Multicentric experience in Retzius-sparing robot-assisted radical prostatectomy performed by expert surgeons for high-risk prostate cancer.

BACKGROUND: The study aim was to report the results of Retzius-Sparing robot-assisted radical Prostatectomy (RSP) in high-risk prostate cancer (HR-PCa) patients in a multicentric setting of expert surgeons and to analyze predictors of positive surgical margins (PSMs) and urinary continence recovery. METHODS: We retrospectively evaluated all consecutive HR-PCa patients who underwent RSP by expert surgeons in 7 centers. Pre-, peri- and postoperative features were collected. Minimum surgical experience required was 100 RSP cases. The oncological outcomes evaluated were PSMs and biochemical relapse (BCR). Urinary continence was defined as no pad or safety pad. Erectile function was defined as erections sufficient for intercourse. RESULTS: We collected 579 patients operated by 9 surgeons. Median age was 66, median PSA was 9,6 ng/mL. ISUP biopsy was 1 in 3.8%, 2 in 23%, 3 in 32,6%, 4 in 19,9%, 5 in 20,7; median surgical time was 195 minutes. Pathological stage was pT2 in 40,1%, pT3a in 35,9%, pT3b in 23,1%, and pT4 in 0,9% of cases. PSMs were present in 31,3% of cases. Urinary continence was achieved in 66,8% of cases one week after catheter removal. At 22 months (median follow-up), 89,1% patients were continent, BCR occurred in 27,5% patients. In multivariate analysis, PSA, prostate volume, surgical time were independent predictors of PSMs; ASA score and PSMs predicted urinary continence. CONCLUSIONS: We report the first multicentric experience of RSP for HR-PCa. Considering HR cases as those with the worst functional results, 89% of continent patients confirms that RSP helps achieve good functional results.

Collision metastasis: Renal cell carcinoma and prostatic adenocarcinoma to a retroperitoneal lymph node.

Prostatic adenocarcinoma and renal cell carcinoma (RCC) can coexist. However, the incidence of collision metastasis of both prostatic adenocarcinoma and RCC is a rare phenomenon. A 50-year-old non-smoker male with end stage renal disease and a history of prostate adenocarcinoma was noted to have a left renal mass in the upper pole during CT surveillance. With the use of immunohistochemical stains the collision of two distinct malignancies from two different topographical regions was elucidated in a retroperitoneal lymph node. We report the second known case of collision metastasis of RCC and prostatic adenocarcinoma to a retroperitoneal lymph node.

Comparative Outcomes of Salvage Retzius-Sparing versus Standard Robotic Prostatectomy: An International, Multi-Surgeon Series.

PURPOSE: Salvage radical prostatectomy is rare due to the risk of postoperative complications. We compare salvage Retzius-sparing robotic assisted radical prostatectomy (SRS-RARP) with salvage standard robotic assisted radical prostatectomy (SS-RARP). MATERIALS AND METHODS: A total of 72 patients across 9 centers were identified (40 SRS-RARP vs 32 SS-RARP). Demographics, perioperative data, and pathological and functional outcomes were compared using Student's t-test and ANOVA. Cox proportional hazard models and Kaplan-Meier curves were constructed to assess risk of incontinence and time to continence. Linear regression models were constructed to investigate postoperative pad use and console time. RESULTS: Median followup was 23 vs 36 months for SRS-RARP vs SS-RARP. Console time and estimated blood loss favored SRS-RARP. There were no differences in complication rates or oncologic outcomes. SRS-RARP had improved continence (78.4% vs 43.8%, p <0.001 for 0-1 pad, 54.1% vs 6.3%, p <0.001 for 0 pad), lower pads per day (0.57 vs 2.03, p <0.001), and earlier return to continence (median 47 vs 180 days, p=0.008). SRS-RARP was associated with decreased incontinence defined as >0-1 pad (HR 0.28, 95% CI 0.10-0.79, p=0.016), although not when defined as >0 pad (HR 0.56, 95% CI 0.31-1.01, p=0.053). On adjusted analysis SRS-RARP was associated with decreased pads per day. Lymph node dissection and primary treatment with stereotactic body radiation therapy were associated with longer console time. CONCLUSIONS: SRS-RARP is a feasible salvage option with significantly improved urinary function outcomes. This may warrant increased utilization of SRS-RARP to manage men who fail nonsurgical primary treatment for prostate cancer.

