Lateral incision 1-stage urethroplasty with oral mucosal graft for patients with penile urethral stricture after hypospadias repair-a preliminary report.

PURPOSE: To report our early experience of a novel surgical approach for penile urethral strictures after hypospadias repair, using a lateral incision to keep the ventral tissue and vasculature of the penis intact and to avoid the need for tissue interposition. PATIENTS AND METHODS: A total of 21 patients underwent lateral incision 1-stage urethroplasty with oral mucosal graft. The median age of the patients was 21 years old (range, 13-47). The median number of prior procedures for hypospadias repair was 3 (range, 1-9) with 18 of 21 patients (85.7%) undergoing greater than 1 prior reconstructive procedure. The mean length of the penile urethral strictures was 4.5 ± 1.7 cm, with a range of 1.0 to 8.0 cm. Selection criteria for lateral incision 1-stage urethroplasty include: non-obliterative stricture, no or mild penile curvature and no urethrocutaneous fistula. RESULTS: Median follow-up was 30 months (range, 6-73). Success was achieved in 17 of 21 patients (80.9%). The 4 (19.0%) patients with treatment failure developed recurrent urethral strictures. Of the 4 men with recurrent strictures, 3 were ultimately treated successfully by DVIU (2) or two-stage urethroplasty (1), and one patient chose repeated dilation. CONCLUSIONS: For patients with penile urethral stricture after hypospadias repair with non-obliterative stricture, no significant penile curvature and no urethrocutaneous fistula, a lateral approach with oral mucosal graft is a simple technique that avoids the need for tissue interposition and keeps the penile ventral tissue and vasculature intact, resulting in a low risk of complications.

An abrupt decrease in arterial blood pressure may predict a high level carbon dioxide embolism in retroperitoneoscopic surgery: case report and a literature review.

BACKGROUND: Carbon dioxide (CO2) embolism is the primary suspect in most cases of intraoperative "cardiovascular" collapse. However, there are few reports about CO2 embolism in retroperitoneal laparoscopy. CASE PRESENTATION: An abrupt decrease in arterial blood pressure was noted in time of retroperitoneoscopic adrenalectomy in a 40 years old male patient with adrenal adenoma. The end-tidal carbon dioxide (EtCO2) and saturation of oxygen were stable with normal cardiography until anesthesiologists found the change of resistant of peripheral circulation, then they gave us a hint of hemorrhage. However, the blood pressure had no reaction to one bolus of epinephrine administration when trying to improve the circulation. Five minutes later, a sudden fall of blood pressure was noted, and then we stopped the processing of cutting tissue and trying to coagulate any bleeding in the operation field. Further vasopressor support proved to be completely ineffective. With the help of transesophageal echocardiography, we found the bubbles in the right atrium, which confirmed the diagnosis of an intraoperative gas embolism (Grade IV). We stopped the carbon dioxide insufflation and deflated the retroperitoneal cavity. All the bubbles in the right atrium totally disappeared and the blood pressure, resistance of peripheral circulation and cardiac output returned to normal 20 min later. We continued the operation and completed it in 40 min with the 10 mmHg air pressure. CONCLUSION: CO2 embolism may occour during retroperitoneoscopic adrenalectomy, and an acute decrease in arterial blood pressure should alert both the urologists and anesthesiologists to this rare and fatal complication.

Preparation of Drug Sustained-Release Scaffold with De-Epithelized Human Amniotic Epithelial Cells and Thiolated Chitosan Nanocarriers and Its Repair Effect on Spinal Cord Injury.

