Clinical Significance of Radical Prostatectomy in Clinical Lymph Node Metastasis in Prostate Cancer.

BACKGROUND: This study aimed to investigate the role of radical prostatectomy (RP) among clinical nodal metastasis prostate cancer and whether histological confirmation of lymph node metastasis through surgery can help with treatment. PATIENTS AND METHODS: After excluding patients with distant metastatic prostate cancer or neoadjuvant androgen deprivation therapy, 42 patients with clinical nodal metastasis who underwent RP at our institution were included in the study. We classified them as having or not having pathological lymph node metastasis. Clinicopathologic data were analyzed in this retrospective chart review. Kaplan-Meier analysis was used to calculate the estimated castration-resistant prostate cancer (CRPC)-free survival, biochemical recurrence (BCR)-free survival, and cancer-specific survival (CSS). RESULTS: There is no significant difference in age, presence of diabetes mellitus, hypertension, BCR time, CRPC time, overall survival, salvage RT rate, and initial prostate-specific antigen level between the two groups. However, there is a significant difference in the pathology N1 group in terms of pathological T stage, pathologic Gleason score, BCR rate, CRPC rate, and CSS. A multivariate Cox proportional hazard regression analysis was used to identify predictors of CRPC-free survival. Patients with pathological lymph node metastasis had a shorter CRPC-free survival [hazard ratio (HR) 4.87; 95% confidence interval (CI) 1.25-19.00, p = 0.02]. CONCLUSION: Radical prostatectomy can confirm lymph node metastasis. Although pathologic diagnosis has no effect on time to BCR and CPRC, because it affects BCR rate, CRPC rate, and CSS, an accurate pathological diagnosis obtained through surgery is beneficial in the treatment of clinical lymph node metastasis prostate cancer.

Association Between Sarcopenia and Survival of Patients with Organ-Confined Renal Cell Carcinoma after Radical Nephrectomy.

BACKGROUND: We aimed to describe the effect of preoperative sarcopenia on oncologic outcomes of organ-confined renal cell carcinoma (RCC) after radical nephrectomy. PATIENTS AND METHODS: A total of 632 patients with pT1-2 RCC who underwent radical nephrectomy between 2004 and 2014 were retrospectively analyzed. From preoperative computerized tomography (CT) scans, skeletal muscle index (SMI) was measured and gender-specific cutoff values at third lumbar vertebra of 52.4 cm2/m2 for men and 38.5 cm2/m2 for women were used to define sarcopenia. Survivals were compared and associations with sarcopenia were analyzed using Kaplan-Meier log rank tests and Cox proportional hazard regression models. Median follow-up was 83 months. RESULTS: Of 632 patients, 268 (42.4%) were classified as sarcopenic. The sarcopenic group was more advanced in age (57 versus 53 years) and more predominantly male (71.3% versus 59.9%). Sarcopenic patients had lower body mass index (BMI, 23.0 versus 25.9 kg/m2), but there was no difference in tumor size, stage, or nuclear grade. Sarcopenia was associated with poorer overall survival (OS) and cancer-specific survival (CSS; OS 94.0% versus 82.1%; p < 0.001 and CSS 97.5% versus 91.8%; p < 0.001). On multivariate analysis, sarcopenia was an independent risk factor for all-cause mortality [hazard ratio (HR) 2.58; 95% CI 1.02-6.54] and cancer-specific mortality (HR 3.07; 95% CI 1.38-6.83). CONCLUSIONS: Sarcopenia at diagnosis was an independent risk factor for all-cause and cancer-specific mortality after radical nephrectomy for pT1-2 RCC. These findings underscore the importance of assessing presence of sarcopenia for risk stratification even among surgical candidates.

Solo-surgeon pure laparoscopic donor nephrectomy using passive camera holder: IDEAL stage 2a study.