Influence of Sociodemographic Factors on Definitive Intervention Among Low-risk Active Surveillance Patients.

OBJECTIVES: To investigate sociodemographic factors influencing decision of initially active surveillance (AS) prostate cancer (CaP) patients to opt for definitive therapy, and, specifically, choice of radical prostatectomy (RP) versus radiation therapy (XRT). METHODS: The Surveillance, Epidemiology, and End Results (SEER) Prostate with Watchful Waiting database was used to identify AS patients diagnosed with NCCN low-risk CaP between 2010 and 2015. We sought to determine predictors of treatment type using multivariable logistic regression analyses. RESULTS: Out of 32,874 men included, 21,255 (64.7%) underwent delayed treatment, with 3,751 (17.6%) and 17,463 (82.2%) opting for RP and XRT, respectively. Patients who were married (Odds Ratio [OR]: 1.18, P <.001), insured (OR 2.94, P <.001), of higher socioeconomic status (OR 1.67 for highest vs lowest, P <.01), and residing in a Southeastern or Midwestern region (ORs 1.26 and 1.22 vs Northeast, respectively, P <.01) were significantly more likely to undergo definitive intervention. A significant interaction between patient race and marital/socioeconomic statuses on the decision-making process was identified. Decision for XRT (vs RP) was more likely in older (OR 11.6 for 70-79 vs 50-59 years, P <.01), unmarried (OR 1.89, P <.01), African American (OR 1.41, P .018), and higher socioeconomic status (OR 1.54 for highest versus lowest quartile, P <.01) patients. CONCLUSION: The majority of patients initially treated with AS underwent delayed treatment. After accounting for pathologic characteristics, the interaction of sociodemographic factors including race, socioeconomic status, marital status, insurance status, and region of residence are significantly associated with the likelihood of undergoing definitive therapy.

Early Experience with Salvage Retzius-sparing Robotic-assisted Radical Prostatectomy: Oncologic and Functional Outcomes.

OBJECTIVE: To report on feasibility, safety, and continence outcomes using the Retzius-sparing approach in the salvage setting (sRS-RARP). MATERIALS AND METHODS: A total of 26 patients underwent robotic salvage prostatectomy at our institution from January 2012 to May 2020 by a single surgeon (RM). Twenty patients underwent sRS-RARP and 6 underwent the standard approach (sRARP). Pre-, intra-, and postoperative outcomes were compared between these groups with emphasis on continence and oncologic safety. RESULTS: Patients had comparable preoperative characteristics with no significant difference in age, race, prostate-specific antigen level, and Gleason score. Most patients underwent primary external beam radiation therapy (69.2%). Median time to biochemical failure was 7.9 years (IQR 6.1-13.4). sRS-RARP required less console time (141.5 vs 199.5.0 minutes, P = .008) and less blood loss (50.0 mL vs 100.0 mL, P = .045) compared to sRARP. Postoperative course was uneventful with a median hospital stay of 1 day. Median catheterization time was 14.0 days (IQR 11.5-17). Patients undergoing sRS-RARP had better immediate (25.0% vs 0.0%, P < .001), 3 month (80.0% vs 0%, P < .001), and 12 month continence rates (100% vs 44%, P = .0384) compared to sRARP patients. Likewise, median time to continence was significantly shorter for sRS-RARP patients (90.0 vs 270.0 days, P = .0095). Biochemical recurrence rate was 20.0% in the sRS-RARP group and 33.3% in the sRARP group (P = .60). CONCLUSION: Early experience suggests that sRS-RARP is feasible, oncologically safe, and may offer improved continence compared to the sRARP approach.

The Unusual Presentation of a Single Case of Synchronous Metastatic Clear Cell Renal Cell Carcinoma to the Gallbladder: A Case Report and Literature Review.

Clear cell renal cell carcinoma, accounts for approximately 70% of all adult renal tumors. This disease is well known for its high metastatic potential, with estimates of 25-50% of patients reporting metastasis to distant structures. However, there have only been several reported cases in medical literature describing hematogenous spread to the gallbladder, with the majority occurring metachronously, in males, and with multiple metastases. This case report follows an extremely unique presentation in a 60-year-old female. Although the patient did not exhibit the usual signs and symptoms or meet the typical demographics seen with metastatic renal cell carcinoma, it should find a place on the differential diagnosis list when a gallbladder lesion is detected on imaging during the initial staging and/or restaging in patients with renal-cell carcinoma.

