Aspirin Use and Lethal Prostate Cancer in the Health Professionals Follow-up Study.

BACKGROUND: Aspirin use probably protects against some malignancies but its effects on lethal prostate cancer (PC) are unclear. OBJECTIVE: To investigate the association between regular aspirin use and lethal PC. DESIGN, SETTING, AND PARTICIPANTS: Participants were aged 40-75 yr at baseline in 1986 and have been followed with biennial questionnaires. The risk analysis includes 49 409 men. The survival analysis includes 5980 PC patients without metastatic disease at diagnosis. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We used Cox proportional hazards regression to examine the association between current, past, or never regular aspirin use (≥2 d/wk) in relation to lethal (metastatic or fatal) PC. We also examined years of use among current users and years since stopping among past users. In the risk analysis, aspirin was updated throughout follow-up. In the survival analysis, aspirin use after diagnosis was assessed. RESULTS AND LIMITATIONS: Some 29% of participants used aspirin regularly at baseline, which increased to 60% by 2010. In the risk analysis, 804 men were diagnosed with lethal PC. Current regular aspirin was associated with a lower risk of lethal prostate cancer (hazard ratio [HR] 0.80, 95% confidence interval [CI] 0.66-0.96) compared to never users. In the survival analysis, 451 of the men diagnosed with nonmetastatic PC later developed lethal disease. Current postdiagnostic aspirin was associated with a lower risk of lethal PC (HR 0.80, 95% CI 0.64-1.00) and overall mortality (HR 0.79, 95% CI 0.69-0.90). When restricted to highly screened men, the risk analysis associations were stronger and survival analysis associations remained statistically significant. Reverse causation and residual confounding remain concerns, as demonstrated by the attenuated results in sensitivity analyses. CONCLUSIONS: Regular aspirin use was associated with a lower risk of lethal PC. Postdiagnostic use was associated with better survival after diagnosis. PATIENT SUMMARY: We found that it may be advisable for prostate cancer patients to take aspirin to improve their survival for both prostate cancer mortality and other mortality outcomes.

High-Intensity Focused Ultrasound (HIFU) as salvage therapy for radio-recurrent prostate cancer: predictors of disease response

ABSTRACT Background Some men with localized radio-recurrent prostate cancer may benefit from salvage high-intensity focused ultrasound (HIFU). Herein, we describe oncologic outcomes and predictors of disease response after salvage whole gland HIFU from our prospective cohort. Materials and Methods Patients with localized radio-recurrent prostate cancer were prospectively enrolled from January 2005 to December 2014. Participants had to meet both biochemical and histological definitions of recurrence. Exclusion criteria included the receipt of prior salvage therapy, presence of metastatic disease, and administration of ADT in the 6-months prior to enrollment. Participants were treated with a single session of whole-gland HIFU ablation with the AblathermTM device (EDAP, France). The primary endpoint was recurrence-free survival (RFS), defined as a composite endpoint of PSA progression (Phoenix criteria), receipt of any further salvage therapy, receipt of ADT, clinical progression, or death. Kaplan-Meier survival analysis was used to determine the primary end-point and stratifications were used to determine the significance of 6 pre-specified predictors of improved RFS (TRUS biopsy grade, number of study entry TRUS biopsy cores positive, palpable disease at study enrollment, pre-HIFU PSA, an undetectable post-HIFU PSA nadir, and receipt of prior hormone therapy). Survival analysis was performed on participants with a minimum of 1-year follow-up. Results Twenty-four participants were eligible for study inclusion with a median follow-up of 31.0 months. Median PSA at study entry was 4.02ng/ml. Median time to PSA nadir was 3 months after treatment and median post-HIFU PSA nadir was 0.04ng/ml. Median 2-year and 5-year RFS was 66.3% and 51.6% respectively. Of our 6 prespecified predictors, an undetectable PSA nadir was the only significant predictor of improved RFS (HR 0.07, 95% CI 0.02-0.29, log-rank P<0.001). One participant underwent an intervention for a urethral stricture. No participants developed osteitis pubis or rectourethral fistulae. Conclusions Salvage HIFU allows for disease control in selected patients with localized radio-recurrent prostate cancer. An undetectable PSA nadir serves as an early predictor of disease response.

Prostate cancer screening among family physicians in Ontario: An update on attitudes and current practice.

