Impact of tumor histology and grade on treatment success of percutaneous renal cryoablation.

BACKGROUND: We analyzed oncological outcomes in patients who underwent percutaneous renal cryoablation (PRC) with documented renal cell carcinoma (RCC) by perioperative biopsy. METHODS: Multicenter retrospective analysis of 153 patients [median follow-up 48 months] who underwent PRC from 09/2005 to 08/2014 was performed. We divided the cohort into patients who developed recurrence versus no recurrence. Kaplan-Meier analyses examined recurrence-free survival (RFS) according to grade and histology. Multivariable analysis (MVA) was performed to identify factors associated with tumor recurrence. RESULTS: One hundred and fifty-three patients were analyzed [18 patients (11.8 %) with recurrence and 135 (88.2 %) patients without recurrence]. There were no differences between the groups with respect to demographics, RENAL score, and number of probes utilized. Recurrence group had larger tumor size (3.1 vs. 2.4 cm; p = 0.011), upper pole tumor location (p = 0.016), and greater proportions of high-grade tumor (33 vs. 0.7 %; p < 0.001) and clear cell histology (77.8 vs. 45.9 %; p = 0.011). Four-year RFS was 100 versus 80 % for grade 1 versus grade 2/3 tumors (p = 0.0002), and 97 versus 88 % for other RCC versus clear cell RCC (p = 0.07). MVA demonstrated tumor size >3 cm (OR 2.46; p = 0.019), clear cell histology (OR 2.12; p = 0.027), and high tumor grade (OR 2.33, p < 0.001) as independent risk factors associated with tumor recurrence. CONCLUSIONS: Association of higher grade and clear cell histology with recurrence and progression suggests need for increased emphasis on preoperative risk stratification by biopsy, with grade 1 and non-clear cell RCC being associated with improved treatment success than higher grade and clear cell RCC.

Association of rise in C-reactive protein with decline in renal function following partial nephrectomy.

INTRODUCTION: To investigate association of C-reactive protein (CRP), a marker of systemic inflammation, with renal functional decline patients undergoing partial nephrectomy (PN) for renal mass. MATERIALS AND METHODS: Retrospective study of patients who underwent PN between February 2006-March 2011, with ≥ 6 months follow up. Data was analyzed between two groups: CRP increase ≥ 0.5 mg/L from 6 months postoperative ('CRP rise,' CRPR), versus no CRP increase = 0.5 ('CRP stable,' CRPS). Primary outcome was change in estimated glomerular filtration rate (ΔeGFR, mL/min/1.73 m²), with de novo postoperative stage III chronic kidney disease (stage III-CKD, eGFR < 60 mL/min/1.73 m²) being secondary. Multivariable analysis (MVA) was conducted to identify risk factors for development of de novo stage III-CKD. RESULTS: A total of 243 patients (206 CRPS/37 CRPR) were analyzed. Demographics and R.E.N.A.L. nephrometry scores were similar. CRPR had significantly higher median ΔeGFR (-13.7 versus -32.0 mL/min/1.73 m², p < 0.001) and de novo stage III-CKD at last follow up (43.2% vs. 3.7%, p < 0.001). Median time to CRP rise was 10 (IQR 6.5-12) months. Median time from CRP rise to de novo stage III-CKD was 9 (IQR 7.5-11) months. MVA found RENAL score (OR 1.89, p = 0.001), hypertension (OR 4.75, p = 0.016), and CRP rise (OR 55.76, p < 0.001) were associated with de novo stage III-CKD. Sensitivity of CRP increase ≥ 0.5 for predicting CKD was 69.6%, specificity 93.3%, positive predictive value 55.2%, and negative predictive value 96.3%. CONCLUSION: Rise in CRP postoperatively is independently associated with renal functional decline after PN and may be useful in identifying patients to evaluate for renoprotective strategies. Further studies are requisite to clarify etiology of this association.

Impact of renal surgery for cortical neoplasms on lipid metabolism.