The disability rate of spinal cord injury (SCI) is extremely high, and stem cell inhibition is one of the most effective schemes in treating the spinal cord, but the survival rate is extremely low after stem cell transplantation, so it cannot be widely used in clinic. Studies have revealed that loading stem cells with biological scaffolds can effectively improve the survival rate and effect after stem cell transplantation. Therefore, this research was devised to analyze the repair effect of thiolated chitosan nanocarriers scaffold carrying de-epithelized human amniotic epithelial cells (HAECs) on SCI. And we used thiolated chitosan as nanocarriers, aiming to provide a reliable theoretical basis for future clinical practice. Through experiments, we concluded that the Tarlov and BBB scores of rats with SCI were raised under the intervention of thiolated chitosan carrying HAECs, while the inflammatory factors in serum, oxidative stress reaction in spinal cord tissue, apoptosis rate of nerve cells, and autophagy protein expression were all suppressed. Thus, the thiolated chitosan carrying HAECs may be applied to treat SCI by suppressing autophagy protein expression, oxidative stress response, and release of inflammatory factors in spinal cord tissue, which may be a new clinical therapy for SCI in the future. Even though we cannot understand exactly the therapeutic mechanism of thiolated chitosan carrying HAECs for SCI, the real clinical application of thiolated chitosan carrying HAECs needs to be confirmed by human experiments.

Outcomes of early endoscopic realignment for blunt straddle injuries to the bulbar urethra: a single-center retrospective study.

BACKGROUND: The optimal acute management of patients with blunt straddle injury to the bulbar urethra remains in question. Conventionally, suprapubic diversion with delayed urethroplasty can always be considered, if necessary, but the role of early endoscopic realignment (EER) in the acute management of blunt straddle injuries to bulbar urethra is controversial. We report our clinical experience and outcomes with EER for patients with straddle injury to the bulbar urethra in a level one trauma center. METHODS: We retrospectively reviewed 44 male patients who were transferred to our trauma center between January 2013 and January 2019 for acute management of blunt straddle injury to the perineum leading to bulbar urethra injuries. We reviewed the medical records of those patients to identify demographics, emergency management and clinical outcomes. RESULTS: The most common injury mechanism was falling onto the perineum (n = 27, 61.4%), followed by motorcycle accident (n = 11, 25.0%) and bicycle accident (n = 6, 13.6%). Of the 44 patients, 14 (31.8%) were partial bulbar urethral ruptures and 30 (68.2%) were complete bulbar urethral ruptures. 31 (70.5%) patients successfully underwent EER and 13 (29.5%) patients failed attempted EER. the difference between successful EER attempts and failed ones in term of injured urethral mucosa integrity was statistically significant (P = 0.035, OR 8.667,95% CI: 0.998-75.235). In patients who underwent successful EER, urethral stricture occurred after catheter removal at a median of 8 (1-28) months in 24 (77.4%) patients and the mean stricture length was 1.8 ± 0.8 (0.5-3.0), which was not statistically significant when compared with those who failed EER (P = 0.103). Overall, 21 out of 24 (87.5%) patients with strictures after EER were successfully managed by urethroplasty. CONCLUSIONS: Although achieving a successful EER attempt is relatively easy for most patients with straddle injury to the bulbar urethra, it does not improve urethral healing significantly. Most patients with stricture formation after EER have to be cured with urethroplasty.

The Significance of Preoperative Serum Sodium and Hemoglobin in Outcomes of Upper Tract Urothelial Carcinoma: Multi-Center Analysis Between China and the United States.

PURPOSE: To analyze the effect of preoperative serum sodium and hemoglobin on oncologic outcomes in upper tract urothelial carcinoma (UTUC) based on a multi-center cohort from China and the United States (U.S.). METHODS: We retrospectively reviewed the records of 775 patients with UTUC treated surgically at tertiary care medical facilities in China or the US from 1998 to 2015. We analyzed associations of preoperative serum sodium and hemoglobin with clinicopathological characteristics, overall survival (OS), cancer-specific survival (CSS) and intravesical recurrence free survival (IVRFS). RESULTS: The US patients had comparatively lower serum sodium and similar hemoglobin at baseline. Preoperative low serum sodium value was associated with tumor multifocality, lymph node metastasis (LNM) and lymphovascular invasion (LVI); preoperative anemia was associated with advanced age, tumor multifocality, high tumor grade and LVI. Preoperative low serum sodium was an independent predictor of worse OS in the entire cohort; preoperative anemia was an independent predictor of worse OS and CSS in the US cohort alone, Chinese cohort alone and the combined cohort. We developed a predictive nomogram for OS which exhibited better prognostic value when it included the values of sodium and anemia, and successfully validated it in different cohorts. CONCLUSION: Preoperative low serum sodium and anemia could be informative in predicting worse pathologic and survival outcomes in different UTUC patient ethnic groups.