INTRODUCTION: This study serves as an update of prostate cancer screening practices among family physicians in Ontario, Canada. Since this population was first surveyed in 2010, the Canadian Task Force on Preventive Health Care (CTFPHC) and the United States Preventive Services Task Force (USPSTF) released recommendations against prostate cancer screening. METHODS: An online survey was developed through input from urologists and family practitioners. It was distributed via email to all members of the Ontario Medical Association's Section on General and Family practice (11 657 family physicians). A reminder email was sent at two weeks and the survey remained active for one month. RESULTS: A total of 1880 family physicians completed surveys (response rate 16.1%). Overall, 80.4% offered prostate cancer screening compared to 91.7% when surveyed in 2010. Physicians new to practice (two years or less) were the most likely to not offer screening (24.6%). A combination of digital rectal exam (DRE) and prostate-specific antigen (PSA) remained the most common form of screening (58.3%). Following the release of the CTFPHC recommendations, 45.6% of respondents said they now screen fewer patients. Participants were less familiar with national urological society guidelines compared to task force recommendations. The majority (72.6%) of respondents feel PSA screening leads to overdiagnosis and treatment. Those surveyed remained split with respect to PSA utility. CONCLUSIONS: Data suggest a decline in screening practices since 2010, with newer graduates less likely to offer screening. CFTPHC and USPSTF recommendations had the greatest impact on clinical practice. Those surveyed were divided with respect to PSA utility. Some additional considerations to PSA screening in the primary care setting, including patient-driven factors, were not captured by our concise survey.

High-intensity Focused Ultrasound (HIFU) as salvage therapy for radio-recurrent prostate cancer: predictors of disease response.

BACKGROUND: Some men with localized radio-recurrent prostate cancer may benefit from salvage high-intensity focused ultrasound (HIFU). Herein, we describe oncologic outcomes and predictors of disease response after salvage whole gland HIFU from our prospective cohort. MATERIALS AND METHODS: Patients with localized radio-recurrent prostate cancer were prospectively enrolled from January 2005 to December 2014. Participants had to meet both biochemical and histological definitions of recurrence. Exclusion criteria included the receipt of prior salvage therapy, presence of metastatic disease, and administration of ADT in the 6-months prior to enrollment. Participants were treated with a single session of whole-gland HIFU ablation with the AblathermTM device (EDAP, France). The primary endpoint was recurrence-free survival (RFS), defined as a composite endpoint of PSA progression (Phoenix criteria), receipt of any further salvage therapy, receipt of ADT, clinical progression, or death. Kaplan-Meier survival analysis was used to determine the primary end-point and stratifications were used to determine the significance of 6 pre-specified predictors of improved RFS (TRUS biopsy grade, number of study entry TRUS biopsy cores positive, palpable disease at study enrollment, pre-HIFU PSA, an undetectable post-HIFU PSA nadir, and receipt of prior hormone therapy). Survival analysis was performed on participants with a minimum of 1-year follow-up. RESULTS: Twenty-four participants were eligible for study inclusion with a median follow-up of 31.0 months. Median PSA at study entry was 4.02ng/ml. Median time to PSA nadir was 3 months after treatment and median post-HIFU PSA nadir was 0.04ng/ ml. Median 2-year and 5-year RFS was 66.3% and 51.6% respectively. Of our 6 pre-specified predictors, an undetectable PSA nadir was the only significant predictor of improved RFS (HR 0.07, 95% CI 0.02-0.29, log-rank P<0.001). One participant underwent an intervention for a urethral stricture. No participants developed osteitis pubis or rectourethral fistulae. CONCLUSIONS: Salvage HIFU allows for disease control in selected patients with localized radio-recurrent prostate cancer. An undetectable PSA nadir serves as an early predictor of disease response.

Pathologic correlation of transperineal in-bore 3-Tesla magnetic resonance imaging-guided prostate biopsy samples with radical prostatectomy specimen.

