Questionnaire in 2004 to 2005. We used Cox proportional hazards regression to analyze the association between folate intake and prostate cancer progression. RESULTS: Prostate cancer progressed in 101 men (8.76%) during a mean 34-month followup. After multivariate adjustment we observed no evidence of an association of the intake of total folate, dietary folate or dietary folate equivalents with prostate cancer recurrence. On secondary analysis by treatment after radical prostatectomy patients in the lowest decile of dietary folate intake had a 2.6-fold increase in the risk of recurrence (HR 2.56, 95% CI 1.23-5.29, p = 0.01). In patients treated with external beam radiation and brachytherapy we observed no evidence of an association between prostate cancer progression and increased folate intake. CONCLUSIONS: Results suggest that the consumption of foods and multivitamins that contain folate is not associated with prostate cancer progression after definitive treatment.

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.

Growth kinetics and short-term outcomes of cT1b and cT2 renal masses under active surveillance.

PURPOSE: Compared to T1a lesions the natural history of untreated renal masses larger than 4 cm is poorly understood. We assessed the growth kinetics and outcomes of cT1b/T2 cortical renal tumors managed by an initial period of active surveillance. We compared these cases to those treated with definitive delayed intervention. MATERIALS AND METHODS: We reviewed our institutional, prospectively maintained renal tumor database to identify enhancing solid and cystic masses managed expectantly. Included in analysis were clinically localized tumors greater than 4.0 cm (T1b or greater) that were radiographically followed for more than 6 months. Tumor size at presentation, annual linear tumor growth rate, Charlson comorbidity index, followup and clinical outcomes were compared in patients who remained on active surveillance and those who underwent delayed surgical intervention. RESULTS: We identified 72 tumors 4 cm or greater in diameter in a total of 68 patients. Active surveillance was the only treatment in 45 patients (66%) while 23 (34%) progressed to intervention. Median tumor size at presentation was 4.9 cm and the mean linear growth rate was 0.44 cm per year. Of the masses 14.7% demonstrated no growth with time. Comparing patients treated exclusively with active surveillance and those who progressed to definitive intervention revealed no difference in median tumor size at presentation (4.9 vs 4.6 cm, p = 0.79) or the median Charlson comorbidity index (3 vs 2, p = 0.6) but significant differences were seen in median age at presentation (77 vs 60 years, p = 0.0002) and the mean linear growth rate (0.37 vs 0.73 cm per year, p = 0.02). After adjustment younger patients (OR 0.91, 95% CI 0.86-0.97) and tumors with a faster linear growth rate (OR 9.1, 95% CI 1.7-47.8) were more likely to be treated with delayed surgical intervention. At a mean ± SD 38.9 ± 24.0 months of followup (median 32, range 6 to 105) 9 patients (13%) had died of another cause and none had progressed to metastatic disease. CONCLUSIONS: Localized cT1b or larger renal masses show growth rates comparable to those of small tumors managed expectantly with a low rate of progression to metastatic disease at short-term followup. An initial period of active surveillance to determine tumor growth kinetics is a reasonable option in select patients with significant competing risks and limited life expectancy.

Laparoscopic pyeloplasty for ureteropelvic junction obstruction in infants.

PURPOSE: Laparoscopic pyeloplasty and open pyeloplasty have comparable efficacy for ureteropelvic junction obstruction in pediatric patients. The role of laparoscopic pyeloplasty in infants is less well defined. We present our updated experience with laparoscopic pyeloplasty in children younger than 1 year. MATERIALS AND METHODS: We retrospectively reviewed the records of all 29 infants treated with transperitoneal laparoscopic pyeloplasty for symptomatic and/or radiographic ureteropelvic junction obstruction from May 2005 to February 2012. Patients were followed with renal ultrasound at regular intervals. Treatment failure was defined as the inability to complete the intended procedure, persistent radiographic evidence of obstruction and/or the need for definitive adjunctive procedures. RESULTS: Transperitoneal laparoscopic pyeloplasty was performed in 29 infants 2 to 11 months old (mean age 6.0 months) weighing 4.1 to 10.9 kg (mean ± SD 7.9 ± 1.6). Followup was available in all except 5 patients (median 13.9 months, IQR 7.7-23.8). Mean operative time was 245 ± 44 minutes. All cases were completed laparoscopically. Three postoperative complications were reported, including ileus, superficial wound infection and pyelonephritis. Two patients had persistent symptomatic and/or radiographic evidence of obstruction, and required reoperative pyeloplasty. The overall success rate was 92%. CONCLUSIONS: Laparoscopic pyeloplasty in infants remains a technically challenging procedure limited to select centers. Our early experience revealed a success rate comparable to that of other treatment modalities with minimal morbidity.

