Time to therapy and safety of testicular tissue cryopreservation in children undergoing gonadotoxic treatment or hematopoietic stem cell transplant.

BACKGROUND: With the use of multimodal treatments and hematopoietic stem cell transplant, the majority of children diagnosed with malignancies and hematologic diseases are now surviving into adulthood. Due to the gonadotoxic effects and potential for future infertility associated with many of these treatments, fertility counseling with sperm cryopreservation prior to starting therapy is the standard of care for post-pubertal males. Unfortunately, the options are limited for pre-pubertal patients or those unable to provide a specimen. Testicular tissue cryopreservation (TTC) is an investigational method to surgically obtain germ cells from testicular tissue and potentially restore future spermatogenesis. While TTC has been shown to be safe, little is reported on the time to treatment following the procedure to ensure adequate wound healing and avoid delays in definitive therapy. OBJECTIVES: The primary outcome was the time to initiation of treatment following TTC. Secondary outcomes were complication rates, delays in treatment due to TTC, and presence of germ cells. METHODS: We conducted a single-institution retrospective cohort study of patients undergoing TTC between 2017 and 2023. Patients at significant risk for treatment related infertility based on established criteria were eligible for TTC. Patients were excluded if they received their oncology or hematology care elsewhere. All patients were enrolled in an IRB approved research protocol with 75% of the tissue submitted for cryopreservation and 25% for research purposes. Time to therapy was defined as the first receipt of gonadotoxic treatment following TTC. RESULTS: A total of 122 patients (53 = malignant, 69 = non-malignant) underwent TTC with a median age of 5.9 years (IQR 2.3-9.35). Germ cells were identified in 115 (94%) specimens. A total of 109 (89%) patients underwent concomitant procedures. The median time to initiation of therapy was 5 (IQR 1.0-7.0) and 7 days (IQR 6.0-13.0) for malignant and non-malignant disease, respectively. The 30-day surgical complication rate was 2.5% and was similar between malignant vs non-malignant diagnoses (p = 0.58). All surgical complications were managed non-operatively. No patients had a delay in definitive treatment due to concern for wound healing or complications. DISCUSSION: Our surgical complication rates are similar to previous studies and are not affected by the time to treatment following TTC. Limitations of the study are its retrospective design, single institution, and short-term follow up. CONCLUSION: TTC can be performed safely, efficiently, and in conjunction with other necessary procedures without resulting in delays of definitive treatment. TTC affords the opportunity for fertility preservation in children who have no other options.

Reoperative Anorectal Procedures in Patients with Anorectal Malformations - Is Bladder Function Affected?

BACKGROUND: Anorectal malformations (ARM) are associated with neurogenic bladder. The traditional surgical ARM repair is a posterior sagittal anorectoplasty (PSARP), which is believed to have a minimal effect on bladder dynamics. However, little is known about the effects of reoperative PSARP (rPSARP) on bladder function. We hypothesized that a high rate of bladder dysfunction existed in this cohort. METHODS: We performed a retrospective review of ARM patients undergoing rPSARP at a single institution from 2008 to 2015. Only patients with Urology follow-up were included in our analysis. Data was collected regarding original level of ARM, coexisting spinal anomalies and indications for reoperation. We assessed urodynamic variables and bladder management (voiding, CIC or diverted) before and after rPSARP. RESULTS: A total of 172 patients were identified, of which 85 met inclusion criteria with a median follow-up of 23.9 months (IQR, 5.9-43.8 months). Thirty-six patients had spinal cord anomalies. Indications for rPSARP included mislocation (n = 42), posterior urethral diverticulum (PUD; n = 16), stricture (n = 19) and rectal prolapse (n = 8). Within 1 year following rPSARP, 11 patients (12.9%) had a negative change in bladder management, defined as need for beginning intermittent catheterization or undergoing urinary diversion, which increased to 16 patients (18.8%) at last follow-up. Postoperative bladder management changed in rPSARP patients with mislocation (p < 0.0001) and stricture (p 0.005) but not for rectal prolapse (p 0.143). CONCLUSIONS: Patients who undergo rPSARP warrant especially close attention for bladder dysfunction as we observed a negative postoperative change in bladder management in 18.8% of our series. LEVEL OF EVIDENCE: Level IV.

Incidence and seasonality of respiratory viruses among medically attended children with acute respiratory infections in an Ecuador birth cohort, 2011-2014.