PURPOSE: To determine the accuracy of in-bore transperineal 3-Tesla (T) magnetic resonance (MR) imaging-guided prostate biopsies for predicting final Gleason grades in patients who subsequently underwent radical prostatectomy (RP). METHODS: A retrospective review of men who underwent transperineal MR imaging-guided prostate biopsy (tpMRGB) with subsequent radical prostatectomy within 1 year was conducted from 2010 to 2015. All patients underwent a baseline 3-T multiparametric MRI (mpMRI) with endorectal coil and were selected for biopsy based on MR findings of a suspicious prostate lesion and high degree of clinical suspicion for cancer. Spearman correlation was performed to assess concordance between tpMRGB and final RP pathology among patients with and without previous transrectal ultrasound (TRUS)-guided biopsies. RESULTS: A total of 24 men met all eligibility requirements, with a median age of 65 years (interquartile range [IQR] 11.7). The median time from biopsy to RP was 85 days (IQR 50.5). Final pathology revealed Gleason 3 + 4 = 7 in 12 patients, 4 + 3 = 7 in 10 patients, and 4 + 4 = 8 in 2 patients. A strong correlation (ρ: +0.75, p < 0.001) between tpMRGB and RP results was observed, with Gleason scores concordant in 17 cases (71%). 16 of the 24 patients underwent prior TRUS biopsies. Subsequent tpMRGB revealed Gleason upgrading in 88% of cases, which was concordant with RP Gleason scores in 69% of cases (ρ: +0.75, p < 0.001). CONCLUSION: Final Gleason scores diagnosed by tpMRGB at 3-T correlate strongly with final RP surgical pathology. This may facilitate prostate cancer diagnosis, particularly in patients with negative or low-grade TRUS biopsy results in whom clinically significant cancer is suspected or detected on mpMRI.

Regular Aspirin Use and the Risk of Lethal Prostate Cancer in the Physicians' Health Study.

BACKGROUND: Regular aspirin use probably protects against some malignancies including prostate cancer (PC), but its impact on lethal PC is particularly unclear. OBJECTIVE: To investigate the association between regular aspirin and (1) the risk of lethal PC in a large prospective cohort and (2) survival after PC diagnosis. DESIGN, SETTING, AND PARTICIPANTS: In 1981/82, the Physicians' Health Study randomized 22 071 healthy male physicians to aspirin, ß-carotene, both, or placebo. After the trial ended in 1988, annual questionnaires have obtained data on aspirin use, cancer diagnoses, and outcomes up to 2009 for the whole cohort, and to 2015 for PC patients. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We evaluated the relationship between regular aspirin (>3 tablets/week) and lethal PC (metastases or PC death). Cox proportional-hazards models estimated hazard ratios (HRs) for the risk of lethal PC in the whole cohort and postdiagnosis survival among men initially diagnosed with nonlethal PC. RESULTS AND LIMITATIONS: Risk analysis revealed that 502 men developed lethal PC by 2009. Current and past regular aspirin was associated with a lower risk of lethal PC (current: HR 0.68, 95% confidence interval [CI] 0.52-0.89; past: HR 0.54, 95% CI 0.40-0.74) compared to never users. In the survival analysis, 407/3277 men diagnosed with nonlethal PC developed lethal disease by 2015. Current postdiagnostic aspirin was associated with lower risks of lethal PC (HR 0.68, 95% CI 0.52-0.90) and overall mortality (HR 0.72, 95% CI 0.61-0.9). We could not assess aspirin dose, and inconsistencies were observed in some sensitivity analyses. CONCLUSIONS: Current regular aspirin use was associated with a lower risk of lethal PC among all participants. Current postdiagnostic use was associated with improved survival after diagnosis, consistent with a potential inhibitory effect of aspirin on PC progression. A randomized trial is warranted to confirm or refute these findings. PATIENT SUMMARY: We examined the potential effect of regular aspirin use on lethal prostate cancer. We found that taking aspirin was associated with a lower risk of lethal prostate cancer, and taking it after diagnosis may help to prevent prostate cancer from becoming fatal.

Data on Medicare eligibility and cancer screening utilization.

Health insurance is associated with increased utilization of cancer screening services. Data on breast, prostate and colorectal cancer screening were abstracted from the 2012 Behavioral Risk Factor and Surveillance System. This data in brief includes two sets of analyses: (i) the use of cancer screening in individuals within the low-income bracket and (ii) determinants for each of the three approaches to colorectal cancer screening (fecal occult blood test, colonoscopy and sigmoidoscopy+fecal occult blood test). Covariates included education attainment, residency, and access to health care provider. The data supplement our original research article on the effect of Medicare eligibility on cancer screening utilization "The impact of Medicare eligibility on cancer screening behaviors" [1].

