Treatment, Outcome, and Relapse of Spontaneous and Nonspontaneous Cerebrospinal Fluid Leak.

Cerebrospinal fluid (CSF) leak can be spontaneous or nonspontaneous. The management options include conservative treatments, blood patch, and surgical repairs. We compared clinical symptoms, image findings, management options, hospitalization, and relapse rates among different causes of CSF leaks. Eighty-one patients were recruited: 20 with spontaneous and 61 with nonspontaneous CSF leaks. Nonspontaneous causes included lumbar puncture, surgery, and trauma. Surgery sites comprised sphenoid, spine, skull base, and calvaria. Spontaneous CSF leak came from the sphenoid or spine. Age, gender, body mass index, initial symptoms, hospitalization, treatment courses, and recurrence rates showed no difference between the groups. The spontaneous group had higher CSF accumulations on their MRIs. MRI pachymeninge enhancement showed the highest sensitivity (78.6%) for intracranial hypotension. Meningitis occurred in 1/3 of sphenoid, skull base, and calvarian surgeries. Earlier reoperation was correlated with shorter hospitalization (r = 0.651), but the recurrence rates were similar. Longer intervals between surgery and CSF leak encouraged reoperation. Among the spontaneous spine and lumbar puncture-related CSF leaks, 57.1% of them responded to 4 days of conservative treatment. Among the trauma-related CSF leaks, 90.9% of them required surgical repair. The demographic data and symptoms were similar in various groups of CSF leak. The symptom onset durations and treatment strategies were different. However, the recurrence rates were similar.

The effect of tumor location on oncologic outcomes in patients with upper urinary tract urothelial carcinoma stratified by pathologic stage.

OBJECTIVES: The aim of this study was to investigate the effect of tumor location on oncologic outcomes in patients with upper urinary tract urothelial carcinoma (UTUC) stratified according to pathologic stage. MATERIAL AND METHODS: Between January 1996 and March 2009, 503 patients with UTUC were enrolled who had undergone radical nephroureterectomies and had no nodal or distal metastases. Preoperative chemotherapy or radiation therapy was not administered to any study patient. Clinicopathologic patient characteristics were obtained and used to analyze recurrence-free survival (RFS), cancer-specific survival, and overall survival with the Cox proportional hazards model. RESULTS: During the median follow-up of 52 months, patients with pathologic tumor (pT) stage 3 ureteral tumors had a shorter duration of RFS compared with those with pT3 renal pelvis tumors (5-y RFS: 50% and 71%, P = 0.047). There was no prognostic relevance to the tumor location in pTa/Tis/T1 and pT2 diseases. RFS and cancer-specific survival were significantly shorter in duration in pT3 ureteral disease compared with pT2 diseases (P<0.001 and P = 0.028). No differences were found in oncologic outcomes between pT3 renal pelvic and pT2 diseases. The presence of pT3 ureteral tumors actually increased the risks of disease recurrence (hazard ratio [HR] = 7.82, P<0.001), cancer-specific death (HR = 5.08, P<0.001), and overall mortality (HR = 3.25, P = 0.031). CONCLUSIONS: Patients with UTUC and pT3 ureteral tumors had an increased risk of disease recurrence and cancer-specific death. These results underscore the need for close follow-up and the consideration of adjuvant chemotherapy for patients with pT3 ureteral cancer.

Prognostic value of saturated prostate cryoablation for localized prostate cancer.

PURPOSE: To evaluate the oncological outcomes and complications of patients with saturated prostate cryoablation. METHODS: A cohort of 208 patients cumulatively treated between June 2008 and December 2012 qualified for study inclusion, each undergoing total-gland cryoablation for prostate cancer. The degree of saturated prostate cryoablation was defined as the average prostate volume per cryoprobe (APVC), and divided into four groups (groups 1-4: <3 ml, 3 to <4 ml, 4 to <5 ml, ≧5 ml, respectively). Post-ablative complications were measured prospectively at weeks 1, 2, 4, 8, 12, and 24 by using the Common Terminology Criteria for Adverse Events. Biochemical failure was gauged by Phoenix criterion. The Kruskal-Wallis rank sum test and Chi-square test were used to compare clinical characteristics of therapeutic subsets. The Cox proportional hazard model was applied for comparison of recurrence risk between groups. RESULTS: APVC group 1 had the highest pre-operative PSA value and smallest prostate size among the groups. Multivariate analysis of risks of biochemical failures revealed that the larger the APVC, the higher the hazard (p for trend = 0.01). Compared to the group 1 patients, the hazard ratios of biochemical failures in groups 2-4 were 4.4 (confidence interval (CI): 0.5-37), 8.8 (CI 1.1-73), and 9.4 (CI 1.1-78), respectively. Nevertheless, the complication rate of APVC group 1 patients was similar to the other three groups. CONCLUSIONS: Saturated prostate cryoablation by reducing APVC would be beneficial for cancer control without compromising patient safety.

Diabetes mellitus with poor glycemic control increases bladder cancer recurrence risk in patients with upper urinary tract urothelial carcinoma.

BACKGROUND: The association of diabetes mellitus and bladder cancer recurrence following radical nephroureterectomies (RNUs) in patients with upper urinary tract urothelial carcinoma (UTUC) was investigated. METHODS: Between January 1996 and March 2009, 538 patients with UTUC who received RNU and had no previous bladder cancer histories were enrolled. The clinicopathological characteristics were obtained and used for the analysis of metachronous bladder recurrence by using Cox proportional hazard model. RESULTS: The diabetic patients (N = 104, 19.3%) were elderly (72 vs 67 years, p < 0.001) and had more hypertension (56.7 vs 34.5%, p < 0.001) as compared with non-diabetic patients. There was no significant difference in the rest of clinicopathological characteristics between patient groups. During the median follow-up duration of 51 months, bladder recurrences were discovered in 47.1 and 33.1% of diabetic and non-diabetic patients with UTUC, respectively. Poorly controlled diabetic patients (HbA1c ≥ 7.0%) exhibited a shorter duration of bladder cancer recurrence-free survival as compared with those with good glycemic controlled diabetes mellitus and without diabetes mellitus (log-rank test, p < 0.001 and <0.001, respectively). In the multivariate analysis, male gender [hazard ratio (HR) = 1.67, p = 0.017], ureteral tumour (HR = 1.61, p = 0.020), end-stage renal disease (HR = 2.09, p = 0.030) and diabetes mellitus with poor glycemic control (HR = 2.10, p < 0.018) independently predicted bladder recurrence after RNU. CONCLUSIONS: Diabetes mellitus with poor glycemic control (HbA1c ≥ 7.0%) increases the risk of subsequent bladder cancer recurrence. These results underscore the need for intensive glycemic control and close follow-up for diabetic patients.