Re-operation within 30 days of radical cystectomy: Identifying high-risk patients and complications using American College of Surgeons National Surgical Quality Improvement Program database.

INTRODUCTION: Radical cystectomy (RC) is a highly morbid procedure, with 30-day complication rates approaching 31%. Our objective was to determine risk factors for re-operation within 30 days following a RC for non-metastatic bladder cancer. METHODS: We included all patients who underwent a RC for non-metastatic bladder cancer using The American College of Surgeons National Surgical Quality Improvement Program database between January 1, 2007 and December 31, 2014. Logistic regression analyses were used to evaluate predictors of re-operation. RESULTS: A total of 2608 patients were included; 5.8% of patients underwent re-operation within 30 days. On multivariable analysis, increasing body mass index (BMI) (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.01-1.07), African American race (vs. Caucasian OR 2.29, 95% CI 1.21-4.34), and history of chronic obstructive pulmonary disease (COPD) (OR 2.33, 95% CI 1.45-3.74) were significant predictors of re-operation within 30 days of RC. Urinary diversion type (ileal conduit vs. continent) and history of chemotherapy or radiotherapy within 30 days prior to RC were not. Patients who underwent re-operation within this timeframe had a significantly higher mortality rate (4.0% vs. 1.6%) and were more likely to experience cardiac (7.2% vs. 1.9%), pulmonary (23.0% vs. 3.0%), neurological (2.0% vs. 0.49%), and venous thromboembolic events (10.5% vs. 5.4%), as well as infectious complications (64.5% vs. 24.1%), with a significantly longer hospital length of stay (16.5 vs. 7.0 days). CONCLUSIONS: Recognizing increasing BMI, COPD, and African American race as risk factors for re-operation within 30 days of RC will allow urologists to preoperatively identify such high-risk patients and prompt them to adopt more aggressive approaches to minimize postoperative surgical complications.

Retzius-sparing robotic-assisted laparoscopic radical prostatectomy: racial considerations for 250 consecutive cases.

Our objective is to report the functional and oncologic outcomes of a cohort of 250 consecutive prostate cancer patients undergoing a Retzius-sparing approach and to assess for racial differences in continence outcomes. This was a prospective, single-center, case series of 250 consecutive prostate cancer patients who underwent a Retzius-sparing robotic-assisted laparoscopic radical prostatectomy by a single surgeon between May 2015 and April 2019. Our primary objective was to report post-operative continence outcomes of patients undergoing this technique. Continence was defined as using zero or one precautionary pad per day. Median follow-up was 24.0 months [interquartile range (IQR) 18.0-30.0 months]. Median age and body mass index were 62.0 years (IQR 57.0-67.0) and 29.0 kg/m2 (IQR 26.0-33.0), respectively. Median PSA was 8.22 ng/ml (IQR 5.74-13.31). 84.8% of patients were intermediate risk or high risk pre-operatively, as per AUA/ASTRO/SUO guidelines. 96.0% had Gleason Score 7 or worse disease on final pathologic analysis. Positive margin incidence was 18.1% and 44.4% in patients with pT2 and pT3 disease, respectively, of which 75.4% were unifocal. Immediate continence (i.e., continence achieved within 1 month post-operatively) was achieved in 45.2% of patients. Three-month and 1-year continence rates were 70.0% and 92.0%, respectively. Caucasian patients experienced earlier return of continence (77% versus 65% at 3 months) compared to African American patients. IPSS scores gradually improved from 8.0 pre-operatively to 4.0 1-year later. Median PSA level was 0.01 ng/ml (IQR 0.01-9.01) post-operatively. Retzius-sparing robotic-assisted laparoscopic radical prostatectomy is an oncologically safe surgical technique with excellent short- and long-term continence outcomes. Caucasian patients may have earlier return of continence compared to African Americans.

Upgrading on radical prostatectomy specimens of very low- and low-risk prostate cancer patients on active surveillance: A population-level analysis.