Impact of resident involvement in endoscopic bladder cancer surgery on pathological outcomes.

OBJECTIVE: Transurethral resection of bladder tumor (TURBT) pathology specimens which lack muscle are associated with clinical upstaging and may necessitate repeat resections, potentially delaying curative treatment. This study evaluated whether resident involvement in TURBT is associated with suboptimal perioperative outcomes. MATERIALS AND METHODS: All TURBTs performed at a Canadian healthcare institution from November 2011 to June 2014 were reviewed. Multivariable logistic regression models assessed associations between intraoperative resident involvement and TURBT muscle presence. Among high-risk patients (high grade, ≥ T1 or carcinoma in situ) who underwent cystectomy, time from TURBT to cystectomy was compared between resident and attending urologists with the log-rank test. RESULTS: In total, 463 TURBTs were identified. In multivariable analyses, residents were less likely to obtain muscle in specimens for all TURBTs [adjusted odds ratio (aOR) 0.59, p = 0.03] and the subset of 275 high-risk TURBTs (aOR 0.41, p = 0.006). Among patients who underwent cystectomy, time to cystectomy was delayed by a median of 23 days when residents were involved in the initial high-risk TURBT compared with attending urologists only (p = 0.024). CONCLUSIONS: In this single academic center series, intraoperative resident involvement was associated with a decreased rate of muscle presence in TURBT specimens and a prolonged time to cystectomy.

Transurethral Resection of the Prostate Biopsy of Suspected Anterior Prostate Cancers Identified by Multiparametric Magnetic Resonance Imaging: A Pilot Study of a Novel Technique.

OBJECTIVE: To describe a novel biopsy technique that involves performing a cognitively directed transurethral resection of the prostate (TURP) to diagnose suspected anterior prostate cancers (APCs) detected by multiparametric magnetic resonance imaging (mpMRI) in patients with prior negative transrectal ultrasound (TRUS)-guided biopsies. METHODS: This is a prospective study in which participants aged 50-75 were offered inclusion if they had an elevated prostate-specific antigen level, a lesion suspicious for APC on mpMRI, and at least one prior negative TRUS-guided prostate biopsy. Prostatic mpMRI was acquired with a 3-Tesla machine without endorectal coil. Preoperative review of the mpMRI images was used to target the suspected APC on TURP biopsy. The primary outcome was the detection rate of clinically significant prostate cancer, defined as the presence of any Gleason pattern ≥ 4 in the specimen. Secondary outcomes included biopsy-related complications including 30-day readmissions. RESULTS: A total of 16 consecutive participants were enrolled. Median age was 64 years, median prostate-specific antigen was 12.4 ng/mL, and participants had a median of 2 prior negative TRUS-guided biopsies. Thirteen (81.3%) participants had clinically significant APCs detected by TURP biopsy. One participant was readmitted within 30-days postprocedure for continuous bladder irrigation. Seven participants (43.8%) underwent radical prostatectomy that confirmed clinically significant disease in all 7 participants. CONCLUSION: Among participants with anterior prostate lesions on mpMRI and prior negative TRUS-guided biopsy, TURP biopsy does detect some clinically significant cancers. This study serves as a proof of concept and further comparative trials are needed prior to widespread adoption.

Primary genitourinary melanoma: Epidemiology and disease-specific survival in a large population-based cohort.

BACKGROUND: Primary genitourinary (GU) melanoma is a rare disease, which is poorly characterized. OBJECTIVE: To examine clinical characteristics and survival outcomes of primary GU melanoma among men and women. DESIGN, SETTING, AND PARTICIPANTS: Retrospective study using the Surveillance, Epidemiology, and End Results database (1973-2010) was used to identify primary GU melanoma cases by tumor site and histology codes. We examined associations of GU melanoma with demographic, clinical, and pathologic characteristics, as well as disease-specific survival (DSS). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: DSS was calculated using the Kaplan-Meier method. Cox-proportional hazard models were used to calculate hazard ratios and 95% CI for factors associated with worse DSS. RESULTS AND LIMITATIONS: A total of 1,586 histologically confirmed cases of primary GU melanoma were identified with a median age of 66.1 years (IQR: 55-80). Incidence of primary GU melanoma was 0.2cases/million among men and 1.80cases/million among women. Overall, 60.1% of patients had localized disease at presentation and 90.5% of patients had cancer-directed surgery. Patients with urothelial melanoma had the worst 5- and 10-year DSS (39% and 29%, respectively). Women with vulvar/vaginal melanoma had worse 5- and 10-year DSS compared to men with penile/scrotal melanoma. In multivariate analysis, decreased survival was associated with increasing age, distant stage, and lymph node involvement. Results are limited by the lack of standardized staging for primary GU melanoma and the retrospective design of our study. CONCLUSIONS: Patients with primary GU melanoma present with advanced stage and have a poor prognosis. Women have worse DSS compared to men. DSS is negatively associated with advanced age at diagnosis, higher stage, and lymph node involvement. PATIENT SUMMARY: Clinicians and patients must be aware of the poor disease-specific outcomes associated with primary GU melanoma. Most importantly, women fare worse than men and mucosal melanomas have worse outcomes compared to cutaneous melanomas.