Metanephric adenofibroma.

A 10-year-old boy underwent a computed tomography (CT) scan for left flank pain following a fall. Imaging demonstrated a 5 cm left upper pole renal mass. Partial nephrectomy revealed metanephric adenofibroma, a benign stromal-epithelial tumor thought to represent a hyperdifferentiated, mature form of Wilms' tumor. We briefly discuss the histopathology and management of this rare tumor.

Increased cancer cell proliferation in prostate cancer patients with high levels of serum folate.

BACKGROUND: A recent clinical trial revealed that folic acid supplementation is associated with an increased incidence of prostate cancer (Figueiredo et al., J Natl Cancer Inst 2009; 101(6): 432-435). As tumor cells in culture proliferate directly in response to available folic acid, the goal of our study was to determine if there is a similar relationship between patient folate status, and the proliferative capacity of tumors in men with prostate cancer. METHODS: Serum folate and/or prostate tissue folate was determined in 87 randomly selected patients undergoing surgery for prostate cancer, and compared to tumor proliferation in a subset. RESULTS: Fasting serum folate levels were positively correlated with prostate tumor tissue folate content (n = 15; r = 0.577, P < 0.03). Mean serum folate was 62.6 nM (7.5-145.2 nM), 39.5% of patients used supplements containing folic acid (n = 86). The top quartile of patients had serum folates above 82 nM, six times the level considered adequate. Of these, 48% reported no supplement use. Among 50 patients with Gleason 7 disease, the mean proliferation index as determined by Ki67 staining was 6.17 ± 3.2% and 0.86 ± 0.92% in the tumors from patients in the highest (117 ± 15 nM) and lowest (18 ± 9 nM) quintiles for serum folate, respectively (P < 0.0001). CONCLUSIONS: Increased cancer cell proliferation in men with higher serum folate concentrations is consistent with an increase in prostate cancer incidence observed with folate supplementation. Unexpectedly, more than 25% of patients had serum folate levels greater than sixfold adequate. Nearly half of these men reported no supplement use, suggesting either altered folate metabolism and/or sustained consumption of folic acid from fortified foods.

Incidentally discovered capillary hemangioma of the prostate.

We present the case of a 69-year-old male with incidentally discovered capillary hemangiomas at radical prostatectomy. Hemangiomas of genitourinary origin are extremely rare, typically benign vascular tumors. This finding represents the first reported hemangioma within a radical prostatectomy specimen.

Outcomes and expanding indications for robotic retroperitoneal lymph node dissection for testicular cancer.

Treatment of testicular cancer has made significant progress in the past decades in terms of reduction of treatment-associated morbidity and preventing over-treatment. At the forefront of this progression is utilization of the da Vinci robot to perform retroperitoneal lymph node dissections (RPLNDs) via a minimally invasive approach. The robot offers multiple potential advantages such as smaller incisions, improved 3D visualization, more precise dissection, and faster convalescence, leading to its increased usage the past several years. In this chapter, we summarize the recent progress made in robotic surgery for testicular cancer and its potential in the future. Promising preliminary data has also renewed interest in defining the role of primary RPLND in patients with seminoma, potentially sparing patients of the harmful long-term radiation and cisplatin-based chemotherapy. SEMS and PRIMETEST trials are ongoing trials that will provide significant insight into this area and potentially expand the role of robotic RPLND.