BACKGROUND: Ecuador annually has handwashing and respiratory hygiene campaigns and seasonal influenza vaccination to prevent respiratory virus illnesses but has yet to quantify disease burden and determine epidemic timing. METHODS: To identify respiratory virus burden and assess months with epidemic activity, we followed a birth cohort in northwest Ecuador during 2011-2014. Mothers brought children to the study clinic for routine checkups at ages 1, 2, 3, 5, and 8 years or if children experienced any acute respiratory illness symptoms (e.g., cough, fever, or difficulty breathing); clinical care was provided free of charge. Those with medically attended acute respiratory infections (MAARIs) were tested for common respiratory viruses via real-time reverse-transcription polymerase chain reaction (rRT-PCR). RESULTS: In 2011, 2376 children aged 1-4 years (median 35 months) were enrolled in the respiratory cohort and monitored for 7017.5 child-years (cy). The incidence of respiratory syncytial virus (RSV) was 23.9 (95% CI 17.3-30.5), influenza 10.6 (2.4-18.8), adenoviruses 6.7 (4.6-28.0), parainfluenzas 5.0 (2.3-10.5), and rhinoviruses, bocaviruses, human metapneumoviruses, seasonal coronaviruses, and enteroviruses <3/100 cy among children aged 12-23 months and declined with age. Most (75%) influenza detections occurred April-September. CONCLUSION: Cohort children frequently had MAARIs, and while the incidence decreased rapidly among older children, more than one in five children aged 12-23 months tested positive for RSV, and one in 10 tested positive for influenza. Our findings suggest this substantial burden of influenza occurred more commonly during the winter Southern Hemisphere influenza season.

Diagnosis, management and recurrence rates of Mitrofanoff polyps.

BACKGROUND: Intraluminal polyps are a known complication following creation of a urinary continent catheterizable channel (Mitrofanoff). These polyps can lead to difficult catheterizations in addition to symptomatic bleeding. However, there is limited data available regarding management and outcomes of these polyps. We aim to describe clinical presentation and management of a large series of polyps occurring in a Mitrofanoff channel. METHODS: We performed a retrospective review of all patients that were treated for polyps in a Mitrofanoff at our institution. Information was collected regarding presenting symptoms, management and recurrence rates of the polyps. RESULTS: A total of 24 patients were identified that fulfilled inclusion criteria. The majority of these polyps developed in channels composed of appendix (87%), while only 3 patients (13%) had polyps develop in an ileal composed channel. Thirteen (54%) of these polyps were incidentally diagnosed while 11 patients presented with a variety of symptoms such as difficulty in catheterization, bleeding with catheterization or both difficulty catheterizing and bleeding. For management of the polyps, a cystoscopy was performed and snaring the polyp with stone basket was performed in 37%, energy was applied to base to remove polyps in 33%, 16% were fulgurated and only 13% were left in situ. All procedures were performed under general anesthesia and all of the pathology was benign showing chronic inflammatory tissue. Eight polyps (33%) recurred after initial treatment. DISCUSSION: We did not observe an asymptomatic channel polyp convert to a symptomatic during our follow up period. Our experience has led us to not intervene on all asymptomatic Mitrofanoff polyps encountered during cystoscopy under assumption they will inevitably become symptomatic. Although we admit our follow up period may not be long enough to make this a universal declaration of best practice when any Mitrofanoff polyp is diagnosed. Endoscopic treatment was effective minimally invasive method to address the symptomatic polyp rather than excision and construction of new channel. CONCLUSIONS: This is the largest series to date of polyps developing in urinary continent catheterizable channels. The majority of these polyps were encountered incidentally however symptomatic polyps presented with difficulty with catheterizations. Symptomatic polyps can be managed endoscopically but recurrence of the polyp can occur.

Clinical Epidemiology and Outcomes of Pediatric Musculoskeletal Infections.