OBJECTIVE: To examine the incidence of and risk factors for development of hyperlipidaemia in patients undergoing radical nephrectomy (RN) or partial nephrectomy (PN) for renal cortical neoplasms, as hyperlipidaemia is a major source of morbidity in chronic kidney disease (CKD). PATIENTS AND METHODS: We conducted a two-centre retrospective analysis of 905 patients (mean age 57.5 years, mean follow-up 78 months), who underwent RN (n = 610) or PN (n = 295) between July 1987 and June 2007. Demographics, preoperative and postoperative hyperlipidaemia were recorded. De novo hyperlipidaemia was defined as that ocurring ≥6 months after surgery in cases where laboratory values met National Cholesterol Education Program Adult Treatment Panel III definitions. The Kaplan-Meier method was used to assess freedom from de novo hyperlipidaemia. Multivariable analysis was conducted to determine the risk factors for de novo hyperlipidaemia. RESULTS: There were no significant differences with respect to demographics, preoperative glomerular filtration rate (GFR) <60 mL/min/1.73 m(2) (P = 0.123) and hyperlipidaemia (P = 0.144). Tumour size (cm) was significantly larger in the RN group vs the PN group (7.0 vs 3.7; P < 0.001). Significantly greater postoperative GFR <60 mL/min/1.73 m(2) was noted in the RN group (45.7 vs 18%, P < 0.001). Significantly, more de novo hyperlipidaemia developed in the RN group than in the PN group (23 vs 6.4%; P < 0.001). The mean time to development of hyperlipidaemia was longer for PN than for RN (54 vs 44 months; P = 0.03). Five-year freedom from de novo hyperlipidaemia probability was 76% for RN vs 96% for PN (P < 0.001). Multivariable analysis showed that RN (odds ratio [OR] 2.93; P = 0.0107), preoperative GFR <60 mL/min/1.73 m(2) (OR 1.98; P = 0.037) and postoperative GFR <60 mL/min/1.73 m(2) (OR 7.89; P < 0.001) were factors associated with hyperlipidaemia development. CONCLUSION: Patients who underwent RN had a significantly higher incidence of and shorter time to development of de novo hyperlipidaemia. RN and pre- and postoperative eGFR <60 mL/min/1.73 m(2) were associated with development of hyperlipidaemia. Further follow-up and prospective investigation are necessary to confirm these findings.

Does radical nephrectomy increase the risk of erectile dysfunction compared with partial nephrectomy? A cohort analysis.

UNLABELLED: Study Type - Therapy (prospective cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Erectile dysfunction (ED) is a form of endothelial dysfunction that is prevalent in patients with chronic kidney disease (CKD). We hypothesized that partial nephrectomy (PN) would limit development of ED compared with radical nephrectomy (RN), primarily due to renal function preservation, and found that patients undergoing RN had significantly higher de novo ED compared with a contemporary, well-matched cohort undergoing PN; in addition to RN, hypertension, CKD and diabetes mellitus were associated with developing ED. To our knowledge, this is the first study demonstrating an increased risk of ED after RN compared with PN. OBJECTIVES: • To evaluate prevalence and risk factors for development of erectile dysfunction (ED) in patients who underwent radical nephrectomy (RN) and partial nephrectomy (PN). • ED is a form of endothelial dysfunction that is prevalent in patients with chronic kidney disease (CKD). PN confers superior renal functional preservation compared with RN; however, the impact on ED is unclear. METHODS: • This was a retrospective study of 432 patients (264 RN/168 PN, mean age 58 years, mean follow-up 5.8 years) who underwent surgery for renal tumours between January 1998 and December 2007. • The primary outcome was rate of de novo ED postoperatively. Secondary outcomes included development of CKD (estimated GFR < 60 mL/min/1.73 m(2) ) and response to phosphodiesterase-5 inhibitors. • Multivariate analysis was performed to determine risk factors for de novo ED postoperatively. RESULTS: • RN and PN groups had similar demographics and comorbidities. • Tumour size (cm) was larger for RN (RN 7.0 vs PN 3.7, P < 0.001) and more preoperative ED existed in PN vs RN (P= 0.042). No differences were observed for preoperative CKD, hyperlipidaemia and diabetes mellitus. • Postoperatively, higher rates of de novo ED (29.5% vs 9.5%, P < 0.001) and CKD (33.0% vs 9.8%, P < 0.001) developed in RN vs PN cohorts, respectively. • Of men with ED, 63% responded to phosphodiesterase inhibitors, without significant difference between the two groups (P= 0.896). • Multivariate analysis demonstrated de novo ED to be associated with RN (odds ratio [OR] 3.56, P < 0.001), hypertension (OR 2.32, P= 0.014), preoperative (OR 8.77, P < 0.001) and postoperative (OR 2.64, P= 0.001) CKD, and postoperative diabetes mellitus (OR 2.93, P < 0.001). CONCLUSIONS: • Patients undergoing RN had significantly higher de novo ED compared with a contemporary, well-matched cohort undergoing PN. In addition to RN, hypertension, CKD and diabetes mellitus were associated with developing ED. • Further investigation on effects of surgically induced nephron loss on ED is requisite.

Peyronie's disease compromises the durability and component-malfunction rates in patients implanted with an inflatable penile prosthesis.