The use of doxazosin before adrenalectomy for pheochromocytoma: is the duration related to intraoperative hemodynamics and postoperative complications?

PURPOSE: No conclusion exists for the optimum duration of preoperative administration of doxazosin (DOX) before adrenalectomy for pheochromocytoma. The purpose of this study is to investigate whether perioperative hemodynamics and postoperative outcomes are related to the duration of DOX administration. METHODS: In total, 132 patients managed preoperatively with single α-receptor blocker DOX were enrolled. All patients underwent adrenalectomy for pheochromocytoma in the Department of Urology, Peking University First Hospital, between January 2001 and July 2019. Patients were divided into three groups based on the duration of preoperative administration of DOX: group A (≤14 days), group B (15-30 days), and group C (>30 days). Patient and tumor characteristics, intraoperative hemodynamics, and postoperative outcomes were recorded and compared. RESULTS: These patients included 57 men and 75 women, with an average age of 48 years. Clinical characteristics, preoperative hemodynamics, medicine management and surgical approaches were comparable between the three groups. Among the three groups, we found that group C (>30 days) had the lowest intraoperative minimum heart rate [group A vs. group B vs. group C = 60 (52-67) vs. 59 (50-61) vs. 51.5 (50-58.75), p = 0.024] and highest risk of postoperative hypotension requiring vasopressor support [group A vs. group B vs. group C = 14 (20.3%) vs. 12 (27.9%) vs. 10 (50.0%), p = 0.032]. CONCLUSION: The current study indicated that preoperative management of pheochromocytoma with single α-receptor blocker DOX for more than 30 days after final dose adjustment might lead to intraoperative bradycardia and more postoperative hypotension requiring vasopressor support. Thus, our study does not support long-term (over 30 days) preoperative administration of pheochromocytoma with single α-receptor blocker DOX in the final dose.

High Preoperative Controlling Nutritional Status Score Predicts a Poor Prognosis in Patients with Localized Upper Tract Urothelial Cancer: A Propensity Score Matching Study in a Large Chinese Center.

PURPOSE: The aim of this study was to elucidate the prognostic value of the preoperative controlling nutritional status (CONUT) score, a new index based on the total lymphocyte count, serum albumin concentration and total cholesterol concentration, in patients with localized upper tract urothelial cancer (UTUC) after radical nephroureterectomy (RNU) using propensity score matching (PSM) analysis. METHODS: We retrospectively reviewed 908 consecutive patients with localized UTUC who underwent RNU between 1999 and 2015. Patients were divided into two groups according to the optimal cutoff value of the preoperative CONUT score. Relationships between the CONUT score with clinicopathological characteristics, overall survival (OS), cancer-specific survival (CSS), and disease-free survival (DFS) were analyzed before and after 1:1 PSM. RESULTS: A high preoperative CONUT score was significantly correlated with older age, low body mass index (BMI), poor American Statistical Association (ASA) score, advanced pathological T stage, and tumor squamous or glandular differentiation (all p<0.05). Kaplan-Meier curves showed poor OS, CSS, and DFS for patients with a high CONUT score before and after PSM (all p<0.001). Furthermore, multivariate analyses revealed that a high preoperative CONUT score was an independent risk factor for poor DFS (hazard ratio [HR] 1.418, 95% confidence interval [CI] 1.132-1.776, p=0.002) before PSM and an independent risk factor for poor DFS (HR 1.333, 95% CI 1.010-1.760, p=0.042) and OS (HR 1.459, 95% CI 1.010-2.107, p=0.044) after PSM. CONCLUSION: A high preoperative CONUT score is an independent prognostic factor for poor outcomes in patients with localized UTUC after RNU.