BACKGROUND: Solo-surgery can be defined as a practice of a surgeon operating alone using a camera holder, without other surgical members except for a scrub nurse. This study was designed to evaluate the feasibility and safety of solo-surgeon pure laparoscopic donor nephrectomy. METHODS: The study protocol was approved by the Institutional Review Board of Asan Medical Center, Seoul, Korea. The brief study protocol was registered on the Clinical Research Information Service site of the Korea Centers for Disease Control and Prevention. Candidates fulfilling all inclusion and exclusion criteria were enrolled in the clinical trial and underwent solo-surgeon pure laparoscopic donor nephrectomy. The feasibility was assessed by the proportion of subjects who could undergo solo-surgeon pure laparoscopic donor nephrectomy without difficulty. The perioperative complications were identified to assess the safety of solo-surgeon pure laparoscopic donor nephrectomy. RESULTS: Of the 47 potential candidates from November 2018 to August 2019, 40 were enrolled in the clinical trial and seven excluded due to declining participation. The feasibility of solo-surgeon pure laparoscopic donor nephrectomy was 100%, without an occasion of any difficulty requiring conversion to the human assisted pure laparoscopic donor nephrectomy. Fourteen intraoperative complications occurred in 10 patients. The most common intraoperative complication was spleen injury. Two of three cases classified as the Satava classification grade II were due to the incomplete stapling of endoscopic stapler. Seventy-eight postoperative complications occurred in 34 patients. The most common postoperative complication was nausea/vomiting and followed by aspartate aminotransferase/alanine aminotransferase elevation. Most postoperative complication was independent of the solo-surgery itself. CONCLUSIONS: Solo-surgeon pure laparoscopic donor nephrectomy using passive camera holder is technically feasible. In terms of safety, it is necessary to adjust the scope of surgery performed alone. Trial Registration CRIS, KCT0003458. Registered 30/01/2019, Retrospectively registered, https://cris.nih.go.kr/cris/search/detailSearch.do/15868 .

Performance of Prostate Imaging Reporting and Data System Version 2.1 for Diagnosis of Prostate Cancer: A Systematic Review and Meta-Analysis.

BACKGROUND: The Prostate Imaging Reporting and Data System (PI-RADS) was introduced in 2012 and updated to version 2.1 (v2.1) in early 2019 to improve diagnostic performance and interreader reliability. PURPOSE: To evaluate the diagnostic performance of PI-RADS v2.1 in comparison with v2. METHODS: A systematic review and meta-analysis of the literature was performed using MEDLINE, EMBASE, and Cochrane databases to identify studies evaluating the diagnostic performance of PI-RADS v2.1 for diagnosing clinically significant prostate cancer (csPCa). STUDY TYPE: Systematic review and meta-analysis. SUBJECT: One thousand two hundred forty-eight patients with 1406 lesions from 10 eligible articles. FIELD STRENGTH/SEQUENCE: Conventional MR sequences at 1.5 T and 3 T. ASSESSMENT: Two reviewers independently identified and reviewed the original articles reporting diagnostic performance of PI-RADS v2.1. STATISTICAL TESTS: Meta-analytic summary sensitivity and specificity were calculated using a bivariate random effects model. Meta-analytic sensitivity and specificity between PI-RADS v2 and v2.1 were compared. RESULTS: The pooled sensitivity and specificity of PI-RADS v2.1 were 87% (95% confidence intervals, 82-91%) and 74% (63-82%), respectively. In five studies available for a head-to-head comparison between PI-RADS v2.1 and v2, there were no significant differences in either sensitivity (90% [86-94%] vs. 88% [83-93%], respectively) or specificity (76% [59-93%] vs. 61% [39-83%], respectively; P = 0.37). The sensitivity and specificity were 81% (73-87%) and 82% (68-91%), respectively, for a PI-RADS score cutoff of ≥4, and 94% (88-97%) and 56% (35-97%) for ≥3. Regarding the zonal location, the sensitivity and specificity for the transitional zone only were 90% (84-96%) and 76% (62-90%) respectively, whereas for the whole gland they were 85% (79-91%) and 71% (57-85%). DATA CONCLUSION: PI-RADS v2.1 demonstrated good overall performance for the diagnosis of csPCa. PI-RADS v2.1 tended to show higher specificity than v2, but the difference lacked statistical significance. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY STAGE: 3.

Risk Stratification of Prostate Cancer According to PI-RADS® Version 2 Categories: Meta-Analysis for Prospective Studies.