OBJECTIVE: To compare the durability and complication rates of surgery to implant an inflatable penile prosthesis (IPP) between patients with and without Peyronie's disease (PD). PATIENTS AND METHODS: We retrospectively reviewed all patients undergoing IPP surgery at one centre (Memphis) between July 1997 and May 2007. Variables included age at surgery, race, body mass index, presence of PD, brand/type of IPP (two vs three pieces), presence of diabetes mellitus (DM), active tobacco use, and complications. The result were assessed using t-tests, chi-square and regression analysis, with P < 0.05 considered to indicate significant differences. RESULTS: In all, 79 men were analysed (mean age 59.8 years, range 38.1-81.5). Nine (11%) patients had PD and had a IPP implanted, with penile modelling. Overall, 43 (54%) patients had pre-existing DM and 51 (65%) actively used tobacco. At a mean (range) follow-up of 19.6 (0.1-115.3) months, six (8%) patients had component malfunctions. Of these, three had DM and four actively smoked. Of the nine patients with PD, three developed component malfunctions, vs three (4%) who did not have PD (P= 0.002). Both groups had similar infection rates (P= 0.98). The mean (range) time to component malfunction was 4.3 (0.1-9.6) months, which was longer (but not significantly) in the PD group, with a mean (median, range) of 10.9 (6.3, 1.1-9.6) months, than the 3.0 (1.0, 0.2-7.9) months in the group without PD (P= 0.4). Groups were matched for rates of DM (P= 0.1) and tobacco use (P= 0.2). PD was a significant predictor of component malfunction on both univariate (P= 0.001) and multivariate analysis (P= 0.002) when adjusting for age (P= 0.2), body mass index (P= 0.7), DM (P= 0.3) and tobacco use (P= 0.8). CONCLUSION: Patients with PD implanted with a IPP, with penile modelling, had significantly higher component malfunction rates. Further, PD independently predicted component malfunction. These findings might be related to stress on the device at the time of surgery, during use, or both. Further study into this relationship is required.

Variation in the incidence of and risk factors for the development of nephrolithiasis after radical or partial nephrectomy.

OBJECTIVE: to examine incidence of and risk factors for the development of nephrolithiasis in patients treated with radical nephrectomy (RN) or partial nephrectomy (nephron-sparing surgery, NSS). PATIENTS AND METHODS: the study comprised a single-centre review of 749 patients treated with RN or NSS from August 1987 to June 2006. Demographics, medical and stone history, metabolic variables and postoperative stone events were recorded. Data were analysed within subgroups based on treatment (RN vs NSS). Multivariate analysis was used to identify risk factors for postoperative stone formation. RESULTS: in all, 499 patients had RN and 250 had NSS (mean age 57.9 years; mean follow-up 6.3 years). There were no significant differences in their demographic factors, but tumours were significantly larger in RN (P < 0.001). There was no significant difference in preoperative urinary pH < 6.0 or stone history. Significantly fewer patients after NSS than RN formed calculi (NSS 1.6% vs RN 8.4%, P < 0.001), developed hypobicarbonataemia (NSS 7.2% vs RN 12.8%, P= 0.020), and a urinary pH of <6.0 (NSS 11.2% vs RN 19.4%, P= 0.004). Multivariate analysis showed that RN (odds ratio 18.18), postoperative urinary pH < 6 (15.63), previous stone disease (13.7), age <60 years (7.33, all P < 0.001), body mass index ≥ 30 kg/m(2) (3.26, P= 0.033), male gender (2.67, P= 0.039), and hypobicarbonataemia (2.46, P= 0.034) were significantly associated with the development of postoperative calculi. CONCLUSIONS: patients undergoing RN have a significantly higher incidence of postoperative nephrolithiasis than a well-matched cohort undergoing NSS. In addition to RN, male sex, urinary pH < 6.0, hypobicarbonataemia, history of stone disease, obesity, and age <60 years were significantly associated with postoperative stone formation.

Comparison of rates and risk factors for developing chronic renal insufficiency, proteinuria and metabolic acidosis after radical or partial nephrectomy.