Preoperative PI-RADS Version 2 scores helps improve accuracy of clinical nomograms for predicting pelvic lymph node metastasis at radical prostatectomy.

BACKGROUND: Lymph node invasion (LNI) is a strong adverse prognostic factor in prostate cancer (PCa). The purpose of this study was to evaluate the role of Prostate Imaging Reporting and Data System version 2 (PI-RADSv2) scores for estimating the risk of LN metastasis. The study also aimed to investigate the additional value of PI-RADSv2 scores when used in combination with clinical nomograms for the prediction of LNI in patients with PCa. METHODS: We retrospectively identified 308 patients who underwent multiparametric magnetic resonance imaging (mpMRI) and RP with pelvic lymph node dissection (PLND). Clinicopathological parameters and PI-RADSv2 scores were assessed. Univariate and multivariate logistic analyses were performed. The area under the receiver operating characteristic curves (AUCs) and decision curve analysis (DCA) were generated for assessing the incremental value of PI-RADSv2 scores combined with the Briganti and Memorial Sloan Kettering Cancer Center (MSKCC) nomograms. RESULTS: Overall, 20 (6.5%) patients had LNI. At univariate analysis, all clinicopathological characteristics and PI-RADSv2 scores were significantly associated to LNI (p < 0.04). However, multivariate analysis revealed that only PI-RADSv2 scores and percentage of positive cores were independently significant (p ≤ 0.006). The PI-RADSv2 score was the most accurate predictor (AUC, 80.2%). The threshold of PI-RADSv2 score was 5, which provided high sensitivity (18/20, 90.0%) and negative predictive value (203/205, 99.0%). When PI-RADSv2 scores were combined with Briganti and MSKCC nomograms, the AUC value increased from 75.1 to 86.3% and from 79.2 to 87.9%, respectively (p ≤ 0.001). The DCA also demonstrated that the two nomograms plus PI-RADSv2 scores improved clinical risk prediction of LNI. CONCLUSIONS: The patients with a PI-RADSv2 score <5 were associated with a very low risk of LNI in PCa. Preoperative PI-RADSv2 scores could help improve the accuracy of clinical nomograms for predicting pelvic LN metastasis at radical prostatectomy.

The Duration of Preoperative Administration of Single α-Receptor Blocker Phenoxybenzamine before Adrenalectomy for Pheochromocytoma: 18 Years of Clinical Experience from Nationwide High-Volume Center.

PURPOSE: There is no consensus for the optimum duration of preoperative administration of phenoxybenzamine (PXB) before adrenalectomy for pheochromocytoma. The aim of this study is to investigate whether perioperative hemodynamics and postoperative outcomes are related to the duration of PXB administration. METHODS: In total, 102 patients managed preoperatively with single α-receptor blocker phenoxybenzamine were enrolled from 469 consecutive patients diagnosed histologically with pheochromocytoma. The patients received surgical treatment in the Department of Urology, Peking University First Hospital, between January 2001 and July 2018. All patients were divided into three groups: Group A (<14 d), Group B (14-30 d), and Group C (>30 d). Patient and tumor characteristics, intraoperative hemodynamics, and postoperative outcomes were recorded and compared among the three groups. RESULTS: These patients included 47 men and 55 women, with an average age of 43 years at the time of surgery. Clinical characteristics, except the status of preoperative biochemical tests (24 hr urine fractioned catecholamine or plasma-fractioned catecholamine) (p=0.020), preoperative hemodynamics, and medicine management and surgical approaches, in the three groups were comparable. Multivariate analyses demonstrated that the size of the tumor (p=0.034) was an independent risk factor for intraoperative hemodynamic instability. Among the three groups, we found no significant difference in intraoperative hemodynamics and postoperative outcomes. CONCLUSION: The data from the current study indicated that the preoperative management of pheochromocytoma with single α-receptor blocker PXB for more than 2 weeks, after the final dose adjustment, could not further reduce the risk of intraoperative hemodynamic instability or postoperative complications. Thus, our study supports that 14 days would be enough for the duration of preoperative management of pheochromocytoma with single α-receptor blocker PXB in final dose.