OBJECTIVES: To understand the epidemiology of acute hematogenous osteomyelitis and septic arthritis, including clinical and demographic features, microbiology, treatment approaches, treatment-associated complications, and outcomes. STUDY DESIGN: Retrospective cohort study of 453 children with acute hematogenous osteomyelitis and/or septic arthritis from 2009 to 2015. RESULTS: Among the 453 patients, 218 (48%) had acute hematogenous osteomyelitis, 132 (29%) had septic arthritis, and 103 (23%) had concurrent acute hematogenous osteomyelitis/septic arthritis. Treatment failure/recurrent infection occurred in 41 patients (9%). Patients with concurrent acute hematogenous osteomyelitis/septic arthritis had longer hospital stays, longer duration of antibiotic therapy, and were more likely to have prolonged bacteremia and require intensive care. Staphylococcus aureus was identified in 228 (51%) patients, of which 114 (50%) were methicillin-resistant S aureus. Compared with septic arthritis, acute hematogenous osteomyelitis and concurrent acute hematogenous osteomyelitis/septic arthritis were associated with higher odds of treatment failure (OR, 8.19; 95% CI, 2.02-33.21 [P = .003]; and OR, 14.43; 95% CI, 3.39-61.37 [P < .001], respectively). The need for more than 1 surgical procedure was also associated with higher odds of treatment failure (OR, 2.98; 95% CI, 1.18-7.52; P = .021). Early change to oral antibiotic therapy was not associated with treatment failure (OR, 0.64; 95% CI, 0.24-1.74; P = .386). Most (73%) medically attended treatment complications occurred while on parenteral therapy. CONCLUSIONS: Musculoskeletal infections are challenging pediatric infections. S aureus remains the most common pathogen, with methicillin-resistant S aureus accounting for 25% of all cases. Concurrent acute hematogenous osteomyelitis/septic arthritis is associated with more severe disease and worse outcomes. Fewer treatment-related complications occurred while on oral therapy. Early transition to oral therapy was not associated with treatment failure.

Prevalence of Nocturia in United States Women: Results From National Health and Nutrition Examination Survey.

INTRODUCTION: Nocturia can be one of the most bothersome lower urinary tract symptoms that can significantly affect quality of life. In both sexes, nocturia has been associated with decreased overall health. We aim to assess the prevalence of nocturia in US females and identify factors associated with significant nocturia. METHODS: A cross-sectional, US population-based database (National Health and Nutrition Examination Survey) was queried for females surveyed during the years 2009 to 2014. Nocturia information was obtained from the question, "how many times do you urinate at night?" Significant nocturia was defined as those women who urinated 2 or more times per night. Demographic characteristics, information on urinary incontinence, and gynecologic/obstetrical history were analyzed. Multivariable logistic regression was performed to identify factors associated with significant nocturia. RESULTS: A total of 7620 adult women were available for analysis. Of all women, 28.8% (95% confidence interval, 27.3-30.3) reported significant nocturia. Nocturia rates increased with increasing age (P < 0.0001). For those women who underwent childbirth, delivery type had no association with nocturia (P = 0.23). On multivariable analysis, only increasing age, black race, body mass index of 30 or greater, urge incontinence, and poor overall health were associated with increased rates of nocturia. Higher levels of education and increased household income were associated with lower rates of nocturia. CONCLUSIONS: Nocturia is prevalent in the United States with almost 30% of all women reporting significant nocturia. Importantly, nocturia does not affect only older individuals, as 1 in 6 women under the age of 40 years report waking 2 or more times per night to urinate.

Outcomes according to channel type for continent catheterizable channels in patients undergoing simultaneous urinary and fecal reconstruction.

INTRODUCTION: When creating a continent catheterizable channel (CCC) the choice of bowel segment used as the conduit should be tempered with the morbidity associated with it. The split-appendix technique allows the creation of both a urinary and fecal CCC without the need for a bowel anastomosis. However, there is concern that by splitting the appendix there is compromise to its blood supply and may affect outcomes. We aim to compare what affect the bowel segment used for urinary and fecal CCCs has on perioperative and long-term outcomes in patients undergoing simultaneous urinary and fecal reconstruction. METHODS: A retrospective review was performed analyzing all patients that underwent simultaneous continent catheterizable urinary and fecal CCC between the years 2010-2016. Patient demographics, channel characteristics, perioperative complications and clinical success rate were analyzed. RESULTS: A total of 106 patients were identified that had simultaneous fecal and urinary CCC created at time of reconstruction. For urinary CCC, there were 64 patients (60.4%) that underwent a split-appendix technique, 27 patients (25.4%) underwent a Monti, and 15 patients (14.2%) had the appendix used only for the urinary channel. Those patients undergoing a split-appendix technique had median operative time of 447 min compared to 619 min when a Monti channel was created. The median length of hospital stay was 9 days for the split-appendix technique compared to 12 and 13 day median hospital stay when the appendix was used only for the urinary channel or a Monti was created, respectively. There was no difference seen in revision free survival of the channel following surgery of any of the channels with median follow-up of 44.5 months. However, there were more subfascial revisions of urinary CCC in those that underwent a Monti (5 patients, 18.5%) compared to other bowel segments (0 patients). CONCLUSIONS: Utilizing a split-appendix approach for creation of urinary and fecal CCCs does not affect 30-day complications or long-term revision rates compared to other established techniques. This technique minimizes the potential surgical morbidity of a bowel anastomosis and provide shorter operative times, when feasible, at time of simultaneous creation of fecal and urinary CCC.