OBJECTIVE: To investigate the incidence of and risk factors for developing chronic renal insufficiency (CRI), proteinuria and metabolic acidosis (MA) in patients treated with radical nephrectomy (RN) or nephron-sparing surgery (NSS). PATIENTS AND METHODS: We retrospectively reviewed 749 patients (mean age 57.7 years; mean follow-up 6.4 years) who had RN or NSS for renal tumours between July 1987 and June 2006 at our institution. The demographics and outcomes were analysed and recorded. The primary outcome variable was the development of an estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m(2), with secondary outcomes being the development of a serum creatinine level of > or =2.0 mg/dL, MA (serum bicarbonate <22 mmol/L), and proteinuria (> or =1+ on dipstick testing). Multivariate logistic regression (MV) was used to identify risk factors for developing an eGFR of <60 mL/min/1.73 m(2), a creatinine level of > or =2.0 mg/dL and MA. RESULTS: Of the 749 patients, 499 had RN and 250 NSS; there were no significant demographic differences between the groups. After surgery a significantly greater proportion of the RN than the NSS group had a low eGFR (44.7% vs 16.0%, P < 0.001), MA (12.8% vs 7.2%, P = 0.02), proteinuria (22.2% vs 13.2%, P = 0.003) and elevated creatinine (14.2% vs 8.4%, P = 0.022). MV showed that diabetes mellitus (odds ratio 8.96, P = 0.002), RN (5.32, P < 0.001), hypertension (4.55, P = 0.003), a body mass index (BMI) of > or =30 kg/m(2) (3.51, P = 0.017), age > or =60 years (2.91, P = 0.015) and smoking (2.44, P = 0.014) were risk factors for developing a low eGFR; and that age > or =60 years (2.00, P = 0.019), diabetes mellitus (10, P < 0.001), hypertension (7.41, P = 0.002), smoking (5.29, P < 0.001) and RN (3.08, P < 0.001) were risk factors for developing an elevated creatinine level; and that being male (2.50, P = 0.019), age > or =60 years (3.13, P = 0.002), a BMI > or =30 (3.52, P < 0.001), RN (9.82, P < 0.001), preoperative eGFR <60 (9.71, P < 0.001) and elevated creatinine (5.9, P = 0.008) were risk factors for developing MA. CONCLUSIONS: Patients undergoing RN had significantly greater CRI, MA and proteinuria rates than a well-matched group undergoing NSS. In addition to RN, age > or =60 years, diabetes mellitus, hypertension and smoking were associated with progression to CRI after surgery.

Survival outcomes in men receiving androgen-deprivation therapy as primary or salvage treatment for localized or advanced prostate cancer: 20-year single-centre experience.

OBJECTIVES: To evaluate the overall survival (OS) and disease-specific survival (DSS) in men receiving primary androgen-deprivation therapy (PADT) or salvage medical ADT (SADT) for prostate cancer. PATIENTS AND METHODS: After Institutional Review Board approval, we retrospectively reviewed patients receiving ADT for prostate cancer between July 1987 and June 2007. Variables included age at diagnosis and ADT induction, race, PSA level before ADT, ADT schedule (continuous/intermittent), clinical/pathological stage, hormone-refractory prostate cancer (HRCP) status, PADT or SADT, and deaths. RESULTS: In all, 548 men were analysed. The mean age at diagnosis and ADT induction were 70.1 and 72.3 years, respectively, and 321 (58.6%) were African-American. The median PSA level before ADT was 16.3 ng/mL. ADT was administered continuously in 497 (90.7%) patients; 342 (62.4%) received PADT while 206 (37.6%) received SADT. At mean (range) follow-up of 81.8 (2.1-445) months, 98 (17.9%) deaths occurred; 31 (31.6%) were cancer-specific. The OS and DSS in the PADT and SADT groups were not significantly different (P = 0.36 and P = 0.81, respectively). Mortality rates/distributions were similar between groups (P = 0.68). Multivariate predictors of OS and DSS included age at diagnosis (P = 0.03) and ADT induction (P = 0.009), tumour stage (P < 0.001), and PSA level at ADT induction (P = 0.01). Progression to HRPC worsened OS and DSS (both P < 0.001). CONCLUSION: PADT and SADT prolong survival in men with prostate cancer. HRPC portends a poor DSS. Age at diagnosis and ADT induction, PSA level before ADT, and disease stage predict both OS and DSS in this population. However, most men died from causes unrelated to prostate cancer, thus questioning the true value of ADT in prolonging patient survival.

Adverse effects of androgen deprivation therapy in prostate cancer: Current management issues.

Prostate cancer (CaP) is the most common visceral malignancy and a leading cause of cancer death in men. Androgen deprivation therapy (ADT) is an established treatment for locally advanced and metastatic CaP, and often used as primary therapy in select patients. As ADT has continued to assume an important role in the treatment of CaP, a greater appreciation of potential adverse effects has been acknowledged in men receiving this therapy. Given that all treatments for CaP are frequently associated with some degree of morbidity and can have a negative impact on health-related quality of life (HRQOL), the potential benefits of any treatment, including ADT, must outweigh the risks, particularly in patients with asymptomatic disease. Once the choice to proceed with ADT is complete, it is imperative for the urologist to possess comprehensive knowledge of the potential adverse effects of ADT. This permits the urologist to properly monitor for, perhaps diminish, and to treat any linked morbidities. Patient complaints related to ADT such as a decrease in HRQOL, cognitive and sexual dysfunction, hot flashes, endocrine abnormalities, cardiovascular disease, and alterations in skeletal and body composition are commonly reported throughout the literature. Herein, we review the principal adverse effects linked with ADT in CaP patients and suggest various universal strategies that may diminish these potential adverse consequences associated with this therapy.

Acupuncture for Analgesia During Transurethral Resection of Bladder Tumor.