INTRODUCTION: A proportion of prostate cancer (PCa) patients initially managed with active surveillance (AS) are upgraded to a higher Gleason score (GS) at the time of radical prostatectomy (RP). Our objective was to determine predictors of upgrading on RP specimens using a national database. METHODS: The Surveillance, Epidemiology, and End Results Prostate with Watchful Waiting database was used to identify AS patients diagnosed with very low- or low-risk PCa who underwent delayed RP between 2010 and 2015. The primary outcome was upgrading to GS 7 disease or worse. Logistic regression analyses were used to evaluate demographic and oncological predictors of upgrading on final specimen. RESULTS: A total of 3775 men underwent RP after a period of AS, 3541 (93.8%) of whom were cT2a; 792 (21.0%) patients were upgraded on RP specimen, with 85.4%, 10.6%, and 3.4% upgraded to GS 7(3+4), 7(4+3), and 8 diseases, respectively. On multivariable analysis, higher prostate-specific antigen (PSA) at diagnosis (5-10 vs. 0-2 ng/ml, odd ratio [OR] 2.59, p<0.001) and percent core involvement (80-100% vs. 0-20%, OR 2.52, p=0.003) were significant predictors of upgrading on final RP specimen, whereas higher socioeconomic status predicted lower odds of upgrading (highest vs. lowest quartile OR 0.75, p=0.013). CONCLUSIONS: Higher baseline PSA and percent positive cores involvement are associated with significantly increased risk of upgrading on RP after AS, whereas higher socioeconomic status predicts lower odds of such events. These results may help identify patients at increased risk of adverse pathology on final specimen who may benefit from earlier definitive treatment.

Renal Cell Carcinoma Presenting as an Isolated Eyelid Metastasis.

Background: Renal cell carcinoma (RCC) has a propensity to metastasize with the most common sites of metastasis being the lungs and bones. Cutaneous metastasis of RCC to the eyelid is exceedingly rare, with only six cases reported in the past decade. We are reporting a case of metastatic renal cell carcinoma (mRCC) that presented with a painless eyelid mass. Case Presentation: We describe a case of a 66-year-old man with a history of chronic kidney disease stage III presenting with a rapidly growing left lower eyelid lesion thought to be a capillary hemangioma. Biopsy revealed polygonal clear cells with small central nuclei with thin-walled vasculature and strong immunostaining with PAX8 consistent with mRCC, clear cell type. Subsequent abdominal CT scan revealed a 5.1 × 4.7 × 4.3 cm heterogeneously enhancing mass with central necrosis in the upper pole of the left kidney. The patient was treated with excision of the eyelid lesion followed by robotic partial nephrectomy of the primary tumor. Follow-up CT scan at 3 and 6 months showed no evidence of recurrence. Conclusion: Isolated eyelid metastasis is an extremely rare form of presentation of mRCC. Interestingly, that patient did not have any other site of metastasis. Cytoreductive partial nephrectomy has been previously reported to be oncologically safe in selected patients.

Population-based outcomes of men with a single negative prostate biopsy: Importance of continued follow-up among older patients.

PURPOSE: To determine in Ontario-based men with a single negative transrectal ultrasound-guided prostate biopsy the long-term rates of prostate cancer-specific mortality, diagnosis, and treatment; number of repeat biopsies; and predictors of prostate cancer diagnosis and mortality. MATERIALS AND METHODS: This was a population-based cohort study, using data from linked, validated health administrative databases, of all Ontario-based men with a negative first biopsy between January 1994 and October 2014. Patients were followed from time of first biopsy till death, administrative censoring, or end of study period. Cumulative incidence functions were used to calculate the study outcomes' cumulative incidences. Univariable and multivariable regression analyses using Fine and Gray's semiparametric proportional hazards model were used to assess predictors of prostate cancer diagnosis and mortality. RESULTS: The study cohort included 95,675 men with a median age of 63.0years. Median follow-up was 8.1years. The 20-year cumulative rates of prostate cancer-specific mortality and diagnosis were 1.8% and 23.7%, respectively. Men ages 70 to 79 and 80 to 84 at initial biopsy had 20-year prostate cancer-specific mortality cumulative rates of 3.2% and 6.4% respectively. The 20-year cumulative rate of receiving radical prostatectomy was 7.6%. Higher socioeconomic status and urban residence were associated with higher diagnosis risks yet lower prostate cancer-specific mortality risks. CONCLUSIONS: This is the first population-based study assessing long-term cancer outcomes in North American men with a single negative transrectal ultrasound-guided prostate biopsy. Following a negative initial biopsy, 23.7% of men are still diagnosed with and 1.8% die of prostate cancer within 20years. Cancer-specific mortality outcomes are significantly worse in older men, with prostate cancer mortality rates several times higher than the rest of the population.