Increased Expression Of SOX2 Predicts A Poor Prognosis And Promotes Malignant Phenotypes In Upper Tract Urothelial Carcinoma.

BACKGROUND: The transcription factor SRY-related HMG-box 2 (SOX2) plays important regulatory roles in diverse biological processes (cell proliferation, migration, invasion and tumorigenicity). However, the relationship between SOX2 and upper tract urothelial carcinoma (UTUC) have not been intensively investigated. This study aims to analyze the expression of SOX2 in UTUC as well as the predictive value for prognosis and the effect on tumor aggressiveness of SOX2. METHODS: Formalin-fixed, paraffin-embedded blocks containing samples from 341 patients with UTUC who underwent radical nephroureterectomy (RNU) at our institute were analyzed for SOX2 expression by immunohistochemistry (IHC). Associations between the SOX2 expression level and clinicopathological characteristics, disease-free survival (DFS) and cancer-specific survival (CSS) were analyzed. SOX2 expression in a normal urothelial cell line, urothelial carcinoma cell lines, 16 UTUC tissues and their pair-matched adjacent normal tissues was evaluated by RT-qPCR. Using RNA interference in vitro, the effects of SOX2 inhibition on cell proliferation, migration, invasion and tumorigenicity were determined. RESULTS: SOX2 expression was significantly upregulated in UTUC tissue samples compared with paired-adjacent nontumorous tissue samples. SOX2 expression was correlated with important clinicopathological features, including tumor stage, tumor grade, tumor architecture and the presence of glandular or sarcoma differentiation, and was an independent predictor of poor DFS and CSS. Further experiments indicated that SOX2 expression was higher in UTUC cell lines than in a normal urothelial cell line. Knocking down SOX2 expression could inhibit malignant phenotypes (cell proliferation, stemness, migration, invasion and tumorigenicity) in UTUC cells. CONCLUSION: SOX2 is an independent prognostic marker of poor DFS and CSS in UTUC patients who have undergone RNU. Moreover, these data suggest that SOX2 may be a promising therapeutic target in UTUC.

Prognostic Significance of Murine Double Minute 2 Expression in Tumor Cells in Upper Tract Urothelial Carcinoma: An Analysis of 341 Cases in a Large Chinese Center.

Aims: The prognostic significance of murine double minute 2 (MDM2) expression remains unknown in patients with upper tract urothelial carcinoma (UTUC). This study was designed to evaluate MDM2 expression and its association with clinicopathological characteristics and tumor outcomes in UTUC patients. Materials and Methods: Expression levels of MDM2 and p53 were determined by immunohistochemistry in a cohort of 341 UTUC patients. Associations of MDM2 and p53 expression levels with clinicopathological characteristics, disease-free survival (DFS), cancer-specific survival (CSS), and intravesical recurrence-free survival (IVRFS) were analyzed. Results: Nuclear expression of MDM2 and p53 were detected in the tumor cells of 129 (37.8%) and 203 (59.5%) patients, respectively. Decreased p53 expression was associated with positive MDM2 staining in tumor cells (p = 0.002). MDM2 expression was correlated with the exposure to aristolochic acids (p = 0.020), better preoperative renal function (p = 0.016), ureter location (p = 0.002), higher pathological T stage (p = 0.006), high tumor grade (p < 0.001), presence of glandular differentiation (p = 0.036), and sarcoma differentiation (p = 0.020). Kaplan-Meier analysis showed that positive MDM2 staining was associated with shorter CSS (p < 0.001), DFS (p < 0.001), and IVRFS (p = 0.020); MDM2+/p53- was associated with shorter CSS (p < 0.001) and DFS (p < 0.001), but not IVRFS (p = 0.145); while CSS, DFS, and IVRFS did not differ significantly between the p53+ and p53- patients (p = 0.307, 0.089, and 0.198, respectively). Multivariate analyses revealed that MDM2 expression in tumor cells independently predicted shorter CSS (p < 0.001; hazard ratio [HR] = 2.600; 95% confidence interval [CI]: 1.625-4.161) and DFS (p < 0.001; HR = 1.863; 95% CI: 1.314-2.641), excepting IVRFS (p = 0.092; HR = 1.590; 95% CI: 0.928-2.726). Conclusions: UTUC patients with elevated MDM2 expression may exhibit more aggressive biological features of the tumor and tend to have shorter CSS and DFS.