PURPOSE: The Prostate Imaging Reporting and Data System (PI-RADS) version 2 (v2) categorizes the likelihood of clinically significant prostate cancer on magnetic resonance imaging and determines the diagnostic pathway. We determined clinically significant prostate cancer and all prostate cancer detection rates in each PI-RADS v2 category. MATERIALS AND METHODS: MEDLINE®, EMBASE® and Cochrane databases were searched for prospective studies reporting the detection rates of clinically significant prostate cancer or all prostate cancer. Random effects models were used to determine pooled detection rates of clinically significant prostate cancer and all prostate cancer for each PI-RADS category. The risk of bias was assessed with the Quality Assessment of Diagnostic Accuracy Studies-2. Meta-regression analysis was performed to identify factors affecting study heterogeneity. RESULTS: Thirteen prospective studies including 4,265 men who underwent magnetic resonance imaging targeted biopsy and/or systematic biopsy for a PI-RADS v2 category 3 or greater, or systematic biopsy for PI-RADS 1-2 were included. The pooled detection rates of clinically significant prostate cancer monotonically increased for each PI-RADS v2 category, ie 4% (95% CI 2-8) for category 1-2, 17% (95% CI 13-21) for category 3, 46% (95% CI 38-55) for category 4 and 75% (95% CI 73-78) for category 5. Substantial study heterogeneity was noted in clinically significant prostate cancer detection rates for categories 1-2 and 4, which were significantly affected by study subject selection (biopsy naïve patients only or not) and studies with a high risk of bias. CONCLUSIONS: PI-RADS v2 can be useful for the stratification of the risk of clinically significant prostate cancer in patients at risk for prostate cancer but the limitations in category 4 still remain.

Association of Muscle Mass with Survival after Radical Prostatectomy in Patients with Prostate Cancer.

PURPOSE: Although muscle mass has been associated with survival in patients with various types of solid tumors, the relationship between muscle mass and survival in patients with prostate cancer remains unclear. We retrospectively investigated the association of muscle mass with survival after radical prostatectomy in patients with prostate cancer. MATERIALS AND METHODS: We reviewed the records of 2,042 patients who underwent radical prostatectomy of prostate cancer between 1998 and 2013. Muscle mass was evaluated by measuring the psoas muscle index on preoperative computerized tomography images. RESULTS: In the lowest, second, third and highest psoas muscle index quartiles the 10-year distant metastasis-free survival rate was 72.5%, 83.8%, 92.3% and 93.7% (p <0.001), the 10-year cancer specific survival rate was 85.7%, 92.1%, 96.8% and 97.6%, and the 10-year overall survival rate was 74.5%, 79.6%, 89.8% and 90.6%, respectively (each p <0.001). The psoas muscle index positively correlated with the body mass index, serum concentrations of IGFBP-3 and bioavailable testosterone, and inversely correlated with patient age, the serum SHBG concentration and the neutrophil-to-lymphocyte ratio. On multivariable analysis the psoas muscle index was independently associated with increased risks of biochemical recurrence, distant metastasis, and cancer specific and overall death. CONCLUSIONS: Low muscle mass may be associated with increased risks of recurrence and mortality in patients who undergo radical prostatectomy of prostate cancer regardless of the body mass index. Large-scale prospective studies are warranted.

Correction to: A novel histone deacetylase inhibitor, CG200745, potentiates anticancer effect of docetaxel in prostate cancer via decreasing Mcl-1 and Bcl-XL.

The blots of control and docetaxel for caspase-9, caspase-3, caspase-8, Bcl-XL, and tubulin in the Figure 4f were reused from Figure 4 of our previous paper published in Journal of Urology in 2010 ( https://doi.org/10.1016/j.juro.2010.07.035 ).

Robot-assisted partial nephrectomy is associated with early recovery of renal function: Comparison of open, laparoscopic, and robot-assisted partial nephrectomy using DTPA renal scintigraphy.

OBJECTIVES: To compare the functional outcomes of open, laparoscopic, and robot-assisted partial nephrectomy (OPN, LPN, and RAPN, respectively) using diethylene triamine penta-acetic acid (DTPA). METHODS: We identified 610 patients who underwent partial nephrectomy for renal cell carcinoma (285 open partial nephrectomy [OPN], 96 laparoscopic partial nephrectomy [LPN], and 229 robot-assisted partial nephrectomy [RAPN]) with preoperative and postoperative DTPA within 1 year. We excluded multiple renal masses and history of immunotherapy or chemotherapy. Predictive factors for glomerular filtration rate (GFR) reduction were assessed using multivariate linear regression. RESULTS: Postoperative complications and disease-free survival were similar in the three groups. Within 1 postoperative year, OPN showed a significantly lower mean ipsilateral GFR than LPN and RAPN (28.9 versus 32.4 versus 32.7 mL/min/1.73 m 2 , respectively; P < 0.001). RAPN was associated with a significantly higher total GFR than OPN within 1 year (76.6 versus 71.2 mL/min/1.73 m 2 , respectively; P = 0.001). On multivariate analysis within 1 year, operation type (OPN versus RAPN: ß = 2.82; 95% confidence interval, 1.17-4.48; P = 0.001) was significantly associated with GFR reduction. CONCLUSION: There was no difference in postoperative complications and disease-free survival among operation types. RAPN could help to promote earlier recovery of ipsilateral GFR than OPN.