Characterization and outcomes of local treatment for primary bladder lymphoma: A population-based cohort analysis.

INTRODUCTION: Primary bladder lymphoma (PBL) is rare, representing 0.2% of extranodal lymphoma and less than 1% of all tumors originating in the bladder. Since the initial description of the disease, low-grade mucosa-associated lymphoid tissue (MALT) lymphoma has been reported as the most common subtype while high-grade disease was thought to represent only 20% of the reported cases. MATERIALS AND METHODS: One hundred and ninety five patients with PBL from the Surveillance, Epidemiology, and End Results (SEER) registry from 1998-2010 were reviewed. Tumors were classified as high or low grade based on histologic subtype of lymphoma based on revised European-American Lymphoma classification system. Socio-demographic and clinical variables were reported, as well as survival outcome analyses using the Kaplan-Meier method and log-rank test. Cox proportional hazard analysis was used to generate hazard ratios for risk factors associated with mortality. RESULTS: Eighty-three patients (42.6%) with low-grade and 112 patients (57.4%) with high-grade bladder lymphoma were studied. There were no differences between the low and high-grade groups for socio-demographic or clinical variables. Median overall survival or patients with low-grade disease was 38 months versus 15 months for patients with high-grade disease (p< 0.001). Analysis demonstrated worse survival outcomes for patients with high-grade disease compared to low-grade disease (p< 0.001). On multivariable analysis, increasing age and high-grade disease were associated with worse disease specific mortality (p< 0.001). CONCLUSION: Patient with high-grade primary bladder lymphoma had worse survival outcomes compared to those with low-grade disease. While transurethral resection provides tissue for diagnosis, immunotherapy/chemotherapy remains the mainstay of treatment for bladder lymphoma. Consolidation chemotherapy has been recommended in young patients not achieving complete remission with immunotherapy/chemotherapy.

Robotic Pyelolithotomy, Extended Pyelolithotomy, Nephrolithotomy, and Anatrophic Nephrolithotomy.

INTRODUCTION: We are a reporting on the indications, techniques, and limitations of robotic surgery in the management of renal stones disease. Robotic surgery is a good tool to manage large kidney and ureteral stones, particularly in patients with anatomic anomalies. We describe three techniques in managing staghorn kidney stones: robotic anatrophic nephrolithotomy, robotic pyelolithotomy, and robotic nephrolithotomy. MATERIAL AND METHODS: Robotic pyelolithotomy (RP) is ideal for patients with large renal pelvis and partial staghorn stone with a wide extra-renal pelvis. Robotic nephrolithotomy (RN) is ideal for stones inside a calyceal diverticulum or a partial staghorn eroding into the renal parenchyma. Renal vascular control could be avoided in most of those surgeries. Robotic anatrophic nephrolithotomy (RAN) is the most complex procedure and is reserved for patients with complete staghorn stones when percutaneous approach was not successful or not feasible. Control of renal vasculature is required for RAN. RESULTS: For robotic kidney surgeries, patients are positioned in a lateral decubitus position. Four or five ports are placed based on the stone location and surgeon's preference. We prefer the trans-peritoneal approach as it gives us the optimal exposure. For RP and RN, hilar control is usually not required. The renal pelvis/ renal parenchyma is incised, and the stones are carefully removed. If needed intra-operative flexible nephoscopy can be used to remove residual stones fragments. The collecting system is closed using an absorbable suture. DJ stent if needed is placed in an antegrade fashion. For RAN, the kidney is fully mobilized, and hilar control is required to avoid excessive bleeding. The kidney is incised along Brodel's line and the stones are extracted. The kidney parenchyma is then closed using 1 or 2 layers. We achieved an almost 100% stone free rate with RP and RN. RAN remains a challenging procedure with a success rate around 70%. CONCLUSION: Robotic surgery is a viable option to manage large renal and ureteral stones particularly in situations where endoscopic approach is not successful or feasible.