The impact of Medicare eligibility on cancer screening behaviors.

INTRODUCTION: Lack of health insurance limits access to preventive services, including cancer screening. We examined the effects of Medicare eligibility on the appropriate use of cancer screening services in the United States. METHODS: We performed a cross-sectional analysis of the 2012 Behavioral Risk Factor and Surveillance System (analyzed in 2014). Univariable and logistic regression analyses were performed for participants aged 60-64 and 66-70 to examine the effects of Medicare eligibility on prevalence of self-reported screening for colorectal, breast, and prostate cancers. Sub-analyses were performed among low-income (<$25,000 annual/household) individuals. RESULTS: Medicare-eligible individuals were significantly more likely to undergo all examined preventive services (colorectal cancer OR: 1.90; 95% CI 1.79-2.04; prostate cancer OR: 1.29; 95% CI 1.17-1.43; breast cancer OR: 1.23; 95% CI 1.10-1.37) and the effect was most pronounced among low-income individuals (colorectal cancer OR: 2.04; 95% CI 1.8-2.32; prostate cancer OR: 1.39; 95% CI 1.12-1.72; breast cancer OR: 1.42, 95% CI 1.20-1.67). Access to a healthcare provider was the strongest independent predictor of undergoing appropriate screening, ranging from OR 2.73 (95% CI 2.20-3.39) for colorectal cancer screening in the low-income population to OR 4.79 (95% CI 3.95-5.81) for breast cancer screening in the overall cohort. The difference in screening prevalence was most pronounced when comparing Medicare-eligible participants to uninsured Medicare-ineligible participants (+33.2%). CONCLUSIONS: Medicare eligibility impacts the prevalence of cancer screening, likely as a result of increased access to primary care. Low-income individuals benefit most from Medicare eligibility. Expanded public insurance coverage to these individuals may improve access to preventive services.

The Contemporary Incidence and Sequelae of Rhabdomyolysis Following Extirpative Renal Surgery: A Population Based Analysis.

PURPOSE: We evaluate the contemporary incidence and consequences of postoperative rhabdomyolysis after extirpative renal surgery. MATERIALS AND METHODS: We conducted a population based, retrospective cohort study of patients who underwent extirpative renal surgery with a diagnosis of a renal mass or renal cell carcinoma in the United States between 2004 and 2013. Regression analysis was performed to evaluate 90-day mortality (Clavien grade V), nonfatal major complications (Clavien grade III-IV), hospital readmission rates, direct costs and length of stay. RESULTS: The final weighted cohort included 310,880 open, 174,283 laparoscopic and 69,880 robotic extirpative renal surgery cases during the 10-year study period, with 745 (0.001%) experiencing postoperative rhabdomyolysis. The presence of postoperative rhabdomyolysis led to a significantly higher incidence of 90-day nonfatal major complications (34.7% vs 7.3%, p <0.05) and higher 90-day mortality (4.4% vs 1.02%, p <0.05). Length of stay was twice as long for patients with postoperative rhabdomyolysis (incidence risk ratio 1.83, 95% CI 1.56-2.15, p <0.001). The robotic approach was associated with a higher likelihood of postoperative rhabdomyolysis (vs laparoscopic approach, OR 2.43, p <0.05). Adjusted 90-day median direct hospital costs were USD 7,515 higher for patients with postoperative rhabdomyolysis (p <0.001). Our model revealed that the combination of obesity and prolonged surgery (more than 5 hours) was associated with a higher likelihood of postoperative rhabdomyolysis developing. CONCLUSIONS: Our study confirms that postoperative rhabdomyolysis is an uncommon complication among patients undergoing extirpative renal surgery, but has a potentially detrimental impact on surgical morbidity, mortality and costs. Male gender, comorbidities, obesity, prolonged surgery (more than 5 hours) and a robotic approach appear to place patients at higher risk for postoperative rhabdomyolysis.

