The Distribution of Metastatic Renal Cell Carcinoma by Presenting Tumor Stage in the Modern Era.

INTRODUCTION: There is a stage migration for detection of kidney cancer, thus we aim to evaluate the distribution of metastatic renal cell carcinoma by presenting clinical T stage over time. MATERIALS AND METHODS: The National Cancer Database was evaluated for patients with metastatic kidney cancer from 2010 to 2016. The primary outcome was the temporal trend of presenting clinical T stage over time. The secondary outcome was overall survival. Kaplan-Meier and Cox regression analyses were performed. RESULTS: The incidence of metastatic kidney cancer has increased, from 3426 new cases in 2010 to 4510 in 2016. While diagnosis of metastasis has increased for all tumor stages over time, there has been a more rapid increase in metastasis of localized renal masses (cT1-T2) as compared to locally advanced disease (cT3-T4). In 2010, 46% of the new metastatic cases diagnosed were cT3-T4, while in 2016 this proportion decreased to 38.2%. Conversely, metastatic cases with cT1-T2 tumors increased from 54% in 2010 to 61.9% in 2016. Cox regression noted an increased risk of death correlating with higher clinical T stage. On Kaplan Meier analysis, the 2-year survival was 29.3%, 30.3%, 28.3%, and 16.0% for cT1, cT2, cT3, and cT4, respectively (logrank P < .001). CONCLUSION: Metastatic kidney cancer is increasingly diagnosed at a lower presenting cT stage. Survival outcomes worsen with increasing cT stage in the setting of metastasis.

A Lack of Palliative Therapy Use in Patients With Advanced Penile Cancer.

OBJECTIVES: Advanced penile cancer is associated with a poor prognosis; therefore, providing patients with realistic expectations, addressing goals of care and offering palliative therapy when appropriate is critical. Our goal was to investigate the National Cancer Database (NCDB) and analyze the role and trends in use of palliative therapy in patients with advanced penile cancer. METHODS: The NCDB 2004-2015 penile cancer data set was queried for patients with locally advanced, defined as cT4NanyM0 and cTanyN3M0, or metastatic disease regardless of tumor or nodal stage. Patients were categorized based on whether they did or did not receive palliative care. Palliative care was cataloged as pain management therapy, surgery, radiation or systemic treatment, any combination therapy or not otherwise specified (NOS). Our primary outcome was receiving palliative therapy. Secondary outcome was the temporal trends in palliative care. Logistic regression (LR) was performed. RESULTS OBTAINED: 385 and 279 patients were identified with locally advanced and metastatic penile cancer respectively. 27 (7.1%) and 49 (17.6%) patients received palliative care. Average age of patients accepting palliative care was 61.9 years old, about 5 years younger than their counterparts who declined therapy (p < 0.011) in the metastatic cohort. Other patient specific demographics and clinical tumor characteristics were not significantly different in either population. Of patients with locally advanced disease pursuing palliative therapy, radiation (29.6%), surgery (14.8%), systemic treatment (14.8%) and combination treatment (22.2%) were the more popular choices. In the metastatic population, radiation (32.7%) and systemic therapy (24.5%) were the most prevalent choices for palliative treatment followed by combination treatment (16.3%), surgery (12.2%), pain management (10.2%), or NOS (4.1%). LR for the receipt of "any palliative therapy" revealed that increasing age (OR 0.971, p = 0.032) decreased the likelihood of accepting palliative therapy in the metastatic population but not in the locally advanced group. Charlson score of 2 (OR 5.966, p = 0.025) and low income (OR 3.968, p = 0.002) predicted receipt of palliative therapy in the locally advanced group. In patients with metastatic disease, African-American race (OR 2.502, p = 0.025), Charlson score 1 (2.175, p = 0.047) and 3+ (5.386, p = 0.020) predicted an increased predilection for receiving palliative therapy. Interestingly, no statistically significant difference in mortality was noted in either cohort. No significant increase in the trend of palliative care administration was seen in locally advanced and metastatic penile cancer between 2004 to 2015 (p = 0.078 and p = 0.942, respectively). CONCLUSION: Locally advanced and metastatic penile cancer carry a high mortality rate yet only 11.4% of all patients studied received palliative care. Its use is more common in younger patients, those with co-morbidities and/or those of black race in the metastatic group. Locally advanced patients with low income or comorbidities were also more likely to opt for palliative therapy. Receipt of palliative care did not affect mortality. No increase in frequency of palliative therapy was seen, suggesting much improvement needs to be done in adopting and implementing palliative care in this patient population.