Time to biochemical relapse after radical prostatectomy and efficacy of salvage radiotherapy in patients with prostate cancer.

BACKGROUND: To investigate the prognostic and therapeutic implications of time to biochemical relapse (BCR) in patients with prostate cancer after radical prostatectomy. METHODS: The records of 3210 consecutive men with prostate cancer who underwent radical prostatectomy between January 1998 and June 2013 were retrospectively reviewed. Patients with BCR were divided into three groups based on quartiles of time to BCR, namely an early group (first quartile), an intermediate group (second and third quartiles) and late group (fourth quartile). RESULTS: 817 (25.5%) patients experienced BCR at a median of 24.9 months after surgery. The 8-year rate of distant metastasis-free survival (64.3% vs. 41.3%, p = 0.002) and cancer-specific survival (86.6% vs. 63.4%, p < 0.001) was higher in the salvage radiotherapy (SRT) group than the androgen deprivation therapy (ADT) group in patients with early BCR, whereas those rates (91.3% vs. 87.9%, p = 0.607 and 100.0% vs. 93.1%, p = 0.144, respectively) were similar in patients with late BCR. In the intermediate BCR group, the impact of SRT over ADT on 8-year cancer-specific survival was modest (91.9% vs. 82.3%, p = 0.057) and was limited to patients with pT2 or pT3a disease. CONCLUSIONS: SRT may decrease the risk of distant metastasis and cancer-specific mortality in patients with early BCR. However, a survival benefit for those with late BCR was not apparent. For patients with intermediate BCR, SRT was associated with a cancer-specific survival benefit in patients with pT2 or pT3a disease. Novel genomic tests and imaging modalities may support clinical decision-making in these patients.

Androgen deprivation therapy during and after post-prostatectomy radiotherapy in patients with prostate cancer: a case control study.

BACKGROUND: Here we assessed the influence of androgen deprivation therapy (ADT) during and/or after post-prostatectomy radiotherapy (RT) on biochemical recurrence (BCR) and radiographic progression in patients with prostate cancer. METHODS: Patients with prostate cancer who underwent post-prostatectomy RT were analyzed. BCR and radiographic progression after RT were compared according to the concurrent or salvage ADT. Cox regression analyses were used to identify risk factors for BCR and radiographic progression. RESULTS: Of the 227 patients who underwent post-prostatectomy RT, 95 (41.9%) received concurrent ADT for a median of 17.0 months. Despite more aggressive disease characteristics in the concurrent ADT group than in the RT-only group, the former had a better 5-year BCR-free survival rate than the latter (66.1 vs. 53.9%; p = 0.016), whereas the radiographic progression rate was not significantly different between two groups. On the other hand, salvage ADT after post-RT BCR significantly delayed radiographic progression (5-year radiographic progression-free survival; 75.2 vs. 44.5%; p = 0.002). CONCLUSIONS: Concurrent ADT improved BCR-free survival, and salvage ADT after post-RT BCR improved radiographic progression-free survival. To maximize the oncological benefit, ADT of sufficient duration should be implemented.

Prognostic Factors Related to Recurrence-Free Survival for Primary Carcinoma in situ of the Bladder after Bacillus Calmette-Guérin: A Retrospective Study.

INTRODUCTION: Primary carcinoma in situ (P-CIS) of the bladder is rare and its clinical behavior and predictive features have not been well described. The purpose of this study was to evaluate the effects of various factors including angiotensin-2 converting enzyme inhibitors/angiotensin II receptor blockers (ACEIs/ARBs) on recurrence-free survival (RFS)-related prognosis in patients with P-CIS. MATERIALS AND METHODS: In our medical center, 5,945 patients were diagnosed with bladder cancer from January 1999 to January 2014. Of these, 64 patients were diagnosed with CIS and were treated with at least 6 cycles of Bacillus Calmette-Guérin (BCG). We accessed variables including patient age, sex, initial presenting symptoms, smoking history, P-CIS descriptions, urine cytology, and medication history related to hypertension. RESULTS AND CONCLUSIONS: We evaluated the use of anti-hypertensive medications (ACEIs/ARBs, p = 0.028), the symptom of non-gross hematuria (p = 0.028), and older age (p = 0.015) as significant factors related to RFS. Older age was also a significant factor for influencing the RFS rate. We found that the use of anti-hypertensive medications (ACEIs/ARBs) improves RFS in patients with P-CIS after BCG therapy. The prognosis was poor when there was no gross hematuria and if patients were at older ages at the time of diagnosis of P-CIS.