Cesium 131 versus iodine 125 implants for prostate cancer: evaluation of early PSA response.

INTRODUCTION: Given the shorter half-life of cesium-131 (Cs-131) compared to iodine-125 (I-125), we hypothesized that initial PSA outcomes may differ. We compare initial PSA outcomes in men undergoing Cs-131 prostate brachytherapy to men treated with I-125. PATIENTS AND METHODS: The first post-treatment PSA (obtained 3-6 months after the procedure) was compared in patients undergoing I-125 prostate brachytherapy to that of patients undergoing Cs-131 prostate brachytherapy at the same institution. Comparisons included the total cohort as well as low and intermediate risk patients. RESULTS: Mean pre-treatment PSA was 6.9 ng/mL in the I-125 cohort, and 6.9 ng/mL in the Cs-131 cohort. Mean initial post-treatment PSA was 0.9 ng/mL (range < 0.1-4.6) in the I-125 cohort and 1.2 ng/mL (range < 0.1-23.5) in the Cs-131 patients. For low risk patients, mean pre-treatment PSA was 5.8 ng/mL in the I-125 cohort, and 5.1 ng/mL in the Cs-131 cohort. Initial mean post-treatment PSA for low risk patients was 1.2 ng/mL (range < 0.1-4.6) in the I-125 group and 1.0 ng/mL (range < 0.1-2.9) in the Cs-131 patients (p = 0.37). For intermediate risk patients, mean pre-treatment PSA was 7.3 ng/mL in the I-125 cohort, and 7.3 ng/mL in the Cs-131 cohort. Mean initial post-treatment PSA in intermediate risk patients was 1.5 ng/mL (range < 0.1-2.9) in the I-125 group and 1.2 ng/mL (range < 0.1-4.6) in the Cs-131 patients (p = 0.52). CONCLUSIONS: Given the shorter half-life of Cs-131 compared to I-125, we hypothesized that initial post-brachytherapy PSA levels were similar between men receiving treatment with Cs-131 and I-125. The aim of the present study is not to predict long term outcome after Cs-131 prostate brachytherapy, but rather to simply compare initial PSA outcomes in men undergoing prostate brachytherapy with I-125 to Cs-131. Long term data are needed to document cancer control achieved with Cs-131.

Effect of carbohydrate-electrolyte sports beverages on urinary stone risk factors.

PURPOSE: We evaluated the effects of consuming carbohydrate-electrolyte sports beverages (Gatorade((R))) on urinary stone risk factors. MATERIALS AND METHODS: Twelve normal subjects (5 men, 7 women) and 12 hypercalciuric stone formers (2 men, 10 women) participated in a 4-week prospective, crossover study consisting of 3 study phases. In phase 1 subjects were placed on a monitored stone prevention diet that was continued throughout the study. In phase 2 subjects ingested 2 l Gatorade daily followed by a 7-day washout period. In phase 3 subjects ingested 2 l water daily. On the final day of phases 1, 2 and 3 a 24-hour urine collection and blood sample were analyzed for stone risk factors. Effects of group and phase were tested using repeated measures ANOVA and paired t tests. RESULTS: Changes in urinary risk factors after Gatorade consumption revealed no statistically significant difference between normal subjects and stone formers. However, intrasubject variation occurred in both groups. Gatorade consumption in both groups increased urinary pH (p = 0.006), urinary chloride (p = 0.044) and urinary sodium (p = 0.008), and decreased urinary potassium (p = 0.035) and urinary uric acid (p = 0.019) in a statistically significant manner. In response to Gatorade consumption urinary volume, calcium and citrate were unchanged compared to water consumption and baseline. CONCLUSIONS: Gatorade increased mean urinary sodium and chloride levels compared to water and baseline. However, the results were within normal urinary parameters. The change did not appear to be clinically significant as urinary calcium was unchanged. Overall consumption of Gatorade does not increase or decrease urinary stone risk factors.