Analysis of Inpatient Palliative Care Consultations for Patients With Metastatic Prostate Cancer.

OBJECTIVE: To characterize the use of palliative care for patients with metastatic prostate cancer and identify its associations with costs, hospital course, and discharge. MATERIALS AND METHODS: Using the National Inpatient Sample database from 2012 to 2013, we identified 99 070 patients with metastatic prostate cancer and analyzed the data from their hospital admissions using descriptive statistics, χ2 analysis, and regression modeling. RESULTS: Palliative care services were consulted in 10.4% (10 300) of metastatic prostate cancer admissions. These admissions were associated with nonelective origin, acute complications, and reduced surgical procedures and chemotherapy. Patients in private, investor-owned hospitals had a 51.6% less consultations (P < .001), while nonprofit and government, nonfederal hospitals had 4.7% and 7.8% more consultations (P < .001). Median costs and charges were only marginally less (2.1% and 5.6%, respectively, P < .001), length of stay was 22% higher (P < .001), and in-house mortality was 147.2% higher in the consultation group (P < .001). Controlling for other factors, patients seen by palliative care were more likely to have do-not-resuscitate orders (odds ratio [OR]: 5.25, P < .001) and be transferred to another facility like hospice (OR: 3.90, P < .001) or to home health (OR: 3.85, P < .001). CONCLUSIONS: Palliative care consultation could improve care for patients with metastatic prostate cancer in a different manner than observed in other diseases. With our characterization of the incidence and patient and hospital factors, we can conclude that there is room to expand palliative care's role beyond uninsured patients in large, urban teaching hospitals.

National Trends in the Utilization of Androgen Deprivation Therapy for Very Low Risk Prostate Cancer.

OBJECTIVE: To analyze national trends using the National Cancer Database (NCDB) in use of androgen deprivation therapy (ADT), outside of standard of care, in patients with very low risk prostate cancer. METHODS: We identified 52,797 men in the NCDB from 2010 to 2015 diagnosed with very low risk prostate cancer as defined (cT1cM0, PSA <10, Gleason ≤6, <3 biopsy cores positive). We evaluated the treatment trends and the proportion of men treated with ADT based on race, income, insurance status, treatment facility volume, and Charlson comorbidity. RESULTS: From 2010 to 2015, prevalence of primary ADT use in patients with very low risk prostate cancer remained 0.7%. Patients treated at low-volume facilities were more likely to receive primary ADT (hazard ratio [HR] 1.29, P <.001) as were black patients (HR 1.47, P <.001). When evaluated over time, the proportion of men treated with primary ADT who were white decreased while the proportion of men who were black increased. CONCLUSION: The use of primary ADT in men with very low risk prostate cancer has not changed over time, and may be over utilized, particularly among black men and those treated at low-volume facilities.

Variability of Retail Pricing of Generic Urologic Medications in a Major US Metropolitan Area.

OBJECTIVE: To investigate retail pricing for generic urologic medications in the St. Louis area as a function of pharmacy type, zip-code, and median income. MATERIALS AND METHODS: Pharmacies spanning 51 zip-codes were identified. From May-June 2017, pharmacies were inquired regarding cost, without insurance, for 30- and 90-tablet prices for finasteride 5 mg, tamsulosin 0.4 mg, oxybutynin 5 mg, and oxybutynin extended release (ER) 5 mg and 10 mg. Median income was determined using US census data. K-means clustering defined groupings based on zip-code, median income, and a combination of the two. Pricing between groups and pharmacy type was compared using Kruskal-Wallis and Wilcoxon rank-sum tests. Associations between pricing and median income were tested using Spearman's rho. RESULTS: 152 chain and 16 independent pharmacies provided data. Retail pricing for generic urologic medications did not vary as a function of zip-code, median income, or a combination of the two. There was a significant difference in the pricing of tamsulosin 0.4 mg, and oxybutynin ER 5 mg and 10 mg based on pharmacy type, where independent pharmacies have significantly lower prices compared to chain (P = .00-.00003). CONCLUSION: Pricing for generic urologic medications demonstrated wide variability at the retail pharmacy level. Compared to chain, independent pharmacies have significantly lower pricing for tamsulosin 0.4 mg, and oxybutynin ER 5 mg and 10 mg. Pharmacy zip-code, median income, and a combination of the two did not correlate with pricing.

