Prognostic significance of lymph node count in surgically treated patients with T2-4 stage nonmetastatic adrenocortical carcinoma.

PURPOSE: The role of lymphadenectomy and the optimal lymph node count (LNC) cut-off in nonmetastatic adrenocortical carcinoma (nmACC) are unclear. METHODS: Within the Surveillance, Epidemiology, and End Results (SEER) database, surgically treated nmACC patients with T2-4 stages were identified between 2004 and 2020. We tested for cancer-specific mortality (CSM) differences according to pathological N-stage (pN0 vs. pN1) and two previously recommended LNC cut-offs (≥4 vs. ≥5) were tested in pN0 and subsequently in pN1 subgroups in Kaplan-Meier plots and multivariable Cox regression models. RESULTS: Of 710 surgically treated nmACC patients, 185 (26%) underwent lymphadenectomy and were assessable for further analyses based on available LNC data. Of 185 assessable patients, 152 (82%) were pN0 and 33 (18%) were pN1. In Kaplan-Meier analyses, CSM-free survival was 74 vs. 14 months (Δ 60 months, P ≤ 0.001) in pN0 vs. pN1 patients, respectively. In multivariable analyses, pN1 was an independent predictor of higher CSM (HR:3.13, P < 0.001). In sensitivity analyses addressing pN0, LNC cut-off of ≥4 was associated with lower CSM (multivariable hazard ratio [HR]: 0.52; P = 0.002). In sensitivity analyses addressing pN0, no difference was recorded when a LNC cut-off of ≥5 was used (HR:0.60, P = 0.09). In pN1 patients, neither of the cut-offs (≥4 and ≥5) resulted in a statistically significant stratification of CSM rate, and neither reached independent predictor status (all P > 0.05). CONCLUSIONS: Lymphadenectomy provides a prognostic benefit in nmACC patients and identifies pN1 patients with dismal prognosis. Conversely, in pN0 patients, a LNC cut-off ≥4 identifies those with particularly favorable prognosis.

Surgically treated pelvic liposarcoma and leiomyosarcoma: The effect of tumor size on cancer-specific survival.

INTRODUCTION: In soft tissue pelvic liposarcoma and leiomyosarcoma, it is unknown whether a specific tumor size cut-off may help to better predict prognosis, defined as cancer-specific survival (CSS). We tested whether different tumor size cut-offs, could improve CSS prediction. MATERIALS AND METHODS: Surgically treated non-metastatic soft tissue pelvic sarcoma patients were identified (Surveillance, Epidemiology, and End Results 2004-2019). Kaplan-Meier plots, univariable and multivariable Cox-regression models and receiver operating characteristic-derived area under the curve (AUC) estimates were used. RESULTS: Overall, 672 (65 %) liposarcoma (median tumor size 11 cm, interquartile range [IQR] 7-16) and 367 (35 %) leiomyosarcoma (median tumor size 8 cm, IQR 5-12) patients were identified. The p-value derived ideal tumor size cut-off was 17.1 cm, in liposarcoma and 7.0 cm, in leiomyosarcoma. In liposarcoma, according to p-value derived cut-off, five-year CSS rates were 92 vs 83 % (≤17.1 vs > 17.1 cm). This cut-off represented an independent predictor of CSS and improved prognostic ability from 83.8 to 86.8 % (Δ = 3 %). Similarly, among previously established cut-offs (5 vs 10 vs 15 cm), also 15 cm represented an independent predictor of CSS and improved prognostic ability from 83.8 to 87.0 % (Δ = 3.2 %). In leiomyosarcoma, according to p-value derived cut-off, five-year CSS rates were 86 vs 55 % (≤7.0 vs > 7.0 cm). This cut-off represented an independent predictor of CSS and improved prognostic ability from 68.6 to 76.5 % (Δ = 7.9 %). CONCLUSIONS: In liposarcoma, the p-value derived tumor size cut-off was 17.1 cm vs 7.0 cm, in leiomyosarcoma. In both histologic subtypes, these cut-offs exhibited the optimal statistical characteristics (univariable, multivariable and AUC analyses). In liposarcoma, the 15 cm cut-off represented a valuable alternative.