Trends in utilisation, perioperative outcomes, and costs of nephroureterectomies in the management of upper tract urothelial carcinoma: a 10-year population-based analysis.

OBJECTIVE: To perform a population-based study to evaluate contemporary utilisation trends, morbidity, and costs associated with nephroureterectomies (NUs), as contemporary data for NUs are largely derived from single academic institution series describing the experience of high-volume surgeons and it is unclear if the same favourable results occur at a national level. PATIENTS AND METHODS: Using the Premier Hospital Database, we captured patients undergoing a NU with diagnoses of renal pelvis or ureteric neoplasms from 2004 to 2013. We fitted regression models, adjusting for clustering by hospitals and survey weighting to evaluate 90-day postoperative complications, operating-room time (OT), prolonged length of stay (pLOS), and direct hospital costs among open (ONU), laparoscopic (LNU) and robotic (RNU) approaches. RESULTS: After applying sampling and propensity weights, we derived a final study cohort of 17 254 ONUs, 13 317 LNUs and 3774 RNUs for upper tract urothelial carcinoma (UTUC) in the USA between 2004 and 2013. During that period, minimally invasive NU (miNU) increased from 36% to 54%, while the total number of NUs decreased by nearly 20%. No differences were noted in perioperative outcomes between the three surgical approaches, including when the analysis was restricted to the highest-volume hospitals and highest-volume surgeons. The OT was longer for LNU and RNU (P < 0.001), while the pLOS rates were decreased (P < 0.001). Adjusted 90-day median direct hospital costs were higher for LNU and RNU (P < 0.001), which disappeared when adjusting for the highest-volume groups, except for RNUs performed by high-volume surgeons. CONCLUSIONS: During this contemporary 10-year study, miNU has been replacing ONU for UTUC with a recent surge in RNU, along with a concurrent reduction in total NUs performed. Despite not being associated with a clinically significant improvement in perioperative outcomes, the costs for miNUs were consistently higher. However, higher hospital volumes suggest a potential cost containment strategy when performing miNUs.

Contrast-enhanced Ultrasonography for Surveillance of Radiofrequency-ablated Renal Tumors: A Prospective, Radiologist-blinded Pilot Study.

OBJECTIVE: To prospectively evaluate the performance of contrast-enhanced ultrasonography (CEUS) for surveillance after radiofrequency ablation (RFA) of small renal masses by comparing CEUS to the contrast-enhanced computed tomography (CECT), the current gold standard. PATIENTS AND METHODS: Patients underwent surveillance after RFA of small renal masses (≤4 cm) consisting of CECT scans at 3 and 6 months and every 6 months thereafter. Participants additionally underwent ≥1 CEUS within 90 days before CECT. Percutaneous biopsy was performed for lesions suspicious for recurrence on CECT. Independent, blinded radiologists interpreted CEUS and CECT scans. Intermodality agreement was evaluated with the kappa coefficient. RESULTS: In total, 37 pairs of CEUS and CECT scans were performed. Median tumor size was 2.5 cm (range, 1.4-4.0 cm). Median follow-up from RFA to CEUS was 25 months. Renal tumor recurrences were diagnosed by CECT in 3 patients and confirmed histopathologically by percutaneous biopsy; 34 CECT scans were negative for recurrence. The diagnostic rate of CEUS was 94.6%; 2 CEUS scans were nondiagnostic because of patient body habitus. Among diagnostic CEUS scans, tumor enhancement was present in 3 and absent in 32. We observed perfect concordance between CEUS and CECT (=1.0; P <.0001). CONCLUSION: This is the first prospective study incorporating radiologist blinding to evaluate CEUS for RFA surveillance. Our findings suggest CEUS may ultimately be incorporated into RFA surveillance protocols. The operator dependency of CEUS is a possible barrier to its widespread adoption. These findings justify larger studies with longer follow-up.

Contemporary trends in high-dose interleukin-2 use for metastatic renal cell carcinoma in the United States.