Adaptive functional change of the contralateral kidney after partial nephrectomy.

Partial nephrectomy aims to maintain renal function by nephron sparing; however, functional changes in the contralateral kidney remain unknown. We evaluate the functional change in the contralateral kidney using a diethylene triamine penta-acetic acid (DTPA) renal scan and determine factors predicting contralateral kidney function after partial nephrectomy. A total of 699 patients underwent partial nephrectomy, with a DTPA scan before and after surgery to assess the separate function of each kidney. Patients were divided into three groups according to initial contralateral glomerular filtration rate (GFR; group 1: <30 ml·min-1·1.73 m-2, group 2: 30-45 ml·min-1·1.73 m-2, and group 3: ≥45 ml·min-1·1.73 m-2). Multiple-regression analysis was used to identify the factors associated with increased GFR of the contralateral kidney over a 4-yr postoperative period. Patients in group 1 had a higher mean age and hypertension history, worse American Society of Anesthesiologists score, and larger tumor size than in the other two groups. The ipsilateral GFR changes at 4 yr after partial nephrectomy were -18.9, -3.6, and 3.9% in groups 1, 2, and 3, respectively, whereas the contralateral GFR changes were 10.8, 25.7, and 38.8%. Age [ß: -0.105, 95% confidence interval (CI): -0.213; -0.011, P < 0.05] and preoperative contralateral GFR (ß: -0.256, 95% CI: -0.332; -0.050, P < 0.01) were significant predictive factors for increased GFR of the contralateral kidney after 4 yr. The contralateral kidney compensated for the functional loss of the ipsilateral kidney. The increase of GFR in contralateral kidney is more prominent in younger patients with decreased contralateral renal function.

Downregulation of androgen receptors by NaAsO2 via inhibition of AKT-NF-κB and HSP90 in castration resistant prostate cancer.

BACKGROUND: Androgen and androgen receptor (AR) play essential roles in the development and maintenance of prostate cancer. The recently identified AR splice variants (AR-Vs) have been considered as a plausible mechanism for the primary resistance against androgen deprivation therapy (ADT) in castration-resistant prostate cancer (CRPC). Sodium meta-arsenite (NaAsO2 ; KML001; Kominox), a trivalent arsenical, is an orally bioavailable and water soluble, which is currently in phase I/II clinical trials for the treatment of prostate cancer. It has a potent anti-cancer effect on prostate cancer cells and xenografts. The aim of this study was to examine the effect of NaAsO2 on AR signaling in LNCaP and 22Rv1 CRPC cells. METHODS: We used hormone-sensitive LNCaP cells, hormone-insensitive 22Rv1 cells, and CRPC patient-derived primary cells. We analyzed anti-cancer effect of NaAsO2 using real-time quantitative reverse transcription-PCR, Western blotting, immunofluorescence staining and CellTiter Glo® luminescent assay. Statistical evaluation of the results was performed by one-way ANOVA. RESULTS: NaAsO2 significantly reduced the translocation of AR and AR-Vs to the nucleus as well as their level in LNCaP and 22Rv1 cells. Besides, the level of the prostate-specific antigen (PSA), downstream target gene of AR, was also decreased. This compound was also an effective modulator of AKT-dependent NF-κB activation which regulates AR. NaAsO2 significantly inhibited phosphorylation of AKT and expression and nuclear translocation of NF-κB. We then investigated the effect of NaAsO2 on AR stabilization. NaAsO2 promoted HSP90 acetylation by down-regulating HDAC6, which reduces the stability of AR in prostate cancer cells. CONCLUSIONS: Here, we show that NaAsO2 disrupts AR signaling at multiple levels by affecting AR expression, stability, and degradation in primary tumor cell cultures from prostate cancer patients as well as CRPC cell lines. These results suggest that NaAsO2 could be a novel therapeutics for prostate cancer.

Obesity as a Risk Factor for Unfavorable Disease in Men with Low Risk Prostate Cancer and its Relationship with Anatomical Location of Tumor.