Outcomes of renal salvage for penetrating renal trauma: a single institution experience.

INTRODUCTION: Conservative management of penetrating renal trauma is emerging, with data originating from centers with variable level of trauma care. This study reviews the outcomes of renal salvage after penetrating trauma at a level I trauma center. MATERIALS AND METHODS: An institutional review board approved trauma registry at Saint Louis University Hospital was retrospectively analyzed, for patients with penetrating renal trauma from 2009 to 2014. Patients were divided into nephrectomy group (NG) or non-nephrectomy group (non-NG), and compared. A multi-variable analysis was performed to determine predictors of nephrectomy, with cross validation to evaluate the performance of the multi-variable model. Data was analyzed using R version 3.3.2. A p value of < 0.05 was considered as significant. RESULTS: A total of 121 patients were identified with penetrating renal trauma. Gunshot injury was the leading cause of injury (87%). Eighteen (15%) patients required nephrectomy. The overall mean injury severity score (ISS). was 20. High grade (grade 4-5) renal injuries were noted in 41 patients (34%). Among these, 14 patients (34%) underwent a nephrectomy, while 27 patients (66%) were managed conservatively to salvage renal units. CT grade of renal injury was the only predictor of nephrectomy, on multi-variable analysis (OR 17.09 CI 2.75-105.99, p = 0.002). CT grade of injury and injury severity score were predictors of endoscopic intervention on a sub group analysis of non-NG. CONCLUSIONS: CT grade of injury predicts nephrectomy after penetrating renal trauma. Conservative management is a feasible option in penetrating renal trauma even with a higher grade of injury.

Successful Nonoperative Management of High-Grade Blunt Renal Injuries.

Current management of high-grade blunt renal trauma favors a nonoperative approach when possible. We performed a retrospective study of high grade blunt renal injuries at our level I trauma center to determine the indications and success of nonoperative management (NOM). 47 patients with blunt grade IV or V injuries were identified between October 2004 and December 2013. Immediate operative patients (IO) were compared to nonoperatively managed (NOM). Of the 47 patients, 3 (6.4%) were IO and 44 (95.6%) NOM. IO patients had a higher heart rate on admission, 133 versus 100 in NOM (P = 0.01). IO patients had a higher rate of injury to the renal vein or artery (100%) compared to NOM group (18%) (P = 0.01). NOM failed in 3 of 44 patients (6.8%). Two required nonemergent nephrectomy and one required emergent exploration resulting in nephrectomy. Six NOM patients had kidney-related complications (13.6%). The renal salvage rate for the entire cohort was 87.2% and 93.2% for NOM. Nonoperative management for hemodynamically stable patients with high-grade blunt renal trauma is safe with a low risk of complications. Management decisions should consider hemodynamic status and visualization of active renal bleeding as well as injury grade in determining operative management.

Sarcomatoid Renal Cell Carcinoma Metastasis to the Penis.

Secondary cancers of the penis are extremely uncommon with less than 300 cases reported in the past 100 years. These cancers are most frequently a result of an aggressive or poorly managed primary prostate or bladder cancer and rarely a metastasis from a primary kidney tumor. Currently, there is no published literature which describes the spread of sarcomatoid renal cell carcinoma (SRCC) to the penis. In this report, we present a 55-year-old-man who presented with a large right-sided SRCC which metastasized to the base of his penis within 1 month of symptom onset. We also discuss the possible route of metastasis based on primary tumor size and location within the retroperitoneum.

Impact of adjuvant androgen deprivation therapy after radical prostatectomy on the survival of patients with pathological T3b prostate cancer.