Renal cell carcinoma and brain metastasis: Questioning the dogma of role for cytoreductive nephrectomy.

INTRODUCTION: Renal cell carcinoma (RCC) brain metastasis is generally viewed as poor prognostic features and often excludes patients from cytoreductive nephrectomy or participation in clinical trials. We aim to evaluate patients presenting with brain metastasis and their outcomes. METHODS: Surveillance Epidemiology and End Results-18 registries database was queried for all patients with metastatic RCC from 2010 to 2014. Patients with renal cancer as their only malignancy were included. Information was available for metastatic disease to bone, liver, lung, and brain. Patients were then further stratified into those with isolated brain metastases and those with additional metastasis to other sites as well. Overall survival was compared between groups using logrank analysis. RESULTS: A total of 6,667 patients were identified with metastatic RCC. Among them, 775 (12.1%) had brain metastasis at time of diagnosis. Of these patients with brain metastasis, 152 (20.4%) had isolated brain metastasis. Only 23.8% of all patients with brain metastasis underwent cytoreductive nephrectomy, compared to 40.8% of patients with isolated brain metastasis. Patients with brain and other metastasis and brain metastasis only treated by cytoreductive nephrectomy exhibited a median survival of 11 and 33 months, respectively. Those patients who did not undergo cytoreductive nephrectomy experienced a median survival of 4 and 5 months, respectively. CONCLUSION: It appears that selected patients with brain metastasis may experience durable long-term survival. This information may be beneficial for patient counseling, surgical planning, and consideration for inclusion in clinical trials.

Utility of Routine Axillary Ultrasound Surveillance in Breast Cancer Survivors with Previously Diagnosed Metastatic Axillary Adenopathy.

OBJECTIVE: The purpose of this study is to evaluate the utility of routine axillary ultrasound surveillance in asymptomatic T1 or T2 breast cancer patients with 1 to 2 positive axillary nodes that did not undergo axillary lymph node dissection. METHODS: A retrospective review of our institutional database identified axillary and breast ultrasound examinations performed between February 1, 2011, and August 31, 2017, in asymptomatic T1 or T2 breast cancer patients with 1 to 2 positive axillary nodes that did not undergo axillary lymph node dissection. From the electronic medical record, patient demographics, imaging data, pathology results, and surgical reports were extracted. Positive predictive values (PPVs) 2 and 3 and cancer detection rate (CDR) were calculated with exact 95% confidence intervals (CIs). RESULTS: An average of 2.1 surveillance examinations was performed in 77 unique patients, yielding 160 total examinations. For 7 patients, 7 biopsies were recommended, and 5 biopsies were performed. No malignancy was diagnosed, yielding a PPV2 of 0% (0/7) (95% CI = 0% to 35%); PPV3 of 0% (0/5) (95% CI = 0% to 45%), and CDR of zero per 1000 (0/160) examinations (95% CI = 0 to 19). CONCLUSION: Given the low frequency of axillary recurrence, routine axillary surveillance ultrasound in women with T1 or T2 breast cancers and 1 to 2 positive lymph nodes would be expected to have a low incremental CDR compared to clinical evaluation alone. Axillary surveillance ultrasound should not be routinely recommended or performed.

Is pelvic lymph node dissection necessary in patients with biopsy proven Gleason 6 prostate cancer? - analysis of the SEER database.