PURPOSE: We investigated the influence of obesity on unfavorable disease in men with low risk prostate cancer eligible for active surveillance and verified the underlying relationship with tumor location. MATERIALS AND METHODS: We analyzed the records of 890 patients with biopsy Gleason score 6 who underwent radical prostatectomy for prostate cancer via multicore (12 or more) biopsy at our institution. Unfavorable disease was defined as primary Gleason pattern 4 or greater, or pathological stage T3 or greater. Multivariate logistic regression analysis was performed to identify factors associated with unfavorable disease. The association of unfavorable disease with anatomical location of the index tumor was assessed. RESULTS: Overall 216 (24.3%), 544 (61.1%) and 130 men (14.6%) had a body mass index of less than 23 (normal), 23 to 27.5 (overweight) and 27.5 kg/m2 or greater (obese), respectively, according to established cutoff points for Asian men. Multivariate analysis showed that age, prostate volume and body mass index were independent factors for predicting unfavorable disease regardless of the various active surveillance criteria used. For Johns Hopkins Hospital criteria the risk of unfavorable disease was higher in obese patients than in normal weight patients (OR 3.30, p = 0.022). Unfavorable disease was more frequent in cases of transition zone cancer than nontransition zone cancer across all criteria for active surveillance (all p <0.01). Among men fulfilling Johns Hopkins Hospital criteria the proportion of transition zone cancer was 4.2% for normal weight, 11.6% for overweight and 16.7% for obesity, respectively (p = 0.022). CONCLUSIONS: Obese men with low risk prostate cancer who are eligible for active surveillance are at higher risk for unfavorable pathological features. Obese men more frequently had transition zone cancer, which was associated with unfavorable pathology findings in those with very low risk prostate cancer.

Recovery of renal function after administration of adipose-tissue-derived stromal vascular fraction in rat model of acute kidney injury induced by ischemia/reperfusion injury.

Acute kidney injury (AKI) induced by ischemia/reperfusion (I/R) injury is a major challenge in critical care medicine. The purpose of this study is to determine the therapeutic effects of the adipose-tissue-derived stromal vascular fraction (SVF) and the optimal route for SVF delivery in a rat model of AKI induced by I/R injury. Fifty male Sprague-Dawley rats were randomly divided into five groups (10 animals per group): sham, nephrectomy control, I/R injury control, renal arterial SVF infusion and subcapsular SVF injection. To induce AKI by I/R injury, the left renal artery was clamped with a nontraumatic vascular clamp for 40 min, and the right kidney was removed. Rats receiving renal arterial infusion of SVF had a significantly reduced increase in serum creatinine compared with the I/R injury control group at 4 days after I/R injury. The glomerular filtration rate of the renal arterial SVF infusion group was maintained at a level similar to that of the sham and nephrectomy control groups at 14 days after I/R injury. Masson's trichrome staining showed significantly less fibrosis in the renal arterial SVF infusion group compared with that in the I/R injury control group in the outer stripe (P < 0.001). TUNEL labeling showed significantly decreased apoptosis in both the renal arterial SVF infusion and subcapsular SVF injection groups compared with the I/R injury control group in the outer stripe (P < 0.001). Thus, renal function is effectively rescued from AKI induced by I/R injury through the renal arterial administration of SVF in a rat model.

Does lymph node dissection during nephroureterectomy affect oncological outcomes in upper tract urothelial carcinoma patients without suspicious lymph node metastasis on preoperative imaging studies?

PURPOSE: This study aimed to investigate the effects of lymph node dissection (LND) on upper tract urothelial carcinoma (UTUC) without suspicious lymph node (LN) metastasis on preoperative imaging studies. METHODS: From 1998 to 2012, 418 UTUC patients without suspicious LN metastasis on preoperative imaging studies were included. Patients were divided into two groups according to the performance of LND. The effects of LND on oncological outcomes were assessed after adjusting other variables. The mean follow-up duration was 69 months. RESULTS: Among the 132 patients who underwent LND, LN metastasis was pathologically identified in 16 patients (12.1 %). The median number of resected LNs for patients who underwent LND was 7. On multivariate analysis, the number of resected LNs and pathologic T stage was significant predictors of LN metastasis. The 5-year recurrence-free survival was 76.4 % for patients without LND and 65.4 % for patients with LND (p = 0.126). In addition, there was no difference in 5-year overall survival between the 2 groups (without LND; 71.7 % vs. with LND; 72.1 %, p = 0.756). Multivariate analysis showed that pathologic T stage, tumor grade, and lymphovascular invasion were risk factors for recurrence. Age at surgery, tumor size, pathologic T stage, tumor grade, and lymphovascular invasion were significantly associated with overall survival. However, performance of LND was not associated with recurrence and survival. CONCLUSIONS: LND could be selectively performed in patients with clinically LN-negative UTUC based on patient/tumor characteristics and operative findings although sufficient LNs should be removed if LND is to be performed.