OBJECTIVE: To determine the impact of adjuvant androgen deprivation therapy (ADT) on survival in patients with seminal vesicle invasion (pT3b) at radical prostatectomy. PATIENTS AND METHODS: We reviewed 12,115 patients who underwent radical prostatectomy between 1987 and 2002 to identify patients with pT3bN0 prostate cancer who received adjuvant ADT (n= 191). These patients were matched by clinical and pathological variables to a group of patients with pT3b prostate cancer who did not receive adjuvant ADT. Median postoperative follow-up was 10 years. Clinical endpoints included biochemical progression-free survival (BPFS), local recurrence-free survival (LRFS), systemic progression-free survival (SPFS), cancer-specific survival (CSS) and overall survival. RESULTS: Patients who underwent adjuvant ADT experienced improved 10-year BPFS (60% vs 16%, P < 0.001), LRFS (87% vs 76%, P= 0.002), SPFS (91% vs 78%, P= 0.004) and CSS (94% vs 87%, P= 0.037). Overall survival was not significantly different between groups (75% vs 69%, P= 0.12). Both luteinizing hormone-releasing hormone agonists (hazard ratio, 0.26; 95% CI, 0.15-0.46; P < 0.001) and bilateral orchiectomy (hazard ratio, 0.13; 95% CI, 0.06-0.31; P < 0.001) improved BPFS. When stratified by type of ADT (hormonal therapy vs orchiectomy), there was no difference in survival outcomes. CONCLUSIONS: Adjuvant ADT improves local, and systemic control after radical prostatectomy for pT3b prostate cancer. There is no difference in survival between patients receiving medical hormonal therapy vs patients undergoing orchiectomy. Given the lack of improvement in overall survival, continued investigation is needed to identify the cohort of pT3b patients at highest risk for cancer progression and therefore most likely to benefit from a multimodal treatment approach.

Role of PSA velocity in predicting pathologic upgrade for Gleason 6 prostate cancer.

BACKGROUND: Pathologic upgrading to Gleason 7 or higher on radical prostatectomy (RP) specimens occurs in many patients with Gleason 6 prostate cancer on preoperative biopsy. We evaluated whether biopsy characteristics and preoperative factors, including preoperative PSA velocity (PSAV), are predictive of pathologic upgrading. MATERIALS AND METHODS: We identified 235 consecutive Gleason 6 prostate cancer patients who underwent biopsies at our institution, had multiple pre-biopsy PSA values, and eventually underwent RP. Preoperative biopsy, clinical characteristics, and PSAV were analyzed to determine the risk of pathologic upgrading or extracapsular extension. These clinical factors were evaluated for association with biochemical recurrence following RP. RESULTS: Overall, 48% of patients were upgraded to Gleason grade 7 or higher following RP. Median PSAV was 0.61 ng/mL/y, and PSAV was similar between upgraded and non-upgraded patients (1.01 vs. 0.78, P = 0.1). PSA velocity level was not associated with extracapsular disease (P = 0.4). PSA velocity > 1 was associated with biochemical recurrence (HR 3.23, P = 0.01) but this was not statistically significant in a multivariable model. Increasing PSA density (HR 2.18, P < 0.001), bilateral cores positive (HR 1.89, P < 0.05), and any biopsy core involvement > 50% (HR 2.52, P < 0.05) were most associated with pathologic upgrading. On multivariate analysis, only bilateral cancer detection at biopsy (HR 1.90, P < 0.05) significantly predicted upgrading. CONCLUSIONS: PSAV has a limited role in predicting Gleason 6 upgrading. Patients with bilateral cancer detected on transrectal biopsy should be encouraged to have radical local therapy due to high risk of harboring more aggressive disease.

Biochemical recurrence following robot-assisted radical prostatectomy: analysis of 1384 patients with a median 5-year follow-up.