Background: Acupuncture has been widely studied, and theories regarding its analgesic mechanism of action have been proposed. It has been used for procedural analgesia; however, no reports of its use in urologic surgery have been reported. In this case report, we demonstrate how acupuncture can be used as an alternative to general anesthesia for transurethral resection of bladder tumor (TURBT). This may serve as an attractive option for bladder cancer patients with medical comorbidities, which predispose them to high risk for general anesthesia. Case Presentation: A 65-year-old Caucasian female with toxicant-induced loss of tolerance (TILT) was found to have a bladder mass. TURBT was discussed, and in light of her TILT syndrome, she elected to undergo the procedure with acupuncture in lieu of general anesthesia for fear of an adverse reaction. Acupuncture was performed by a trained practitioner with therapeutic needles placed in the ears, hands, abdomen, and lower extremities bilaterally. She was subsequently taken to the operating room where we performed a TURBT of a bladder tumor overlying the left ureteral orifice. The procedure was generally well tolerated and the patient experienced mild pain. There were no perioperative complications. The tumor was estimated to be 3 cm in largest diameter, and a total of 8 g of aggregate tissue was sent to our pathologists. Pathology analysis demonstrated adequate resection with detrusor muscle present in the sample. The bladder tumor was low-grade papillary urothelial cell carcinoma (Stage Ta). She has had tumor recurrence and has undergone repeat TURBT, but to date, she is 22 months free of bladder cancer. Conclusion: In this case report, we demonstrate that acupuncture is a safe and effective alternative to general anesthesia for patients undergoing TURBT. Since tobacco use is prevalent among bladder cancer patients, many of these individuals have associated medical comorbidities, which predispose them to high risk with general anesthesia. Therefore, acupuncture may serve as an attractive alternative for certain patients in this population.

Patterns of sexual and erectile dysfunction and response to treatment in patients receiving androgen deprivation therapy for prostate cancer.

OBJECTIVE: To investigate the incidence of patient-reported erectile (ED) and sexual dysfunction and response to treatment in men after the induction of androgen deprivation therapy (ADT) for prostate cancer, as ADT-induced changes in serum testosterone can result in changes in libido and sexual function. PATIENTS AND METHODS: We retrospectively reviewed patients receiving ADT for prostate cancer at our institution between January 1989 and July 2005; those receiving only neoadjuvant ADT were excluded. Variables included age, race, body mass index, prostate-specific antigen level before ADT, Gleason sum, clinical stage, ADT type (medical vs surgical) and schedule (continuous vs intermittent), previous treatment for prostate cancer, presence of pre-existing or new-onset diabetes mellitus (DM), and presence of ED before ADT. After ADT induction, charts were reviewed for reporting of ED, changes in libido, and initiation of ED therapy (medical or surgical). RESULTS: In all, 395 patients (mean age of 71.7 years; 59.0% African-American, 41.0% Caucasian/other, at initiation ADT) were analysed. At mean follow-up of 87.4 months, 57 (14.4%) patients reported ED; 40 of these (70%) reported new-onset ED, while 17 (30%) reported ED before ADT. Response rates were 33-80% with medical therapy, including 44% receiving phosphodiesterase-5 inhibitor monotherapy. On multivariate analysis, age <70 years (P < 0.001) and the absence of DM (P = 0.024) were associated with reporting ED after ADT. CONCLUSIONS: Patients receiving ADT for prostate cancer have variable degrees of ED. Successful outcomes are possible, particularly when implementing multimodal therapy. Younger patients and those with no DM are more likely to report ED after ADT induction.

Nonoperative management of blunt renal trauma: is routine early follow-up imaging necessary?

BACKGROUND: There is no consensus on the role of routine follow-up imaging during nonoperative management of blunt renal trauma. We reviewed our experience with nonoperative management of blunt renal injuries in order to evaluate the utility of routine early follow-up imaging. METHODS: We reviewed all cases of blunt renal injury admitted for nonoperative management at our institution between 1/2002 and 1/2006. Data were compiled from chart review, and clinical outcomes were correlated with CT imaging results. RESULTS: 207 patients were identified (210 renal units). American Association for the Surgery of Trauma (AAST) grades I, II, III, IV, and V were assigned to 35 (16%), 66 (31%), 81 (39%), 26 (13%), and 2 (1%) renal units, respectively. 177 (84%) renal units underwent routine follow-up imaging 24-48 hours after admission. In three cases of grade IV renal injury, a ureteral stent was placed after serial imaging demonstrated persistent extravasation. In no other cases did follow-up imaging independently alter clinical management. There were no urologic complications among cases for which follow-up imaging was not obtained. CONCLUSION: Routine follow-up imaging is unnecessary for blunt renal injuries of grades I-III. Grade IV renovascular injuries can be followed clinically without routine early follow-up imaging, but urine extravasation necessitates serial imaging to guide management decisions. The volume of grade V renal injuries in this study is not sufficient to support or contest the need for routine follow-up imaging.