Replacing surveillance cystoscopy with urinary biomarkers in followup of patients with non-muscle-invasive bladder cancer: Patients' and urologic oncologists' perspectives.

INTRODUCTION: Urinary biomarkers are being developed to detect bladder cancer recurrence/progression in patients with non-muscle-invasive bladder cancer (NMIBC). We conducted a questionnaire-based study to determine what diagnostic accuracy and cost would such test(s) need for both patients and urologic oncologists to comfortably forgo surveillance cystoscopy in favour of these tests. METHODS: Surveys were administered to NMIBC patients at followup cystoscopy visit and to physician members of the Society of Urologic Oncology. Participants were questioned about acceptable false-negative (FN) rates and costs for such alternatives, in addition to demographics that could influence chosen error rates and costs. RESULTS: A total of 137 patient and 51 urologic oncologist responses were obtained. Seventy-seven percent of patients were not comfortable with urinary biomarker(s) alternatives to repeat cystoscopy, with a further 14% willing to accept such alternatives only if the FN rate were 0.5% or lower. Seventy-five percent of urologic oncologists were comfortable with an alternative urinary biomarker test(s), with 37% and 33% willing to accept FN rates of 5% and 1%, respectively. Forty-seven percent of patients were not willing to pay out-of-pocket for such tests, while 61% of urologic oncologists felt that a price range of $100-500 would be reasonable. CONCLUSIONS: This is the first survey evaluating patient and urologic oncologist perspectives on acceptable error rates and costs for urinary biomarker alternatives to surveillance cystoscopy for patients with NMIBC. Despite potential responder bias, this study suggests that urinary biomarker(s) will require sensitivity equivalent to that of cystoscopy in order to completely replace it in surveillance of patients with NMIBC.

Decreasing suicide risk among patients with prostate cancer: Implications for depression, erectile dysfunction, and suicidal ideation screening.

OBJECTIVE: Prostate cancer is the most common malignancy among males, accounting for 19% of cancers, and the third most common cancer-related cause of death. Suicide rates in the United States have increased among males over the last decade. Further, suicide rates are higher in oncology patients, including patients with prostate cancer, compared to the general population. The objective of this article is to review the current literature and address the relationship between prostate cancer, depression, erectile dysfunction, and suicidal ideation. MATERIALS AND METHODS: We reviewed the current literature pertaining to prostate cancer and depression, and prostate cancer and suicide. Furthermore, associations were made between erectile dysfunction and depression. RESULTS: Men with prostate cancer at increased risk for suicidal death are White, unmarried, elderly, and men with distant disease. Time since diagnosis is also an important factor, since men are at risk of suicide>15 years after diagnosis. Approximately 60% of men with prostate cancer experience mental health distress, with 10%-40% having clinically significant depression. Additionally, patients that received androgen deprivation therapy (ADT) are 23% more likely to develop depression compared to those without ADT. Longitudinal studies of prostate cancer patients suggest that erectile dysfunction after curative treatment may have a significant psychological effect leading to depression. Herein, a newly proposed screening algorithm suggests for an evaluation with the expanded prostate cancer index composite-clinical practice, patient health questionnaire-9, and an 8-question suicidal ideation questionnaire to assess for health-related quality of life, depression, and suicidal ideation. CONCLUSION: The burden of screening for erectile dysfunction, depression and suicidal ideation lies with the entire health care team, as there appears to be an association between these diagnoses, that is, compounded in patients with prostate cancer. The screening algorithm should assist with guiding timely and appropriate psychiatric referral to optimize outcomes in these high-risk patients.

Retzius-Sparing Robotic-Assisted Laparoscopic Radical Prostatectomy: A Safe Surgical Technique with Superior Continence Outcomes.