INTRODUCTION: Since the advent of prostate-specific antigen (PSA) screening there has been a decreased incidence of lymph node positive disease (LND). Nevertheless, because of possible upgrading, LND is frequently performed with preoperative Gleason 6 prostate cancer. We utilized the Surveillance Epidemiology and End Results (SEER) database to evaluate the frequency of LND and preoperative variables for node positivity in contemporary patients with preoperative Gleason 6 disease. MATERIALS AND METHODS: SEER-18 registries database was queried for all patients diagnosed with prostate cancer between the years 2010 and 2014. Patients were excluded that had unknown histology or unknown preoperative or postoperative Gleason score. We evaluated the rate of LND, Gleason upgrading, and node positive events. RESULTS: There were 16,544 patients with preoperative Gleason 6 disease that met our inclusion criteria. Of these, 35.4% (5,856 patients) had LND and 64.6% (10,688 patients) did not. Gleason upgrade on final pathology was found in 51.9% and 45.0% of the LND and no LND cohorts, respectively. There were only 62 (1.1%) patients with node positive disease following LND. These patients had higher preoperative PSA and clinical stage disease. CONCLUSION: In a contemporary cohort of patients with preoperative Gleason 6 prostate cancer LND continues to be performed in about 35% of cases. Despite significant rate of Gleason upgrading on final pathology, only 1% will have node positive disease. With available data on morbidity of LND, the LND for preoperative Gleason 6 prostate in contemporary PSA screened cancer cohorts is likely not warranted.

Robotic conversion of cecostomy tube to catheterizable antegrade continence enema (ACE): Surgical technique.

INTRODUCTION: Antegrade continence enema (ACE) is a well described treatment for pediatric patients with neurogenic bowel refractory to medical and retrograde management. ACE can be carried out either by catheterizable channel with enteric conduit or a cecostomy tube appliance. For those patients who have issues with pain or leakage around the cecostomy appliance or wish to be appliance free, we present our initial results and description of a novel technique of laparoscopic conversion of cecostomy to catheterizable ACE which uses the existing tract and requires no enteric conduit. METHODS: A single institution, retrospective chart review was carried out for 2014-2017 to identify patients undergoing ACE conversion. Preoperative parameters included age, sex, weight, neurogenic bowel etiology and time from initial cecostomy. Perioperative data included length of surgery, length of hospitalization and postoperative complications (via Clavien-Dindo scale). Postoperative follow up, ancillary procedures pertinent to the ACE and status at time of submission are also presented. RESULTS: Six patients were identified (mean age 14.1 +/- 4.3 years) with median follow up of 36 months (range 18-65). Neurogenic bowel etiology was spina bifida in five and spinal cord injury in one; all patients had concurrent neurogenic bladder with preexisting appendicovesicostomy. Mean operative time was 168 +/- 37 min (range 122-228) and mean length of hospital stay was 2 days (range 1-4). Success rate is 83% (5/6 continue to catheterize ACE channel), with one patient opting back for appliance through same tract. One patient has required operative revision for stomal stenosis. CONCLUSION: To our knowledge, this is the first report describing robotic-assisted laparoscopic conversion of cecostomy tube to a catheterizable ACE. The surgical technique we describe is simple and safe with minimal morbidity to the patient. It does not require an enteral conduit, and may represent a valid treatment in patients without the option of using the appendix.

Genital Wart and Human Papillomavirus Prevalence in Men in the United States From Penile Swabs: Results From National Health and Nutrition Examination Surveys.

INTRODUCTION: Human papillomavirus (HPV) is a common sexually transmitted infection in the United States that can lead to both malignant (high-risk) and benign (low-risk) findings. These low-risk findings include both genital condyloma, anal warts, and adult or juvenile papillomatosis, which are directly attributable to subtypes HPV 6 and HPV 11. We aim to estimate the prevalence of genital wart infections in men in the US population using a nationwide sample. METHODS: The NHANES database was queried for all men aged 18 to 59 years during the years 2013 to 2014. During these years, the survey included penile swabs that were tested for HPV infection from 37 subtypes using PCR. Information was also obtained regarding patient reported history of having a genital wart infection previously. RESULTS: A total of 1757 men had information regarding HPV DNA. Fifty-three men tested positive for HPV 6 or HPV 11 DNA. This corresponds to an estimated prevalence of 2.9% (95% confidence interval, 2.2-3.8) of men aged 18-59 years. In addition, 2.2% (95% confidence interval, 1.5-3.3) of men reported a history of genital wart infection. There was no significant association with genital HPV DNA detection with age. Increasing number of sexual partners was associated with higher rates of both genital warts and HPV 6 and HPV 11 DNA. CONCLUSIONS: The estimated prevalence of genital HPV DNA in the US male population is 2.9%. This burden of disease could potentially be lowered with increased usage of quadrivalent and nonavalent vaccinations.