Tubeless percutaneous nephrolithotomy for complex renal stone disease: single center experience.

OBJECTIVE: Tubeless percutaneous nephrolithotomy (PCNL) has become an option for treatment of renal stone disease, though no clearly defined algorithm exists for selection of patients suitable to tubeless PCNL. We investigated our experience with tubeless PCNL to evaluate its safety and efficacy for cases of complex renal calculi. PATIENTS AND METHODS: Retrospective review of all tubeless PCNLs performed for complex renal calculus disease (bilateral stones, partial/complete staghorn, infundibular stenosis/calyceal diverticulum, pre-existing renal insufficiency) between January 2001 and January 2006. All patients had a ureteral stent placed in an antegrade fashion following stone treatment, and a foley catheter remained in place overnight. No patient received nephrostomy tube (NT). Imaging (CT or KUB) was obtained at the first outpatient follow-up visit. Patient demographics, incidence of complications, clinical outcomes and stone-free rates were noted and analyzed. "Stone free" was defined as negative imaging (CT or KUB). RESULTS: Forty-two patients (47 renal units) were treated with tubeless PCNL for complex renal stone disease (5 bilateral, 25 total/partial staghorn, 12 renal insufficiency, and 10 infundibular stenosis or calyceal diverticulum). Mean age was 58.2+/-9.4 years. Mean length of hospital stay was 2.1 days. Mean preoperative and postoperative hematocrit were 40.5+/-4.5 and 37.2+/-5.8, respectively (p=0.001). Single-procedure stone free rate was 74.5%, and the two-procedure stone free rate was 91.5%. One patient (2.4%) required a blood transfusion and one patient (2.4%) developed urosepsis. CONCLUSIONS: Tubeless PCNL is safe and effective and can be utilized in cases of complex renal stone disease.

Prevalence and predictive factors for the development of de novo psychiatric illness in patients receiving androgen deprivation therapy for prostate cancer.

OBJECTIVE: Androgen deprivation therapy (ADT) remains a widely utilized modality for treatment of localized and advanced prostate cancer. While ADT-induced alterations in testosterone have demonstrated impacts on quality of life, the effects on mental health remain ill-defined. We investigated the prevalence of de novo psychiatric illness and predictive factors following ADT induction for prostate cancer. MATERIALS AND METHODS: We retrospectively reviewed patients receiving ADT for prostate cancer at our institution between 1/1989-7/2005, excluding men receiving only neoadjuvant ADT. Variables included age, race, body mass index, prostate-specific antigen (PSA), Gleason sum, clinical stage, ADT type (medical/surgical) and schedule (continuous/intermittent), and presence of pre-ADT and newly diagnosed psychiatric illness. The cohort was divided into three groups for analysis: pre-ADT psychiatric illness, de novo psychiatric illness, and no psychiatric illness. Data analysis utilized statistical software with p < 0.05 considered significant. RESULTS: Three-hundred and ninety-five patients with a mean age of 71.7 years at ADT initiation were analyzed. Thirty-four men (8.6%) were diagnosed with pre-ADT psychiatric illness. At mean follow-up of 87.4 months, 101 (27.9%) men were diagnosed with de novo psychiatric illness, most commonly including: depression (n = 57; 56.4%), dementia (n = 14; 13.9%), and anxiety (n = 9; 8.9%). On multivariate analysis, increasing pre-ADT PSA was predictive of post-ADT anxiety (p = 0.01). Overall and disease-specific survival outcomes were similar between groups. CONCLUSIONS: De novo psychiatric illness was identified in 27.9% of men. While no predictive factors were identified for de novo psychiatric illness, increasing PSA was associated with de novo anxiety. Prospective investigation using validated instruments is requisite to further delineate the relationship between ADT and psychiatric health.

Contemporary analysis of erectile, voiding, and oncologic outcomes following primary targeted cryoablation of the prostate for clinically localized prostate cancer.