Preserving Renal Function through Partial Nephrectomy Depends on Tumor Complexity in T1b Renal Tumors.

This study aimed to determine patients with T1b renal cell carcinoma (RCC) who could benefit from partial nephrectomy (PN) and method to identify them preoperatively using nephrometry score (NS). From a total of 483 radical nephrectomy (RN)-treated patients and 40 PN-treated patients who received treatment for T1b RCC between 1995 and 2010, 120 patients identified through 1:2 propensity-score matching were included for analysis. Probability of chronic kidney disease (CKD) until postoperative 5-years was calculated and regressed with respect to the surgical method and NS. Median follow-up was 106 months. CKD-probability at 5-years was 40.7% and 13.5% after radical and PN, respectively (P = 0.005). While PN was associated with lower risk of CKD regardless of age, comorbidity, preoperative estimated renal function, the effect was observed only among patients with NS ≤ 8 (P < 0.001) but not in patients with NS ≥ 9 (P = 0.746). Percent operated-kidney volume reduction and ischemia time were similar between the patients with NS ≥ 9 and ≤ 8. In the stratified Cox regression accounting for the interaction observed between the surgical method and the NS, PN reduced CKD-risk only in patients with NS ≤ 8 (hazard ratio [HR], 0.054; P = 0.005) but not in ≥ 9 (HR, 0.996; P = 0.994). In T1b RCC with NS ≥ 9, the risk of postoperative CKD was not reduced following PN compared to RN. Considering the potential complications of PN, minimally invasive RN could be considered with priority in this subgroup of patients.

Association of Robotic-Assisted vs Laparoscopic Radical Nephrectomy With Perioperative Outcomes and Health Care Costs, 2003 to 2015.

IMPORTANCE: Use of robotic surgery has increased in urological practice over the last decade. However, the use, outcomes, and costs of robotic nephrectomy are unknown. OBJECTIVES: To examine the trend in use of robotic-assisted operations for radical nephrectomy in the United States and to compare the perioperative outcomes and costs with laparoscopic radical nephrectomy. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used the Premier Healthcare database to evaluate outcomes of patients who had undergone robotic-assisted or laparoscopic radical nephrectomy for renal mass at 416 US hospitals between January 2003 and September 2015. Multivariable regression modeling was used to assess outcomes. EXPOSURES: Robotic-assisted vs laparoscopic radical nephrectomy. MAIN OUTCOMES AND MEASURES: The primary outcome of the study was the trend in use of robotic-assisted radical nephrectomy. The secondary outcomes were perioperative complications, based on the Clavien classification system, and defined as any complication (Clavien grades 1-5) or major complications (Clavien grades 3-5, for which grade 5 results in death); resource use (operating time, blood transfusion, length of hospital stay); and direct hospital cost. RESULTS: Among 23 753 patients included in the study (mean age, 61.4 years; men, 13 792 [58.1%]), 18 573 underwent laparoscopic radical nephrectomy and 5180 underwent robotic-assisted radical nephrectomy. Use of robotic-assisted surgery increased from 1.5% (39 of 2676 radical nephrectomy procedures in 2003) to 27.0% (862 of 3194 radical nephrectomy procedures) in 2015 (P for trend <.001). In the weighted-adjusted analysis, there were no significant differences between robotic-assisted and laparoscopic radical nephrectomy in the incidence of any (Clavien grades 1-5) postoperative complications (adjusted rates, 22.2% vs 23.4%, difference, -1.2%; 95% CI, -5.4 to 3.0%) or major (Clavien grades 3-5) complications (adjusted rates, 3.5% vs 3.8%, difference, -0.3%; 95% CI, -1.0% to 0.5%). The rate of prolonged operating time (>4 hours) for patients undergoing the robotic-assisted procedure was higher than for patients receiving the laparoscopic procedure in the adjusted analysis (46.3% vs 25.8%; risk difference, 20.5%; 95% CI, 14.2% to 26.8%). Robotic-assisted radical nephrectomy was associated with higher mean 90-day direct hospital costs ($19 530 vs $16 851; difference, $2678; 95% CI, $838 to $4519), mainly accounted for operating room ($7217 vs $5378; difference, $1839; 95% CI, $1050 to $2628) and supply costs ($4876 vs $3891; difference, $985; 95% CI, $473 to $1498). CONCLUSIONS AND RELEVANCE: Among patients undergoing radical nephrectomy for renal mass between 2003 and 2015, the use of robotic-assisted surgery increased substantially. The use of robotic-assistance was not associated with increased risk of any or major complications but was associated with prolonged operating time and higher hospital costs compared with laparoscopic surgery.