PURPOSE: To report early operative outcomes and assess continence in 100 consecutive patients who underwent Retzius-sparing robotic-assisted laparoscopic radical prostatectomy (RALP). MATERIALS AND METHODS: This was a prospective, single-center, consecutive case series of 100 and 100 patients undergoing a Retzius-sparing and a conventional RALP, respectively, by a single surgeon between March 2015 and April 2017. RESULTS: Baseline patient characteristics were similar between the two groups. The Retzius-sparing approach required significantly less console time (120.0 minutes vs 144.0 minutes, p < 0.001). There were no differences between intra- and post-operative complication rates, and hospital length of stay was similar in the two groups. Incidence of positive surgical margins was nonsignificantly different between the two groups, with 17% and 13% of pT2 patients and 49% and 48% of pT3 patients in the Retzius-sparing and conventional groups, respectively. Patients in the Retzius-sparing group had significantly superior rates of achieving post-operative urinary continence (log-rank test: p < 0.001), with 20% of patients continent within the first month, compared with 8% of patients in the conventional group. The mean number of pads per day needed at 3, 6, 9, and 12 months post-operatively was also significantly lower in the Retzius-sparing group. CONCLUSIONS: Retzius-sparing RALP requires shorter console time, is oncologically safe, and leads to significantly superior continence outcomes compared with conventional RALP.

Comorbidity Is a Competing Factor for Disease Recurrence Postnephrectomy.

OBJECTIVE: There is a relation between tumor stage and grade with the risk of cancer recurrence in patients undergoing surgical treatment for kidney cancer. The association of patient comorbidity with disease recurrence is less well characterized. The objective of this study was to explore the association between comorbidity and the recurrence of kidney cancer. METHODS: We performed a retrospective analysis of 263 patients who received a partial or radical nephrectomy from January 1, 2000 through April 30, 2013. Patient data included race, sex, body mass index, age-adjusted Charlson Comorbidity Index (aaCCI) score, tumor histology, tumor T classification, and Fuhrman grade. The primary outcome was cancer recurrence, either local or distant. Logistic regression was used to assess the association of these risk factors with the outcome. RESULTS: The median follow-up time was 19.6 months (interquartile range 5.2-53.7). There were 101 (38.4%) African American patients and 150 (57.0%) men. The median body mass index was 28.3 and the median aaCCI was 3.0. The Fuhrman grade was G1 in 9.5% of patients, G2 in 45.2%, G3 in 32.8%, and G4 in 12.5%. Nineteen (7.2%) patients experienced disease recurrence, including 13 (4.9%) patients with metastatic disease. The risk factors significantly associated with recurrence included Fuhrman grade (odds ratio [OR] 3.0, 95% confidence interval [CI] 1.23-7.30), tumor T classification (OR 1.33, 95% CI 1.00-1.76), and CCI (OR 0.74, 95% CI 0.57-0.95). CONCLUSIONS: Physiologic factors, in addition to tumor characteristics, play a significant role in predicting cancer-specific survival in patients with kidney cancer. The reduced odds of recurrence with higher aaCCI may indicate that competing health factors have an impact before recurrence on survival in certain patients.

Zero-fragment Nephrolithotomy: A Multi-center Evaluation of Robotic Pyelolithotomy and Nephrolithotomy for Treating Renal Stones.

BACKGROUND: Robotic pyelolithotomy (RPL) and robotic nephrolithotomy (RNL) may be utilized for treating kidney stones as an alternative to percutaneous nephrolithotomy or flexible ureteroscopy. OBJECTIVE: To describe the techniques of RPL and RNL, and present multi-center outcome data for patients undergoing these procedures. DESIGN, SETTING, AND PARTICIPANTS: This study was a retrospective analysis of 27 patients undergoing RPL and RNL at five tertiary academic institutions between 2008 and 2014. SURGICAL PROCEDURE: RPL and RNL without use of renal ischemia. MEASUREMENTS: We assessed stone clearance by visual assessment and postoperative imaging. We also examined other factors, including complications (Clavien grade), estimated blood loss, operative time, and length of stay. RESULTS AND LIMITATIONS: Twenty-seven patients underwent 28 procedures for a mean renal stone size of 2.74cm (standard deviation: 1.4, range: 0.8-5.8). The mean stone volume was 10.2cm3. RPL accounted for 26 of these procedures. RNL was performed in one patient, while another underwent combined RPL-RNL. Indications included failed previous endourological management (13), staghorn calculi (five), gas containing stone (one), calyceal diverticulum (one), complex urinary tract reconstruction (two), and patient preference (four). The mean patient age was 35.6 yr and mean body mass index was 25.5kg/m2. Mean operative time/console times were 182min and 128min, respectively. The mean estimated blood loss was 38ml. The mean length of stay was 1.7 d. There was no significant change in preoperative and postoperative serum creatinine levels. The overall complication rate was 18.5% (Clavien 1=3.7%; 2=7.4%; 3b=7.4%). The complete stone-free rate was 96%. CONCLUSIONS: RPL and RNL are safe and reasonable options for removing renal stones in select patients. In particular, RPL allows the removal of stones without transgressing the parenchyma, reducing potential bleeding and nephron loss. PATIENT SUMMARY: The robotic approach allows for complete removal of the renal stone without fragmentation, thereby maximizing chances for complete stone clearance in one procedure.