BACKGROUND: There is a paucity of data on long-term oncologic outcomes for patients undergoing robot-assisted radical prostatectomy (RARP) for prostate cancer (PCa). OBJECTIVE: To evaluate oncologic outcomes in patients undergoing RARP at a high-volume tertiary center, with a focus on 5-yr biochemical recurrence-free survival (BCRFS). DESIGN, SETTING, AND PARTICIPANTS: The study cohort consisted of 1384 consecutive patients with localized PCa who underwent RARP between September 2001 and May 2005 and had a median follow-up of 60.2 mo. No patient had secondary therapy until documented biochemical recurrence (BCR). BCR was defined as a serum prostate-specific antigen ≥ 0.2 ng/ml with a confirmatory value. BCRFS was estimated using the Kaplan-Meier method. Event-time distributions for the time to failure were compared using the log-rank test. Univariable and multivariable Cox proportional hazards regression models were used to determine variables predictive of BCR. INTERVENTION: All patients underwent RARP. MEASUREMENTS: BCRFS rates were measured. RESULTS AND LIMITATIONS: This cohort of patients had moderately aggressive PCa: 49.0% were D'Amico intermediate or high risk on biopsy; however, 60.9% had Gleason 7-10 disease, and 25.5% had ≥ T3 disease on final pathology. There were 189 incidences of BCR (31 per 1,000 person years of follow-up) at a median follow-up of 60.2 mo (interquartile range [IQR]: 37.2-69.7). The actuarial BCRFS was 95.1%, 90.6%, 86.6%, and 81.0% at 1, 3, 5, and 7 yr, respectively. In the patients who recurred, median time to BCR was 20.4 mo; 65% of BCR incidences occurred within 3 yr and 86.2% within 5 yr. On multivariable analysis, the strongest predictors of BCR were pathologic Gleason grade 8-10 (hazard ratio [HR]: 5.37; 95% confidence interval [CI], 2.99-9.65; p < 0.0001) and pathologic stage T3b/T4 (HR: 2.71; 95% CI, 1.67-4.40; p < 0.0001). CONCLUSIONS: In a contemporary cohort of patients with localized PCa, RARP confers effective 5-yr biochemical control.

Early oncological outcomes of robot-assisted radical prostatectomy for high-grade prostate cancer.

OBJECTIVE: To evaluate the oncological outcomes of patients with specimen Gleason 8 and 9 prostate cancers and to determine factors that predict biochemical recurrence-free survival (BCRFS) after robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: Of 4156 patients who underwent RARP from January 2001 to 2009, we identified 368 men with Gleason 8 or 9 tumours who met the inclusion criteria. BCR was defined as a PSA level of ≥0.2 ng/mL with a second rising value. The Kaplan-Meier method and log-rank test were used to compare BCRFS while factors that predict BCRFS were determined by Cox proportional hazards modelling. RESULTS: The median age and PSA level were 62 years and 6.4 ng/mL for men with Gleason 8, and 63 years and 6.7 ng/mL for Gleason 9 cancers. The median (interquartile range, IQR) overall follow-up was 23 (10-46) months and 19 (7-37) months for Gleason 8 and 9 tumours, respectively. At 60 months the mean (se) overall BCRFS was 36 (5)% and for Gleason 8 it was 47 (6)% and for Gleason 9 it was 21 (7)% (P < 0.001). At 5 years, extraprostatic extension (pT3a) resulted in BCRFS of 52 (9)% for Gleason 8 tumours and 21 (11)% for Gleason 9 (P= 0.012). On multivariable analysis, lymph node invasion, specimen Gleason score, pathological stage and tumour volume predicted BCRFS. CONCLUSIONS: Early results suggest RARP monotherapy performs comparably to RP for BCRFS in men with high-grade prostate cancer. There are significant oncological differences between Gleason 8 and 9 tumours.

Robotic partial nephrectomy for renal tumors larger than 4 cm.

BACKGROUND: Minimally invasive partial nephrectomy (PN) is most commonly performed for renal tumors < or =4 cm in size. Robotic PN (RPN) for tumors >4 cm has not been assessed. OBJECTIVE: To evaluate the safety and feasibility of RPN for tumors >4 cm in the context of patients undergoing RPN for tumors < or =4 cm. DESIGN, SETTING, AND PARTICIPANTS: We reviewed data for 71 consecutive patients who underwent transperitoneal RPN at a tertiary care center between August 2007 and September 2009 by a single surgeon. Patients were stratified into two groups: 15 with tumors >4 cm on preoperative imaging (group 1) and 56 patients with tumors < or =4 cm (group 2). INTERVENTION: All patients underwent transperitoneal RPN by a single surgeon. MEASUREMENTS: Preoperative, perioperative, pathologic, and functional outcomes data were analyzed and compared between groups. We used chi(2) and student t tests for categorical and continuous variables, respectively. A p value <0.05 was considered statistically significant. RESULTS AND LIMITATIONS: Mean radiographic tumor size was 5.0 cm (4.1-7.9) for group 1 and 2.1cm (0.7-3.8) for group 2. No significant differences were found between groups for estimated blood loss, total operative time, hospital stay, complication rates, and change in estimated glomerular filtration rate. Patients with larger tumors had longer median warm ischemia times (25 vs 20 min; p=0.011). Limitations of our study include the retrospective nature the analysis, small sample size, and single-surgeon experience. CONCLUSIONS: In our initial experience, RPN for tumors >4 cm is safe and feasible, showing comparable outcomes to RPN for smaller tumors, although with longer warm ischemia times. Future studies with extended follow-up are necessary to determine the viability of RPN for large tumors as an effective form of treatment.