BACKGROUND: Targeted therapies (TTs) have revolutionized metastatic renal cell carcinoma (mRCC) treatment in the past decade, largely replacing immunotherapy including high-dose interleukin-2 (HD IL-2) therapy. We evaluated trends in HD IL-2 use for mRCC in the TT era. METHODS: Our cohort comprised a weighted estimate of all patients undergoing HD IL-2 treatment for mRCC from 2004 to 2012 using the Premier Hospital Database. We assessed temporal trends in HD IL-2 use including patient, disease, and hospital characteristics stratified by era (pre-TT uptake: 2004-2006, uptake: 2007-2009, and post-TT uptake: 2010-2012) and fitted multivariable regression models to identify predictors of treatment toxicity and tolerability. RESULTS: An estimated 2,351 patients received HD IL-2 therapy for mRCC in the United States from 2004 to 2012. The use decreased from 2004 to 2008. HD IL-2 therapy became increasingly centralized in teaching hospitals (24% of treatments in 2004 and 89.5% in 2012). Most patients who received HD IL-2 therapy were men, white, younger than 60 years, had lung metastases, and were otherwise healthy. Vasopressors, intensive care unit admission, and hemodialysis were necessary in 53.4%, 33.0%, and 7.1%, respectively. Factors associated with toxicities in multivariable analyses included being unmarried, male sex, and multiple metastatic sites. African Americans and patients with single-site metastases were less likely to receive multiple treatment cycles. CONCLUSIONS: HD IL-2 therapy is used infrequently for mRCC in the United States, and its application has diminished with the uptake of TT. Patients are being increasingly treated in teaching hospitals, suggesting a centralization of care and possible barriers to access. A recent slight increase in HD IL-2 therapy use likely reflects recognition of the inability of TT to effect a complete response.

The Effect of Resident Involvement on Perioperative Outcomes in Transurethral Urologic Surgeries.

OBJECTIVE: To conduct the first study of intra- and postoperative outcomes related to intraoperative resident involvement in transurethral resection procedures for benign prostatic hyperplasia and bladder cancer in a large, multi-institutional database. DESIGN: Relying on the American College of Surgeons National Surgical Quality Improvement Program Participant User Files (2005-2012), we abstracted all cases of endoscopic prostate surgery (EPS) for benign prostatic hyperplasia and transurethral resection of bladder tumors (TURBTs). Multivariable logistic regression models were constructed to assess the effect of trainee involvement (postgraduate year [PGY] 1-2: junior, PGY 3-4: senior, PGY ≥ 5: chief or fellow) vs attending only on operative time and length of hospital stay, as well as 30-day complication, reoperation, and readmission rates. RESULTS: In all, 5093 EPS and 3059 TURBTs for a total of 8152 transurethral resection procedures were performed during the study period for which data on resident involvement were available. In multivariable analyses, resident involvement in EPS or TURBT was associated with increased odds of prolonged operative times and hospital readmissions in 30 days independent of resident level of training. Resident involvement was not associated with overall complications or reoperation rates. CONCLUSIONS: Resident involvement in lower urinary tract surgeries is associated with increased readmissions. Strategies to optimize resident teaching of these common urologic procedures in order to minimize possible risks to patients should be explored.

The impact of method of distal ureter management during radical nephroureterectomy on tumour recurrence.