Treatment modalities for small-sized urolithiases and their impact on health-related quality of life.

INTRODUCTION: Health-related quality of life (HRQoL) is often reduced in patients with urolithiasis. The objective of this study was to perform a systematic review to describe impact on HRQoL based on different modalities of treatment for small urolithiases with a diameter smaller or equal to 10 mm. METHODS: Electronic databases were searched with no language or date restrictions to identify studies which were included if they reported: adult patients (≥18 years old), renal or ureteral stone(s) confirmed on imagery, validated reporting of HRQoL, and stone diameter equal or smaller than 10 mm undergoing active surveillance, medical expulsive therapy (MET), shockwave lithotripsy (SWL), or ureteroscopy (URS). RESULTS: Of 672 citations, nine articles were eligible. Five studies (all ureteral) reported HRQoL according to medical stone management. Three of them found that HRQoL in MET patients was better than in active surveillance patients and two studies found no difference in HRQoL between MET and active surveillance groups. Four studies (three ureteral, one renal) reported HRQoL according to surgical stone management. Of the ureteral stone studies, two reported better HRQoL in URS patients than in SWL patients, while one study found no difference between URS and SWL groups. In the renal stone study, SWL patients had better HRQoL than URS patients. CONCLUSIONS: Patients with urinary stones 10 mm or smaller have better HRQoL when treated with MET vs. active surveillance, when treated with SWL vs. URS for renal stones, and when treated with URS vs. SWL for ureteral stones. There is an important need for more studies on this topic.

The impact of kidney stone disease on quality of life in high-risk stone formers.

OBJECTIVE: To assess the impact of kidney stone disease (KSD) and its treatment on the health-related quality of life (HRQOL) of high-risk stone formers with hyperparathyroidism, renal tubular acidosis, malabsorptive disease, and medullary sponge kidney. PATIENTS AND METHODS: The Wisconsin Stone Quality of Life questionnaire was used to evaluate HRQOL in 3301 patients with a history of KSD from 16 institutions in North America between 2014 and 2020. Baseline characteristics and medical history were collected from patients, while active KSD was confirmed through radiological imaging. The high-risk group was compared to the remaining patients (control group) using the Wilcoxon rank-sum test. RESULTS: Of 1499 patients with active KSD included in the study, the high-risk group included 120 patients. The high-risk group had significantly lower HRQOL scores compared to the control group (P < 0.01). In the multivariable analyses, medullary sponge kidney disease and renal tubular acidosis were independent predictors of poorer HRQOL, while alkali therapy was an independent predictor of better HRQOL (all P < 0.01). CONCLUSIONS: Among patients with active KSD, high-risk stone formers had impaired HRQOL with medullary sponge kidney disease and renal tubular acidosis being independent predictors of poorer HRQOL. Clinicians should seek to identify these patients earlier as they would benefit from prompt treatment and prevention.

The Effect of Treatment Intensification on Other-Cause Mortality in Clear-Cell Metastatic Renal Cell Carcinoma Patients.

BACKGROUND: The effect of treatment intensification (systemic therapy [ST] + cytoreductive nephrectomy (CN) vs. ST alone) is unknown regarding rates of other-cause mortality (OCM) in clear-cell metastatic renal cell carcinoma (ccmRCC). We hypothesized that intensified treatment (ST + CN) may result in higher OCM, than when ST is used alone. METHODS: Within the Surveillance, Epidemiology, and End Results database, all ccmRCC patients treated 2010-2018 either with ST + CN or ST alone were identified. Propensity score matching (PSM), cumulative incidence plots, multivariable competing risks regression analyses and 6 months' landmark analyses addressed OCM and cancer-specific mortality (CSM) according to treatment status. RESULTS: Of 2271 ccmRCC patients, 1233 (54%) were treated with ST + CN vs 1038 (46%) with ST alone. After 1:1 PSM, OCM was 5.3 vs. 4.6 % (P = .5) and CSM was 73.4 vs. 88.4% (P < .001) in ST + CN vs. ST alone patients. In multivariable competing risks regression, the combination of ST and CN was not associated with higher OCM (HR 1.3; 95% CI 0.8-2.1; P = .4), vs. ST alone. However, the combination of ST and CN was independently associated with lower CSM (HR 0.5; 95% CI 0.5-0.6; P < .001), vs. ST alone. After 6 months' landmark analyses, these multivariable associations remained unchanged. CONCLUSIONS: The current study indicates no OCM-disadvantage in ST + CN ccmRCC patients, relative to their ST alone counterparts. Conversely, a strong association with lower CSM was recorded in ST + CN patients, relative to their ST alone counterparts. These associations are robust and remained unchanged after strictest statistical adjustment including control for immortal time bias.

