Race is associated with discontinuation of active surveillance of low-risk prostate cancer: results from the Duke Prostate Center.

BACKGROUND: Active surveillance (AS) is increasingly utilized in low-risk prostate cancer (PC) patients. Although black race has traditionally been associated with adverse PC characteristics, its prognostic value for patients managed with AS is unclear. METHODS: A retrospective review identified 145 patients managed with AS at the Duke Prostate Center from January 2005 to September 2011. Race was patient-reported and categorized as black, white or other. Inclusion criteria included PSA <10 ng ml(-1), Gleason sum ≤ 6, and ≤ 33% of cores with cancer on diagnostic biopsy. The primary outcome was discontinuation of AS for treatment due to PC progression. In men who proceeded to treatment after AS, the trigger for treatment, follow-up PSA and biopsy characteristics were analyzed. Time to treatment was analyzed with univariable and multivariable Cox proportional hazards models and also stratified by race. RESULTS: In our AS cohort, 105 (72%) were white, 32 (22%) black and 8 (6%) another race. Median follow-up was 23.0 months, during which 23% percent of men proceeded to treatment. The demographic, clinical and follow-up characteristics did not differ by race. There was a trend toward more uninsured black men (15.6% black, 3.8% white, 0% other, P = 0.06). Black race was associated with treatment (hazard ratio (HR) 2.93, P = 0.01) as compared with white. When the analysis was adjusted for socioeconomic and clinical parameters at the time of PC diagnosis, black race remained the sole predictor of treatment (HR 3.08, P = 0.01). Among men undergoing treatment, the trigger was less often patient driven in black men (8 black, 33 white, 67% other, P = 0.05). CONCLUSIONS: Black race was associated with discontinuation of AS for treatment. This relationship persisted when adjusted for socioeconomic and clinical parameters.

In vivo determination of urinary stone composition using dual energy computerized tomography with advanced post-acquisition processing.

PURPOSE: We assessed whether dual energy computerized tomography with advanced post-image processing can accurately differentiate urinary calculi composition in vivo. MATERIALS AND METHODS: A total of 25 patients scheduled to undergo ureteroscopic/percutaneous nephrolithotomy were prospectively identified. Dual energy computerized tomography was performed using 64-slice multidetector computerized tomography. Novel post-processing (DECTSlope) used pixel by pixel analyses to generate data sets grayscale encoding ratios of relative differences in attenuation of low (DECT80 kVp) and high energy (DECT140 kVp) series. Surgical extraction and Fourier spectroscopy resulted in 82 calculi. Of these stones 51 showed minor admixtures (uric acid, ammonium urate, struvite, calcium oxalate monohydrate and brushite) and 31 were polycrystalline (mixtures of calcium oxalate monohydrate/dihydrate and calcium phosphate). Analyses identified stone clusters of equal composition and distinct attenuation descriptors on DECT140 kVp, DECT80 kVp and DECTSlope. Iterative cross-validation of the 3 dual energy computerized tomography data sets was used to identify characteristic attenuation limits for each stone type. RESULTS: Attenuatio profiles showed substantial overlap among various stones on DECT140 kVp (uric acid 427.3±168.1 HU, ammonium urate 429.9±99.7 HU, struvite 480.2±123.5 HU, calcium oxalate monohydrate 852.4±301.4 HU, brushite 863.7±180.1 HU and polycrystalline 858.1±210.5 HU) and on DECT80 kVp (uric acid 493.6±182.8 HU, ammonium urate 591.5±157.9 HU, struvite 712.4±173.9 HU, calcium oxalate monohydrate 1,240.5±494.7 HU, brushite 1,532.1±273.1 HU and polycrystalline 1,358.7±316.8 HU). Statistically spectral separation was not sufficient to characterize stones unambiguously based on DECT140 kVp/DECT80 kVp attenuation. Analysis of attenuation showed sufficient spectral separation on DECTSlope (uric acid 14.9±10.9 U, ammonium urate 56.1±1.8 U, struvite 42.7±1.4 U, calcium oxalate monohydrate 62.8±1.8 U and brushite 113.2±5.3 U). Polycrystalline stones (51.8±3.7 U) overlapped with struvite and ammonium urate stones. This overlap was resolved as all struvite/ammonium urate stones measured 900 HU or less and all polycrystalline stones measured more than 900 HU on DECT80 kVp. CONCLUSIONS: Dual energy computerized tomography with novel post-processing allows accurate discrimination among main subtypes of urinary calculi in vivo and, thus, may have implications in determining the optimum clinical treatment of urinary calculi from a noninvasive, preoperative radiological assessment.