The impact of previous inguinal or abdominal surgery on outcomes after robotic radical prostatectomy.

OBJECTIVES: To evaluate our experience with robotic radical prostatectomy (RRP) in the setting of previous inguinal or abdominal surgery. METHODS: From a prospective cohort of 3950 consecutive patients who underwent transperitoneal RRP between September 2001 and September 2008, we identified 1049 (27%) patients with a history of abdominal or inguinal surgery. Demographic data including body mass index, age at the time of surgery, serum prostate-specific antigen, and clinical stage were prospectively recorded. Clinical endpoints measured included estimated blood loss (EBL), console time, total operative time, and perioperative complications. Degree of adhesiolysis at the time of surgery was graded into minor, moderate, or large. RESULTS: In comparing patients with previous abdominal or inguinal surgery with no surgery, there were no differences in EBL (150 vs 151 mL, P = .79), total operative time (158 minutes v second 155 minutes, P = .15), body mass index (27.8 vs 27.4, P = .2), preoperative prostate-specific antigen (6.1 vs 6.3, P = .07) and clinical stage (P = .71). A total of 243 (24%) of patients with previous surgery required adhesiolysis vs 246 (8%) of patients with no previous surgery (P <.001). Appendectomy was the most common previous surgery identified (11%). Patients with a previous history of colectomy had the highest incidence of adhesiolysis (72%). A total of 5 bowel injuries were recorded in the cohort of 3950 patients; of these 3 patients had a history of prior abdominal surgery. CONCLUSIONS: Previous abdominal or inguinal surgery is not a contraindication to RRP. The majority of these patients can have their procedure safely performed without an increased risk of complications.

Postoperative surveillance for renal cell carcinoma: a multifactorial histological subtype specific protocol.

OBJECTIVE: To create a model that adjusts surveillance after surgery to the natural history of surgically treated renal cell carcinoma (RCC), and to assess the cost of several surveillance models with a long-term longitudinal follow-up, as although there are many models for predicting the outcome in RCC, most surveillance protocols remain based primarily on stage alone, and thus might be inaccurate as they do not incorporate many other pathological features that have a significant effect on recurrence. PATIENTS AND METHODS: We identified 1864, 357 and 118 patients with pM0 clear cell, papillary and chromophobe RCC, respectively, who had a a radical or partial nephrectomy between 1970 and 2000. All recurrences were classified according to location (abdomen, thorax, bone, brain). Cox proportional hazards models were used to determine which pathological features were independently predictive of recurrence in each group. Three subtype-specific protocols were devised based on site-specific recurrence rates. RESULTS: Positive surgical margins, the 2002 Tumour-Node-Metastasis classification, size, nuclear grade, and histological tumour necrosis were independently associated with abdominal recurrence in patients with clear-cell RCC. These same features, except for surgical margins, were significantly associated with thoracic recurrence. The 2002 classification and nuclear grade were independently associated with abdominal and thoracic recurrence in patients with papillary RCC. No multivariate analysis was done for chromophobe RCC as there were only 10 recurrences to the abdomen and three to the thoracic region. However, these patients were stratified according to stage and grade, as recurrences in this group had a clear stage- and grade-specific pattern. CONCLUSIONS: We present a subtype-specific multifactorial surveillance protocol based on significant predictors of recurrence. This protocol is better than algorithms based on stage alone and can be used to effectively tailor postoperative imaging to the individual patient.

Choice of hemostatic agent influences adhesion formation in a rat cecal adhesion model.