Characteristics of Anteriorly Located Prostate Cancer and the Usefulness of Multiparametric Magnetic Resonance Imaging for Diagnosis.

PURPOSE: We analyzed the pathological and oncologic characteristics of anteriorly located prostate cancer and assessed the usefulness of magnetic resonance imaging to detect anterior prostate cancer. MATERIALS AND METHODS: We analyzed the records of 728 consecutive patients treated with radical prostatectomy. Patients were categorized with anterior or prostate cancer or tumors involving the anterior and posterior prostate according to the dominant tumor location on whole mount section. RESULTS: The anterior and posterior prostate cancer groups and the group with cancer at both locations represented 31.0%, 46.7% and 22.3% of the total number of patients, respectively. Anterior prostate cancer was less commonly palpable (p <0.001) and needed more frequent repeat biopsy (p = 0.012) than posterior prostate cancer. Moreover, the anterior group had fewer positive cores than the posterior group (p <0.001) despite comparable tumor volumes. Gleason score upgrading was more frequently observed in anterior than in posterior prostate cancer (p = 0.003). However, final pathological features did not significantly differ. Only the seminal vesicle involvement rate was lower in anterior than in posterior prostate cancer (p <0.001). Estimated 5-year biochemical recurrence-free survival in patients with anterior prostate cancer was 87.5%, significantly higher than in patients with posterior prostate cancer (77.4%, p = 0.001) and patients with anterior plus posterior involvement (74.4%, p <0.001). Multivariate analysis revealed that anterior location was an independent prognostic factor for biochemical recurrence (HR 0.403) along with other well-known prognostic factors. To detect anterior prostate tumors the sensitivity and specificity of magnetic resonance imaging were 78.1% and 58.2%, respectively. CONCLUSIONS: Anterior prostate cancer had pathological features and favorable oncologic outcomes comparable to those of posterior prostate cancer but also more frequent Gleason score upgrading. Magnetic resonance imaging had moderate diagnostic performance for detecting lesions in the anterior prostate.

Percutaneous Kidney Biopsy for a Small Renal Mass: A Critical Appraisal of Results.

PURPOSE: We report the diagnostic accuracy of renal mass biopsy for a small renal mass (4 cm or less) and identify predictors of successful renal mass biopsy in a contemporary cohort of patients from 2 large tertiary referral centers. MATERIALS AND METHODS: A total of 442 biopsies of renal tumors 4 cm or less at 2 tertiary centers between 2008 and 2015 were included in study. Biopsy outcomes (malignant, benign or nondiagnostic) and concordance rates between renal mass biopsy and final surgical pathology were determined. Univariate and multivariate logistic regression analyses were performed to identify factors indicative of nondiagnostic biopsy. RESULTS: The initial biopsy was diagnostic in 393 cases (88.9%) and nondiagnostic in 49 (11.1%). Of diagnostic biopsies 76% revealed renal cell carcinoma and 24% were benign. Renal cell carcinoma histological subtyping and grading was possible in 90.2% and 31.3% of cases, respectively. A second biopsy was performed in 11 of the 49 nondiagnostic cases and a diagnosis was possible in 100%, including renal cell carcinoma in 10 and oncocytoma in 1. Small tumor size, cystic nature of tumors and biopsy during the initial years of the study were independent predictors of nondiagnostic biopsy. The rates of accuracy in identifying malignancies, histiotyping and 2-tier grading between renal mass biopsy and surgical pathology were 97.1%, 95.1% and 68.8%, respectively. CONCLUSIONS: Renal mass biopsy for a small renal mass can be performed accurately. Nondiagnostic renal mass biopsy was common for smaller masses and cystic masses, and during the initial years of the study. A second biopsy should be considered in nondiagnostic biopsy cases.