Primary urethral carcinoma: A Surveillance, Epidemiology, and End Results data analysis identifying predictors of cancer-specific survival.

OBJECTIVES: Primary urethral carcinoma (PUC) is rare, accounting for <1% of genitourinary malignancies. Current knowledge regarding is founded upon tertiary care centers reporting their experiences. We aim to identify factors predictive of outcomes using a nationwide registry database. MATERIALS AND METHODS: The Surveillance, Epidemiology, and End Results-18 registries database was queried for cases of PUC ranging between 2004 and 2010. To identify PUC cases, ICD-O site code C68.0 was used as a filter, hence identifying PUC with histologic subtypes including urothelial carcinoma (UC), squamous cell carcinoma (SCC), and adenocarcinoma (AC). Tumor characteristics were compared using log-rank analysis, and survival outcomes were compared using Cox proportional hazards models. RESULTS: A total of 419 PUC cases were identified, 250 (59.7%) male and 169 (40.3%) female patients. The most common histology in men was UC (134, 53.6%), followed by SCC (87, 34.8%) and AC (29, 11.6%). The most common histology in women was AC (79, 46.7%), followed by SCC (43, 25.4%) and UC (42, 24.9%). Log-rank analysis illustrated significant difference in cancer-specific survival (CSS) for T-stage, N-stage, M-stage, and stage of PUC with all histological variants combined (P < 0.001). Multivariate Cox proportional hazards model demonstrated that stage and age were significant for survival, with a risk ratio of 1.033 (95% confidence interval [CI], 1.020-1.046)/year of increased age (P < 0.001) and 3.71 (95% CI, 2.72-5.05) for patients with regional or distant spread. CONCLUSIONS: Knowledge of patient and tumor characteristics that influences survival is paramount in dictating management. The present study illustrates that age and stage are factors significantly associated with CSS in PUC.

Clinical and Patient-reported Outcomes of 1-sided Anterior Urethroplasty for Long-segment or Panurethral Strictures.

OBJECTIVE: To evaluate clinical and patient-reported urinary and sexual outcomes after a long-segment stricture repair using the 1-sided urethral dissection, penile invagination, and dorsal buccal mucosa graft onlay technique described by Kulkarni et al. METHODS: Patients from 4 institutions after single-stage repairs for long-segment urethral strictures (>8 cm) from January 2002 to April 2016 were reviewed. Technique described by Kulkarni et al was used in all cases. Clinical outcomes included uroflowmetry (Qmax) and post-void residuals. Patient-reported outcome measures included International Prostate Symptom Score survey, Sexual Health Inventory for Men, Male Sexual Health Questionnaire, and Global Response Assessment questionnaire to measure voiding, sexual, ejaculatory symptoms, and overall improvement, respectively. RESULTS: Seventy-three patients with a minimum of 12 months' follow-up were included. The mean age and stricture length were 56 (21-80) years and 13.6 (8-21) cm, respectively. At a mean follow-up of 44 (12-162) months, 9 of 73 (12%) strictures recurred. The mean baseline International Prostate Symptom Score of 23 (7-24) decreased to 10 (1-17) on follow-up (P <.001). Eight of 42 patients (21.4%) reported an increase, and 6 of 42 patients (14.3%) decreased in Sexual Health Inventory for Men following urethroplasty. Ejaculatory function on Male Sexual Health Questionnaire improved after urethroplasty from 8 preoperatively to 11 postoperatively (P <.004). All patients reported improvement after urethroplasty on Global Response Assessment questionnaire. Post-void dribbling and chordee occurred in 45% and 25% of patients, respectively. CONCLUSION: Durable patency in most patients is demonstrated in this study. PROMs indicate an improvement in urinary function and moderate effect on sexual function. Transient penile chordee was evident in 25% of patients.

Comparison of survival for partial vs. radical nephrectomy in young patients with T1a renal cell carcinoma treated at commission on cancer-accredited facilities and influence of comorbidities on treatment choice.