PURPOSE: To evaluate erectile function (EF) and voiding function following primary targeted cryoablation of the prostate (TCAP) for clinically localized prostate cancer (CaP) in a contemporary cohort. MATERIALS AND METHODS: We retrospectively reviewed all patients treated between 2/2000-5/2006 with primary TCAP. Variables included age, Gleason sum, pre-TCAP prostate specific antigen (PSA), prostate volume, clinical stage, pre-TCAP hormonal ablation, pre-TCAP EF and American Urologic Association Symptom Score (AUASS). EF was recorded as follows: 1 = potent; 2 = sufficient for intercourse; 3 = partial/insufficient; 4 = minimal/insufficient; 5 = none. Voiding function was analyzed by comparing pre/post-TCAP AUASS. Statistical analysis utilized SAS software with p < 0.05 considered significant. RESULTS: After exclusions, 78 consecutive patients were analyzed with a mean age of 69.2 years and follow-up 39.8 months. Thirty-five (44.9%) men reported pre-TCAP EF level of 1-2. Post-TCAP, 9 of 35 (25.7%) regained EF of level 1-2 while 1 (2.9%) achieved level 3 EF. Median pre-TCAP AUASS was 8.75 versus 7.50 postoperatively (p = 0.39). Six patients (7.7%) experienced post-TCAP urinary incontinence. Lower pre-TCAP PSA (p = 0.008) and higher Gleason sum (p = 0.002) were associated with higher post-TCAP AUASS while prostate volume demonstrated a trend (p = 0.07). Post-TCAP EF and stable AUASS were not associated with increased disease-recurrence (p = 0.24 and p = 0.67, respectively). CONCLUSIONS: Stable voiding function was observed post-TCAP, with an overall incontinence rate of 7.7%. Further, though erectile dysfunction is common following TCAP, 25.7% of previously potent patients demonstrated erections suitable for intercourse. While long-term data is requisite, consideration should be made for prospective evaluation of penile rehabilitation following primary TCAP.

Osteoporosis and fractures after androgen deprivation initiation for prostate cancer.

INTRODUCTION: Androgen deprivation therapy (ADT) is widely utilized for treatment of localized and advanced prostate cancer (CaP). ADT is associated with increased rates of osteoporosis; however, its impact on fracture risk is not completely understood. We investigated incidence and predisposing factors for osteoporosis and fractures in a large, contemporary, single institution series of patients treated with ADT for CaP. METHODS: We retrospectively reviewed medical records of all patients who received ADT for CaP between 1/1989 and 7/2005. Primary endpoints of investigation were osteoporosis and non-pathologic fractures. Independent variables included age, race, body mass index (BMI), pretreatment serum PSA, Gleason sum, clinical stage, ADT type (medical versus surgical) and schedule (continuous versus intermittent), and receipt of calcium, vitamin D or bisphosphonate supplementation. Data were analyzed by Chi-square test, Student's t-test, Linear Regression, and Logistic Regression (p < 0.05 significant). RESULTS: A total of 395 patients were analyzed (mean age 71.7 years, 59% African American, 41% Caucasian/other). At mean follow-up of 66.1 months, 92 (23%) patients developed osteoporosis and 27 (7%) patients developed non-pathologic fractures. On univariate analysis, age, race, BMI, and ADT duration were significantly associated with osteoporosis development, while BMI, ADT duration, and presence of osteoporosis were significantly associated with fracture incidence. Regression analysis revealed that age > 70 at ADT initiation, continuous ADT, and increased treatment duration predicted osteoporosis development, while only osteoporosis was independently predictive of fracture development. CONCLUSIONS: Patients receiving continuous ADT for CaP are at increased risk for developing osteoporosis which may lead to fractures, with an incidence of 7% in our study population.

Novel Selective Agents for the Degradation of Androgen Receptor Variants to Treat Castration-Resistant Prostate Cancer.

Androgen receptor (AR) mediates the growth of prostate cancer throughout its course of development, including in abnormal splice variants (AR-SV)-driven advanced stage castration-resistant disease. AR stabilization by androgens makes it distinct from other steroid receptors, which are typically ubiquitinated and degraded by proteasomes after ligand binding. Thus, targeting AR in advanced prostate cancer requires the development of agents that can sustainably degrade variant isoforms for effective therapy. Here we report the discovery and characterization of potent selective AR degraders (SARD) that markedly reduce the activity of wild-type and splice variant isoforms of AR at submicromolar doses. Three SARDs (UT-69, UT-155, and (R)-UT-155) bind the amino-terminal transcriptional activation domain AF-1, which has not been targeted for degradation previously, with two of these SARD (UT-69 and UT-155) also binding the carboxy-terminal ligand binding domain. Despite different mechanisms of action, all three SARDs degraded wild-type AR and inhibited AR function, exhibiting greater inhibitory potency than the approved AR antagonists. Collectively, our results introduce a new candidate class of next-generation therapeutics to manage advanced prostate cancer. Cancer Res; 77(22); 6282-98. ©2017 AACR.

National trends in hospitalization from indwelling urinary catheter complications, 2001-2010.