High aspartate transaminase/alanine transaminase ratio predicts poor prognosis in patients with localized upper tract urothelial cancer: a propensity score-matched study in a large Chinese center.

Purpose: The aim of this study was to evaluate the prognostic value of the aspartate transaminase/alanine transaminase (AST/ALT) ratio in a large Chinese cohort surgically treated for localized upper tract urothelial carcinoma (UTUC) using propensity score matching (PSM) analysis. Methods: Data of 908 consecutive patients with localized UTUC who underwent radical nephroureterectomy (RNU) were retrospectively evaluated. The endpoints of prognosis were progression-free survival (PFS), cancer-specific survival (CSS) and overall survival (OS) after RNU. We compared these endpoints according to the AST/ALT ratio before and after 1:1 PSM. The independent predictors for PFS, CSS and OS were also analyzed. Results: A high AST/ALT ratio was correlated with unfavorable factors, including elderly age, female gender, history of coronary disease, alcohol and tobacco consumption, lower body mass index, and larger tumor volume. Before PSM, the Kaplan-Meier curves showed significantly poorer survival outcomes in PFS, CSS, and OS (all P<0.001) for patients with high AST/ALT ratios. After PSM, the high AST/ALT ratio group also had significantly inferior survival outcomes in terms of PFS, OS and CSS (all P<0.001). Furthermore, multivariate analyses revealed that the AST/ALT ratio was an independent predictor for PFS, CSS and OS before PSM (PFS hazard ratio [HR] 1.454, P=0.001; CSS HR 2.577, P<0.001; OS HR 1.925, P<0.001) and after PSM (PFS HR 1.711, P<0.001; CSS HR 2.588, P<0.001; OS HR 1.957, P<0.001). Conclusion: The preoperative AST/ALT ratio can be a convenient and useful prognostic biomarker for patients with localized UTUC.

Identification of plasma secreted phosphoprotein 1 as a novel biomarker for upper tract urothelial carcinomas.

The key prognostic factor at the time of diagnosis of upper tract urothelial carcinomas (UTUC) is whether the tumor is in the muscle-invasive or non-muscle invasive stage. It is critical to identify novel molecular biomarkers for early detection and target therapy. Plasma proteins secreted by tumor tissues have excellent potential as biomarkers for UTUC. In this study, we conducted a systematic study to identify plasma markers for UTUC based on RNA-seq data from five UTUC tissues and paired adjacent noncancerous mucosa. Through bioinformatics analysis, we found secreted phosphoprotein 1 (SPP1) was the most significant gene that coding secretory protein. Then, qRT-PCR and enzyme-linked immunosorbent assay were performed to evaluate the expression and clinical significance of SPP1 in UTUC. Results found that SPP1 mRNA was upregulated in UTUC cells and tissues, and high SPP1 mRNA expression level was closely related to advanced stage and high grade. Moreover, it is suggested that plasma SPP1 may be a potential biomarker to help identify early-stage UTUC patients and predict invasive and high-grade UTUC. In conclusion, plasma SPP1 is a novel biomarker for UTUC.

Prevalence, clinicopathological features, and prognosis in upper tract urinary carcinoma patients with severe preoperative chronic kidney disease.