INTRODUCTON: Radical nephroureterectomy for upper tract urothelial carcinoma (UTUC) must include some form of distal ureter management to avoid high rates of tumour recurrence. It is uncertain which distal ureter management technique has the best oncologic outcomes. To determine which distal ureter management technique resulted in the lowest tumour recurrence rate, we analyzed a multi-institutional Canadian radical nephroureterectomy database. METHODS: We retrospectively analyzed patients who underwent radical nephroureterectomy with distal ureter management for UTUC between January 1990 and June 2010 at 10 Canadian tertiary hospitals. Distal ureter management approaches were divided into 3 categories: (1) extravesical tenting for ureteric excision without cystotomy (EXTRAVESICAL); (2) open cystotomy with intravesical bladder cuff excision (INTRAVESICAL); and (3) extravesical excision with endoscopic management of ureteric orifice (ENDOSCOPIC). Data available for each patient included demographic details, distal ureter management approach, pathology and operative details, as well as the presence and location of local or distant recurrence. Clinical outcomes included overall recurrence-free survival and intravesical recurrence-free survival. Survival analysis was performed with the Kaplan-Meier method. Multivariable Cox regression analysis was also performed. RESULTS: A total of 820 patients underwent radical nephroureterectomy with a specified distal ureter management approach at 10 Canadian academic institutions. The mean patient age was 69.6 years and the median follow-up was 24.6 months. Of the 820 patients, 406 (49.5%) underwent INTRAVESICAL, 316 (38.5%) underwent EXTRAVESICAL, and 98 (11.9%) underwent ENDOSOPIC distal ureter management. Groups differed significantly in their proportion of females, proportion of laparoscopic cases, presence of carcinoma in situ and pathological tumour stage (p < 0.05). Recurrence-free survival at 5 years was 46.3%, 35.6%, and 30.1% for INTRAVESICAL, EXTRAVESICAL and ENDOSCOPIC, respectively (p < 0.05). Multivariable Cox regression analysis confirmed that INTRAVESICAL resulted in a lower hazard of recurrence compared to EXTRAVESICAL and ENDOSCOPIC. When looking only at intravesical recurrence-free survival (iRFS), a similar trend held up with INTRAVESICAL having the highest iRFS, followed by ENDOSCOPIC and then EXTRAVESICAL management (p < 0.05). At last follow-up, 406 (49.5%) patients were alive and free of disease. CONCLUSION: Open intravesical excision of the distal ureter (INTRAVESICAL) during radical nephroureterectomy was associated with improved overall and intravesical recurrence-free survival compared with extravesical and endoscopic approaches. These findings suggest that INTRAVESICAL should be considered the gold standard oncologic approach to distal ureter management during radical nephroureterectomy. Limitations of this study include its retrospective design, heterogeneous cohort, and limited follow-up.

Defining a new testosterone threshold for medical castration: Results from a prospective cohort series.

BACKGROUND: We seek to determine if testosterone levels below the accepted castration threshold (50 ng/dL) have an impact on time to progression to castrate-resistant prostate cancer (CRPC). METHODS: This is a prospective cohort series of patients undergoing androgen deprivation therapy (ADT) with luteinizing hormone-releasing hormone agonist or antagonist at a tertiary centre from 2006 to 2011. Serum testosterone level was assessed every 3 months. Patients with any testosterone >50 ng/dL were excluded. Patients were stratified into groups based on those achieving mean testosterone levels <20 ng/dL and <32 ng/dL. Progression to CRPC was assessed with the Kaplan-Meier method and compared with the log-rank test. RESULTS: A total of 32 patients were included in this study. Mean patient follow-up was 25.7 months. Patients with a 9-month serum testosterone <32 ng/dL had a significantly increased time to CRPC compared to patients with testosterone 32 to 50 ng/dL (p = 0.001, median progression-free survival (PFS) 33.1 months [<32 ng/dL] vs. 12.5 months [>32 ng/dL]). Patients with first year mean testosterone <32 ng/dL also had a significantly increased time to CRPC compared to 32 to 50 ng/dL (p = 0.05, median PFS 33.1 months [<32 ng/dL] vs. 12.5 months [32-50 ng/dL]). A testosterone <20 ng/dL compared to 20 to 50 ng/dL did not significantly predict with time to CRPC. CONCLUSION: This study supports a lower testosterone threshold to define optimal medical castration (T <32 ng/dL) than the previously accepted standard of 50 ng/dL. Testosterone levels during ADT serve as an early predictor of disease progression and thus should be measured in conjunction with prostate-specific antigen.

A novel endoscopic treatment for ureteric remnant hemorrhage post laparoscopic radical nephrectomy.

Laparoscopic radical nephrectomy is commonly used to treat renal masses. Given the ubiquitous presence of this technique, rare complications are becoming more commonplace. It is thus essential that practicing urologists be aware of all possible complications as well as the novel management approaches that exist. This report presents a situation in which a patient developed rapid-onset, postoperative gross hematuria. This complication is rare and multiple sources of bleeding must be considered. In the situation reported here, the ureteric remnant was the cause of the unremitting gross hematuria. While others have described surgical exploration as the primary treatment, the authors were successful in using a minimally invasive endoscopic approach with fulguration and instillation of a fibrin sealant. Indeed, they propose that the endoscopic approach described herein may be considered first line in cases of unremitting gross hematuria originating from the ureteric remnant.