PURPOSE: There is a paucity of data comparing effects of partial nephrectomy (PN) vs. radical nephrectomy (RN) on overall survival in young patients. In this study, the National Cancer Database was used to evaluate the survival outcomes of those treated with PN and RN, and influence of comorbidities on surgical treatment (PN vs. RN) in young patients while accounting for Charlson-Deyo Comorbidity Score (CDCS). MATERIALS AND METHODS: Patients between 20 and 44 years old (n = 9,849) surgically treated for pT1a renal cell carcinoma between 2004 and 2013 were identified from the National Cancer Database. Kaplan-Meier log-rank analysis and Cox proportional hazards model were performed to compare overall survival and calculate the hazard ratio between those undergoing RN and PN. Binary logistic regression was used to calculate odds ratios for receiving RN compared to PN. The effect measures in all models were adjusted for potential confounding factors. RESULTS: After adjusting for comorbidities, PN offered an overall survival advantage over RN (P<0.001, hazard ratio = 0.464, 95% CI: 0.359-0.601) at a mean follow-up of 48.4 months (0-130.96), including young patients with no comorbidities (P<0.001). Compared to those with a CDCS = 0, patients were more likely to be treated with RN if they had a CDCS>1 (odds ratios = 2.049, 95% CI: 1.527-2.750). CONCLUSIONS: Young patients treated with PN demonstrate an overall survival advantage. This survival advantage is observed after an early follow-up even in those without comorbidities. It is still not clear if the survival advantage seen is due to treatment itself or selection bias.

Are we underestimating the rates of incontinence after prostate cancer treatment? Results from NHANES.

PURPOSE: Local therapy for prostate cancer (PCa) includes radical prostatectomy (RP) and radiotherapy (XRT), both of which share a complication of urinary incontinence. Post-treatment incontinence has been reported to occur 6-69%, yet no truly patient-centered report has been compiled. We evaluated patient-reported incontinence rates and bother scores after treatment for prostate cancer. METHODS: The NHANES database was queried for all men who reported a diagnosis and treatment of PCa from 2001 to 2010. A control arm of men without a diagnosis of PCa age 60-80 years was constructed for baseline incontinence rates. Incontinence was patient-reported and obtained through questionnaires. Three additional cohorts were created for patients treated with RP, XRT or combination RP and XRT. RESULTS: We identified 316 men treated for prostate cancer, of which 136 reported RP and 125 reported XRT, who were compared to 3534 controls. Men that underwent RP experience significant incontinence rates of 23% compared to 12% of those patients treated with XRT, whereas those patients with combined therapy had incontinence rates of 52% (p < 0.0001). Bother scores did not significantly vary, but were increased compared to baseline. Urge incontinence did not differ between treatment groups, but stress incontinence was significantly higher in surgical patients. CONCLUSION: These data from a nationwide sample of patient-reported urinary outcomes have limited interviewer bias and report significantly higher incontinence rates, which may impact prostate cancer discussions. This further underscores the importance of patient-reported outcomes in the evaluation of treatment success and counseling for patients with prostate cancer.

Surgical Techniques in the Management of Small Renal Masses.

This article provides a review and outline of the various surgical techniques for small renal masses. It covers surgical approaches and compares outcomes of open versus minimally invasive surgery. The article discusses renal nephrometry scoring and renal ischemia at time of resection. Techniques for controlling the renal hilum and controlling blood flow to the kidney are described. Extirpative techniques for small renal masses are reviewed along with a comparison of outcomes. With careful adherence to key oncologic and surgical principles, negative margins, no complications, and no or minimal decline in renal functional outcomes can be achieved.

The metastatic potential of renal tumors: Influence of histologic subtypes on definition of small renal masses, risk stratification, and future active surveillance protocols.