The Association of Fatty Acid Levels and Gleason Grade among Men Undergoing Radical Prostatectomy.

BACKGROUND: Epidemiological data suggest that omega-6 (ω-6) fatty acids (FAs) may be associated with cancer incidence and/or cancer mortality, whereas ω-3 FAs are potentially protective. We examined the association of the ratio of ω-6 to ω-3 FA (ω-6:ω-3) and individual FA components with pathological results among men with prostate cancer (PCa) undergoing radical prostatectomy. METHODS: Sixty-nine men were included in the study. Components of ω-6 (linoleic acid (LA), arachidonic acid (AA), and dihomo-γ-linolenic acid (DGLA)) and ω-3 (docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA)) were analyzed by liquid chromatography/mass selective detector separation. Logistic regression analysis was performed to determine association of FA with pathological high grade (Gleason ≥4+3) disease. RESULTS: The were 35 men with low grade disease (Gleason ≤3+4) and 34 men with high grade disease. Men with low grade disease were significantly younger (58y vs 61y, p = 0.012) and had lower D'Amico clinical classification (p = 0.001) compared to men with high grade disease. There was no significant association of ω-6:ω-3 with high grade disease (OR 0.93, p = 0.78), however overall ω-6, ω-3, and individual components of ω-6 and ω-3 FAs except EPA were significantly associated with high grade disease (ω-6: OR 3.37, 95% CI: 1.27,8.98; LA: OR 3.33, 95% CI:1.24,8.94; AA: OR 2.93, 95% CI:1.24,6.94; DGLA: OR 3.21, 95% CI:1.28,8.04; ω-3: OR 3.47, 95% CI:1.22,9.83; DHA: OR 3.13, 95% CI:1.26,7.74). ω-6 and ω-3 FA components were highly correlated (Spearman ρ = 0.77). CONCLUSION: Higher levels of individual components of ω-6 and ω-3FAs may be associated with higher-grade PCa. IMPACT: Studies into the causative factors/pathways regarding FAs and prostate carcinogenesis may prove a potential association with PCa aggressiveness.

Female, Black, and Unmarried Patients Are More Likely to Present With Metastatic Bladder Urothelial Carcinoma.

BACKGROUND: Although there are well-established risk factors for the diagnosis of bladder cancer, there is no consensus regarding risk factors for presentation of advanced or metastatic disease at diagnosis. The objective of this study was to identify the demographic and clinical factors associated with metastasis at diagnosis in patients with bladder urothelial carcinoma. PATIENTS AND METHODS: Patients diagnosed with bladder urothelial carcinoma from 2004 to 2010 were identified in the Surveillance, Epidemiology, and End Results (SEER) database (n = 108,417). The primary outcome was metastatic disease at the time of diagnosis. Demographic and socioeconomic variables were analyzed, and multivariable logistic regression models were performed to generate odds ratios (OR) for factors associated with metastasis at diagnosis. RESULTS: Of patients with bladder cancer, 3018 (2.8%) had metastasis at diagnosis and 105,399 (97.2%) had nonmetastatic disease. Patients with metastatic disease at diagnosis were more frequently female (29.6% vs. 23.6%, P < .001), black (9.4% vs. 5.0%, P < .001), and unmarried (44.1% vs. 32.5%, P < .001) compared to patients with nonmetastatic disease. On multivariable analysis, the following characteristics were confirmed to be independently associated with metastatic disease at diagnosis: female gender (vs. male, OR 1.21), black race (vs. white, OR 1.71), unmarried (vs. married, OR 1.46), unemployed (OR 1.02), and foreign-born status (OR 1.01). CONCLUSION: Female gender, black race, unmarried, unemployed, and foreign-born status are independently associated with metastasis at diagnosis for bladder urothelial carcinoma. All clinicians should be aware of these potential health care disparities in order to involve social services and other support mechanisms in efforts to improve early care.