PURPOSE: The purpose of this study is to investigate national trends in hospitalization from indwelling urinary catheters complications from 2001 to 2010. MATERIALS AND METHODS: The Healthcare Utilization Project Nationwide Inpatient Sample database was analyzed for this study. We examine hospitalization rates, patient demographics, hospital stays, insurance provider, hospital type, geographic location, and septicemia rates of patients hospitalized for indwelling urinary catheter complications from 2001 to 2010. RESULTS: Hospitalization from indwelling urinary catheters almost quadrupled from 11,742 in 2001 to 40,429 in 2010. The increases have been due to patients who are older and predominantly male compared to all hospitalization. The "national bill" increased from $213 million to $1.3 billion (a factor of 6) after adjusting for inflation. Most patients had urinary tract infections, 77 % in 2001 and 87 % in 2010. Septicemia in indwelling urinary catheter hospitalization patients has increased from 21 % in 2001 to 40 % in 2010. In 2010, secondary diseases associated with hospitalization due to indwelling urinary catheters included urinary tract infections (86.5 %), adverse effects of medical care (61.9 %), bacterial infection (48.6 %), and septicemia (40.3 %). CONCLUSIONS: Hospitalization due to indwelling urinary catheter complications has almost quadrupled from 11,742 in 2001 to 40,429 in 2010, and the majority of patients had urinary tract infections. Septicemia is of particular concern since rates have almost doubled (from 21 to 40 % over the period) in these patients. The specific medical indication for urinary catheters used postoperatively should be scrutinized, and the duration of placement should be minimized to reduce future complication rates.

Nomogram to predict prostate cancer diagnosis on primary transrectal ultrasound-guided prostate biopsy in a contemporary series.

OBJECTIVE: Transrectal ultrasound-guided biopsy (TRUSB) remains the mainstay for prostate cancer (CaP) diagnosis. Numerous variables have shown associations with development of CaP. We present a nomogram that predicts the probability of detecting CaP on TRUSB. METHODS: After obtaining institutional review board approval, all patients undergoing primary TRUSB for CaP detection at a single center at our institution between 2/2000 and 9/2007 were reviewed. Patients undergoing repeat biopsies were excluded, and only the first biopsy was included in the analysis. Variables included age at biopsy, race, clinical stage, prostate specific antigen (PSA), number of cores removed, TRUS prostate volume (TRUSPV), body mass index, family history of CaP, and pathology results. S-PLUS 2000 statistical software was utilized with p < 0.05 considered significant. Cox proportional hazards regression models with restricted cubic splines were utilized to construct the nomogram. Validation utilized bootstrapping, and the concordance index was calculated based on these predictions. RESULTS: A total of 1,542 consecutive patients underwent primary TRUSB with a median age of 64.2 years (range 34.9-89.2 years), PSA of 5.7 ng/ml (range 0.3-3,900 ng/ml), number of cores removed of 8.0 (range 1- 22) and TRUSPV of 36.4 cm(3) (range 9.6-212.0 cm(3)). CaP was diagnosed in 561 (36.4%) patients. A nomogram was constructed incorporating age at biopsy, race, PSA, body mass index, clinical stage, TRUSPV, number of cores removed, and family history of CaP. The concordance index when validated internally was 0.802. CONCLUSIONS: We have developed and internally validated a model predicting cancer detection in men undergoing TRUSB in a contemporary series. This model may assist clinicians in risk-stratifying potential candidates for TRUSB, potentially avoiding unnecessary or low-probability TRUSB.

RENAL nephrometry score is associated with complications after renal cryoablation: a multicenter analysis.

OBJECTIVE: To analyze outcomes and complications of percutaneous (PRC) and laparoscopic renal cryoablation (LRC) using the radius, endophytic, nearness to collecting system, anterior/posterior, and location (RENAL) nephrometry system. METHODS: Retrospective multicenter analysis of 154 consecutive patients who underwent either ultrasound-guided LRC (n = 88) or computed tomography (CT)-guided PRC (n = 66) from March 2003 to December 2011. RENAL score and demographics were compared to postoperative complications (Clavien). Multivariable analysis was carried out for factors associated with development of postprocedure complications. RESULTS: Mean age was 68 years (94 men/60 women). Median follow-up was 34 months (range 23.6-45.6 months). Mean tumor size was 2.6 ± 1 cm. Mean RENAL score was 5.2 ± 1.4. Differences in (A)nterior/posterior component and (H)ilar domain of the RENAL scores were noted, with PRC favoring posterior tumors and hilar lesions compared to LRC (P < .001 and P = .044, respectively). There were 14.9% complications, all of which were low-grade (Clavien 1,2). There were no differences in complications between LRC and PRC (15.9% vs 13.6%, P = .82). Most common complication type was hemorrhagic in 9 of 154 patients (5.8%); significant increase in the hemorrhagic complication rate was noted for patients with "N" ("nearness") component score of 2 or 3 (5/36, or 13.9%), compared to patients with "N" score of 1 (4/115 or 3.5%, P = .033). multivariable analysis demonstrated that increasing RENAL score was associated with postprocedure complications (odds ratio [OR] = 1.37, P = .025). When separated into individual domains, multivariable analysis revealed that "N" score 3 was significantly associated with postoperative complications (OR 16.15, P = .027). CONCLUSION: Increasing RENAL score was associated development of postprocedure complications after renal cryotherapy. Further investigation is requisite to elucidate the role of RENAL nephrometry score in risk stratification prior to renal cryotherapy.