INTRODUCTION: Hemostatic agents are frequently used during abdominal surgery and some are linked to adhesion formation. We sought to evaluate the impact of several commonly used hemostatic agents on adhesion formation in a rat peritoneal model. METHODS: In our study, Wister outbred rats underwent laparotomy and excision of a portion of their peritoneum to initiate adhesion formation process. One of six different hemostatic agents, namely, activated starch microspheres (Arista AH; Medafor Inc., Minneapolis, MN), glutaraldehyde activated collagen (BioGlue; Cryolife Inc., Kennesaw, GA), thrombin coated collagen microspheres (FloSeal; Baxter Inc., Deerfield, IL), thrombin activated fibrin polymer (Tisseel, Baxter), polyethylene glycol polymer (CoSeal, Baxter), or oxidized cellulose (Surgicel; Ethicon Inc., Somerville, NJ), was placed in the area of peritoneal defect. All animals were sacrificed on post-op day 7 and strength and extent of adhesion formation was determined. Histopathological examination of rat caecum was also performed. RESULTS: Arista and CoSeal showed significantly lower adhesion formation than controls (P < 0.05). Higher adhesion scores were seen in BioGlue (P < 0.05) treated rats. Additionally, histopathologic examination showed that BioGlue caused statistically more inflammation and necrosis than controls (P < 0.05). Total adhesion score increased with residual amount of agent present at 7 d. CONCLUSIONS: Use of Arista and CoSeal may help in reducing peritoneal adhesions after intra-abdominal surgeries. Furthermore, there appears to be a relationship between the creation of inflammation and necrosis in tissues and the eventual formation of adhesions. This could aid in improving the design of these agents in the future.

Timing of androgen deprivation therapy and its impact on survival after radical prostatectomy: a matched cohort study.

PURPOSE: We assessed the impact of the timing of androgen deprivation on disease progression after radical prostatectomy for patients with localized prostate cancer. MATERIALS AND METHODS: We evaluated all patients who underwent radical prostatectomy between 1990 and 1999. Patients with pathological lymph node negative disease who received androgen deprivation therapy were then separated into 5 groups for analysis based on the time of hormone therapy initiation: 1--adjuvant androgen deprivation, 2--androgen deprivation therapy started at a postoperative prostate specific antigen of 0.4 ng/ml or greater, 3--at prostate specific antigen 1.0 or greater, 4--at prostate specific antigen 2.0 or greater and 5--at systemic progression. The first 4 groups were matched by clinical and pathological features to control groups who did not receive androgen deprivation after surgery using a nested, matched cohort design. Median followup for the entire cohort was 10 years. Clinical end points included systemic progression-free survival and cancer specific survival. RESULTS: After matching clinicopathological variables adjuvant androgen deprivation therapy was associated with improved 10-year systemic progression-free survival (95% vs 90%, p <0.001) and 10-year cancer specific survival (98% vs 95%, p = 0.009), although overall survival for these patients remained unchanged (84% vs 83%, p = 0.427). In contrast, we found that men who started hormonal therapy at a postoperative prostate specific antigen of 0.4 or greater, 1.0 or 2.0 did not have improved systemic progression-free or cancer specific survival. CONCLUSIONS: Adjuvant hormonal therapy modestly improves cancer specific survival and systemic progression-free survival after prostatectomy. The benefit of hormone therapy is lost when androgen deprivation is delivered at the time of prostate specific antigen recurrence or systemic progression.

Relative contraindication to endoscopic subureteral injection for vesicoureteral reflux: congenital refluxing megaureter with distal aperistaltic segment.

OBJECTIVES: Endoscopic subureteral injection for the management of vesicoureteral reflux has become a well-established first-line minimally invasive treatment strategy. One potential pitfall is the creation of ureteral obstruction. No predictors are available to determine which patients will develop this rare, but real, complication. METHODS: A retrospective evaluation of 2 girls, aged 3 and 4 years, with grade 4 and 3 reflux, respectively, and documented ureteral obstruction after endoscopic treatment with dextranomer/hyaluronic acid copolymer. Before treatment, both patients had had refluxing megaureters with a distal aperistaltic segment. RESULTS: Ultimately, they both required open, cross-trigonal ureteral reimplantation with resolution of vesicoureteral reflux and ureteral obstruction. CONCLUSIONS: Congenital refluxing megaureter with a distal aperistaltic segment might be a relative contraindication to endoscopic subureteral injection of a bulking agent for the management of vesicoureteral reflux.