Tubeless percutaneous nephrolithotomy--the new standard of care?

PURPOSE: Traditionally the placement of a nephrostomy tube at the conclusion of percutaneous nephrolithotomy is considered the standard of care. However, the need for nephrostomy tube placement has been questioned by numerous authors. We evaluated the literature regarding tubeless percutaneous nephrolithotomy, and determined potential candidates for tubeless percutaneous nephrolithotomy and whether this procedure can be considered the new standard of care for complex stone removal. MATERIALS AND METHODS: A MEDLINE search was conducted between May 1997 and January 2010 to detect studies reporting tubeless percutaneous nephrolithotomy. "Nephrolithiasis," "percutaneous nephrolithotomy," "tubeless" and "lithotripsy" were used as medical subject headings (MeSH) key words. Additional citations were identified by reviewing the reference lists of the included articles. All relevant articles were reviewed for indications, outcomes and complications. RESULTS: The data obtained from 50 reports document comparable complication rates between tubeless and standard percutaneous nephrolithotomy. Tubeless percutaneous nephrolithotomy demonstrated advantages such as less pain, less debilitation, less costs and a shorter hospital stay. Mean stone-free rates for tubeless percutaneous nephrolithotomy were as high as 89%. CONCLUSIONS: Tubeless percutaneous nephrolithotomy appears to be safe and efficacious in uneventful procedures, in children, in obese patients, in simultaneous bilateral procedures, in supracostal access and in renal units with coexisting anatomical anomalies. Nephrostomy tube placement should still be considered in certain cases such as those with more than 2 nephrostomy access tracts, those necessitating a second look and those with intraoperative complications such as significant bleeding or collecting system perforation.

Intraoperative and postoperative complications of radical retropubic prostatectomy in a consecutive series of 1,000 cases.

PURPOSE: We critically examined the intraoperative and postoperative complications associated with radical retropubic prostatectomy in the modern era. MATERIALS AND METHODS: Between April 18, 1994 and July 13, 2000, 1,000 men underwent radical retropubic prostatectomy performed by a single surgeon. The whole inpatient hospital medical record of 909 patients, the outpatient charts of 955 and a self-administered patient survey completed by 679 were reviewed by 2 data managers not involved in surgical management or followup care. In all 1,000 cases at least 1 of the 3 data sources was reviewed. RESULTS: Mean patient age was 60.3 years. In 73%, 99.8% and 95.7% of cases serum prostate specific antigen was 10 ng./ml. or less, disease was clinical stage T1 or T2 and Gleason score was 7 or less, respectively, while 19.9% of pathological specimens showed positive margins. There were 8 intraoperative complications (0.8%). All 5 rectal injuries and the single ureteral injury were detected during the initial surgical procedure and repaired without sequelae. Only 14 men (1.4%) had any other complications during hospitalization. Until postoperative day 30, 4 pulmonary emboli (0.4%) with or without deep vein thrombosis and 5 myocardial infarctions (0.5%) developed. There were no intraoperative or in-hospital postoperative deaths and only 1 postoperative death secondary to myocardial infarction during the initial 30 days. Reexploration was done for hemorrhage and a disrupted anastomosis in 3 and 2 cases, respectively. Mean hospitalization was 2.3 days, 9.7% of patients required allogenic blood transfusion and 15 (1.5%) were rehospitalized. CONCLUSIONS: Our series represents a rigorous assessment of the complications associated with radical retropubic prostatectomy. It shows that in the hands of an experienced urological surgeon, this procedure is associated with minimal intraoperative and postoperative morbidity. Of the patients 98% had no intraoperative or postoperative complications. Our series enables appropriate contemporary comparisons to be made with laparoscopic prostatectomy and radiation therapy. This outcomes analysis implies that radical retropubic prostatectomy cannot be assumed to have greater morbidity than radiation therapy and it sets a high standard for those advocating laparoscopic radical prostatectomy.