BACKGROUND: Studies regarding the prevalence and factors associated with severe pre-operative chronic kidney disease (CKD) in upper tract urinary carcinoma (UTUC) patients were rare due to the low prevalence of UTUC. We conducted the present study to investigate the prevalence, clinicopathological features, and prognosis in UTUC patients with severe preoperative CKD. METHODS: The study included 731 patients with UTUC treated with radical nephroureterectomy (RNU) in a large Chinese center. Estimated glomerular filtration rate (eGFR) was calculated by re-expressed Modification of Diet in Renal Disease (MDRD) formulas for the Chinese population. Severe preoperative CKD was defined as CKD stage 4-5 (eGFR <30 mL/min). Relationships of CKD stage 4-5 with clinicopathological characteristics, overall survival (OS), cancer-specific survival (CSS), contralateral recurrence-free survival and intravesical recurrence (IVR)-free survival were analyzed. RESULTS: A total of 73 (10.0%) patients presented severe preoperative CKD in this cohort. Multivariate logistic analysis indicated that female gender (OR =1.791; 95% CI: 1.018-3.150; P=0.043), lower BMI (OR =0.452; 95% CI: 0.262-0.778; P=0.004), concomitant bladder tumor (OR =2.944; 95% CI: 1.360-6.373; P=0.006), lower pathological T stage (OR =0.578; 95% CI: 0.339-0.984; P=0.043), tumor necrosis (OR =2.764; 95% CI: 1.411-5.416; P=0.003), and exposure of aristolochic acid (AA) (OR =3.115; 95% CI: 1.536-6.316; P=0.002) were significantly related to severe CKD. Multivariate Cox's regression analysis showed that severe preoperative CKD was significantly associated with worse OS (HR =1.840; 95% CI: 1.150-2.944; P=0.011) and worse contralateral recurrence-free survival (HR =3.269; 95% CI: 1.607-6.650; P=0.001), while no statistical difference in terms of CSS or IVR-free survival were noticed. CONCLUSIONS: Female gender, lower BMI, concomitant bladder tumor, lower pathological T stage, exposure of AA, and tumor necrosis were independently associated with severe preoperative CKD in UTUC patients. UTUC patients with severe preoperative CKD possess worse OS and higher possibility of contralateral upper urinary tract recurrence.

Segmental ureterectomy can be performed safely in patients with urothelial carcinoma of distal ureter.

INTRODUCTION: We aimed to compare oncological outcomes by surgery type (segmental ureterectomy [SU] vs. radical nephroureterectomy [RNU]) in a large cohort of patients with upper tract urothelial carcinoma (UTUC) of the distal ureter. METHODS: We performed a retrospective analysis of 219 patients with UTUC of the distal ureter among 931 patients with UTUC who underwent SU and RNU. Clinicopathological outcomes were evaluated. Cancer-specific survival (CSS), overall survival (OS), local recurrence-free survival (RFS), intravesical recurrence-free survival (IVRFS), contralateral recurrence-free survival, and distal metastasis-free survival were assessed by the Kaplan-Meier method and Cox regression, estimating hazard ratios (HR) and 95% confidence intervals (CIs). RESULTS: A total of 179 (81.7%) patients underwent RNU and 40 (18.3%) underwent SU: 85 males (47.5%) with RNU and 17 (42.5%) with SU (p=0.568). The median age with RNU and SU was 71 years (range 31-86) and 70 years (range 46-90), respectively (p=0.499). The T stage of the two groups did not differ (p=0.122), nor did mean tumour length (3.35±2.62 vs. 3.25±2.14; p=0.953), grade (p=0.075), tumour necrosis (p=0.634), or followup time (months) (58.1±8.1 vs. 63.7±3.4; p=0.462). The two groups did not differ in CSS (p=0.358) or OS (p=0.206), and surgery type did not predict CSS (HR 0.862; 95% CI 0.469-1.585; p=0.633) or OS (HR 0.764; 95% CI 0.419-1.392; p=0.379). Local RFS was higher with RNU than SU (96.2% vs. 86.0%; p=0.02), but the groups did not differ in IVRFS (p=0.661), contralateral RFS (p=0.183), or distant metastasis-free survival (p=0.078). On multivariate analysis, SU was associated with local RFS (HR 5.069; 95% CI 1.029-24.968; p=0.046) and distant metastasis-free survival (HR 6.497; 95% CI 1.196-35.283; p=0.03). Local RFS was lower with SU than RNU for patients with pT3-4 stage (p=0.006). CONCLUSIONS: Long-term oncological outcomes were equivalent with SU and RNU in patients with UTUC of the distal ureter. SU affected local recurrence survival, especially with advanced tumour stage, and distant metastasis survival.