OBJECTIVE: The influence of histology in metastatic potential is often overlooked when discussing the management options of small renal masses (SRM), with size or growth rate often serving as the triggers for the intervention. We aim to re-examine the definition of a SRM by evaluating the metastatic potential of renal masses incorporating tumor size and histology to create metastatic risk tables. MATERIALS AND METHODS: Surveillance Epidemiology and End Results (SEER)-18 registries database was queried for all cases of clear cell, papillary, and chromophobe renal cell carcinoma (RCC) diagnosed between 2004 and 2012. There were 55,478 cases identified that included 43,783, 8,587, and 3,208 cases of clear cell, papillary, and chromophobe, respectively. Tumors were stratified using 1-cm increments to determine the metastatic potential by calculating the metastatic rate at presentation for different size intervals in histologic categories. RESULTS: For all 3 histologies, tumors measuring 5cm or less had a rate of metastatic RCC at presentation of less than 4%. The metastatic potential was highest for clear cell, followed by papillary and then chromophobe tumors. Setting a cutoff of no more than 3% for metastatic potential to be called a SRM, makes clear cell carcinoma and papillary carcinoma a SRM up to 4cm, whereas the chromophobe RCC would be considered a SRM up to 7cm. CONCLUSION: Although clinical staging and tumor size have been the key determinants in decision-making of patients with solid renal tumors, the histology-specific risks of metastatic potential are different for each mass. The definition of a SRM should be based on the metastatic potential and not on tumor size alone. This information could be helpful for counseling and managing patients with SRMs as well as for modifying active surveillance protocols.

Adjuvant Radiation Improves Survival in Older Women Following Breast-Conserving Surgery for Estrogen Receptor-Negative Breast Cancer.

PURPOSE: Published prospective trials have questioned the role of post-lumpectomy radiotherapy in older women with early-stage, estrogen receptor-positive (ER+) breast cancer. As the population with ER- tumors may be at greater risk for relapse, particularly given that endocrine therapy is not effective, we hypothesize the addition of radiation would be of benefit in patients age ≥ 70. METHODS AND MATERIALS: The Surveillance, Epidemiology, and End Results database was queried from 1998 to 2011 for patients age ≥ 70 years receiving breast-conserving surgery for T1, ER- invasive ductal carcinoma. Patients were separated into 2 cohorts: those treated with and without adjuvant radiotherapy. Chi-square analysis, unpaired t test and Kaplan-Meier log-rank were used to compare patient and tumor characteristics as well as overall and cancer-specific survival between the cohorts. RESULTS: Overall, 3685 patients received radiation and 1493 patients received lumpectomy alone. Patients treated with adjuvant radiation were younger (median age 76 vs. 78 years, P < .0001). Patients who received radiation had improved overall survival, with 5-year survival rates of 81.0% versus 61.7% without radiation (P < .0001). Cancer-specific survival was also improved with radiotherapy, with 5-year cancer-specific survival rates of 93.1% versus 85.0% (P < .0001). CONCLUSIONS: This analysis of the SEER database demonstrates that women ages 70 and older treated with lumpectomy and radiotherapy for ER-, early-stage breast cancer have improved overall survival and breast cancer-specific survival compared with patients treated with lumpectomy alone. This information may help in the decision-making process for this patient population.

Chromophobe Renal Cell Carcinoma is the Most Common Nonclear Renal Cell Carcinoma in Young Women: Results from the SEER Database.

PURPOSE: The renal cell cancer incidence is relatively low in younger patients, encompassing 3% to 7% of all renal cell cancers. While young patients may have renal tumors due to hereditary syndromes, in some of them sporadic renal cancers develop without any family history or known genetic mutations. Our recent observations from clinical practice have led us to hypothesize that there is a difference in histological distribution in younger patients compared to the older cohort. MATERIALS AND METHODS: We queried the SEER (Surveillance, Epidemiology and End Results) 18-registry database for all patients 20 years old or older who were surgically treated for renal cell carcinoma between 2001 and 2008. Patients with unknown race, grade, stage or histology and those with multiple tumors were excluded from study. Four cohorts were created by dividing patients by gender, including 1,202 females and 1,715 males younger than 40 years old, and 18,353 females and 30,891 males 40 years old or older. Chi-square analysis was used to compare histological distributions between the cohorts. RESULTS: While clear cell carcinoma was still the most common renal cell cancer subtype across all genders and ages, chromophobe renal cell cancer was the most predominant type of nonclear renal cell cancer histology in young females, representing 62.3% of all nonclear cell renal cell cancers (p <0.0001). In all other groups papillary renal cell cancer remained the most common type of nonclear renal cell cancer. CONCLUSIONS: It is possible that hormonal factors or specific pathway dysregulations predispose chromophobe renal cell cancer to develop in younger women. We hope that this work provides some new observations that could lead to further studies of gender and histology specific renal tumorigenesis.