Preoperative predictors of nonorgan-confined disease in upper-tract urothelial carcinoma differ between China and the United States.

OBJECTIVE: To compare preoperative predictors of nonorgan-confined (NOC) disease in patients with upper-tract urothelial carcinoma (UTUC) from the United States (US) and China. METHODS: Clinicopathologic data of patients with UTUC treated surgically at tertiary care facilities in the US or China from 1998 to 2015 were, retrospectively, compiled. Patient characteristics, preoperative imaging, cytology, ureteroscopic findings, and serum markers (neutrophil-to-lymphocyte ratio, estimated glomerular filtration rate, hemoglobin, and albumin) were evaluated. After excluding patients who received neoadjuvant chemotherapy, rates of NOC disease at definitive surgery were tabulated. Logistic regression and receiver operating characteristic analyses were performed to determine predictors of NOC for each country using previously published nomograms, and the cohorts were compared. RESULTS: Totally, 753 patients with UTUC were included for analysis (451 Chinese and 302 US). NOC rates were similar between the 2 countries (31% vs. 29%, P = 0.568). On multivariable analysis, cT3 stage (P = 0.001) and high-grade pathology on ureteroscopy (P = 0.011) were significant predictors for NOC in the US, while male gender (P = 0.034), tumor location on imaging (P = 0.009), tumor size on imaging (P = 0.044), neutrophil-to-lymphocyte (P = 0.043), and preoperative estimated glomerular filtration rate (P = 0.028) were significant in China. Areas under the curve differed by nomogram used (Western model: 0.750 in US, vs. 0.670 in China; Chinese model: 0.763 in US, vs. 0.828 in China). CONCLUSION: Predictors for NOC in UTUC differ between the US and China. There may be unique population-based markers that more profoundly influence the accuracy of nomograms in certain populations. Our findings highlight the importance of considering population differences when clinically applying predictive tools in UTUC.

A Multi-Institutional Comparison of Clinicopathological Characteristics and Oncologic Outcomes of Upper Tract Urothelial Carcinoma in China and the United States.

PURPOSE: We evaluated differences in clinicopathological characteristics and oncologic outcomes between patients with upper tract urothelial carcinoma in mainland China and the United States. MATERIALS AND METHODS: We retrospectively compiled clinicopathological and oncologic outcomes data on patients with upper tract urothelial carcinoma treated surgically at tertiary care medical facilities in the United States or China from 1998 to 2015. Baseline demographics, comorbidities and pathological features were evaluated. Oncologic end points, including intravesical recurrence and cancer specific survival, were obtained after excluding patients who received systemic chemotherapy. Multivariable Cox regression was performed to determine predictors of adverse oncologic outcomes for each country. RESULTS: A total of 775 patients with upper tract urothelial carcinoma were identified, including 451 in China and 324 in the United States. Median followup was 42 months. American patients were more frequently male (65% vs 44%) and smokers (79% vs 18%), and had a worse mean ASA® (American Society of Anesthesiologists®) score (2.7 vs 2.2) and prior bladder cancer (41% vs 4%, all p <0.001). Chinese patients more often had preoperative hydronephrosis (56% vs 40%), high grade pathology (98% vs 77%), muscle invasion (64% vs 38%) and nodal metastases (26% vs 6%, all p <0.001). American patients had worse overall survival on Kaplan-Meier analysis (p = 0.049). However, country of origin did not predict local relapse or cancer specific survival. CONCLUSIONS: Patient and disease characteristics of upper tract urothelial carcinoma differed between the Chinese and American cohorts. Chinese patients appeared relatively healthier at presentation but more often exhibited adverse pathological features. While evaluation and management patterns may account for these variations, the pathological findings may reflect a differential underlying pathogenesis of disease. Additional study is warranted to further characterize these differences.