Prognostic Significance of Radiographic Lymph Node Invasion in Contemporary Metastatic Renal Cell Carcinoma Patients.

PURPOSE: To test the prognostic significance of radiographic cN-stage in metastatic renal cell carcinoma (mRCC) patients with low metastatic burden (1 site of metastasis), relying on the Surveillance, Epidemiology, and End Results database (SEER 2010-2020). METHODS: Included were mRCC patients with 1 site of metastasis, treated with systemic therapy without cytoreductive nephrectomy (CN). Kaplan-Meier plots and multivariable Cox-regression models addressed cancer-specific mortality (CSM) according to radiographic cN-stage (ccN1 vs. ccN0). Separate subgroup analyses were performed, addressing radiographic N-stage in patients with distinct histology (clear-cell vs. RCC not otherwise specified [RCC NOS]). RESULTS: Of 1756 mRCC patients, 545 (31%) were radiographic cN1. Overall, the median CSM-free survival of the cohort was 11 months. Median CSM-free survival was 8 vs. 14 months in radiographic cN1 vs. cN0 mRCC patients (HR 1.49, P < .0001). In multivariable Cox regression analyses, radiographic cN1 status was an independent predictor of higher CSM (HR 1.39; P = .01). In subgroup analyses, addressing patients with clear-cell histology and patients with RCC NOS separately, radiographic cN1 status remained independently associated with a higher CSM in both groups (clear-cell: HR 1.36; P = .03; RCC NOS: HR 2.06; P = .009). CONCLUSION: In mRCC patients with low metastatic burden, presence or absence of radiographic lymph node invasion results in a clinically meaningful discrimination between those with poor prognosis and others. In consequence, consideration of radiographic lymph node invasion might be of great value in this specific population of mRCC patients.

Prognostic Significance of Pathologic Lymph Node Invasion in Metastatic Renal Cell Carcinoma in the Immunotherapy Era.

BACKGROUND: This study aimed to test the prognostic significance of pathologically confirmed lymph node invasion in metastatic renal cell carcinoma (mRCC) patients in this immunotherapy era. METHODS: Surgically treated mRCC patients were identified in the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2018. Kaplan-Meier plots and multivariable Cox-regression models were fitted to test for differences in cancer-specific mortality (CSM) and overall mortality (OM) according to N stage (pN0 vs pN1 vs. pNx). Subgroup analyses addressing pN1 patients tested for CSM and OM differences according to postoperative systemic therapy status. RESULTS: Overall, 3149 surgically treated mRCC patients were identified. Of these patients, 443 (14%) were labeled as pN1, 812 (26%) as pN0, and 1894 (60%) as pNx. In Kaplan-Meier analyses, the median CSM-free survival was 15 months for pN1 versus 40 months for pN0 versus 35 months for pNx (P < 0.001). In multivariable Cox regression analyses, pN1 independently predicted higher CSM (hazard ratio [HR], 1.88; P < 0.01) and OM (HR, 1.95; P < 0.01) relative to pN0. In sensitivity analyses addressing pN1 patients, postoperative systemic therapy use independently predicted lower CSM (HR, 0.73; P < 0.01) and OM (HR, 0.71; P < 0.01). CONCLUSION: Pathologically confirmed lymph node invasion independently predicted higher CSM and OM for surgically treated mRCC patients. For pN1 mRCC patients, use of postoperative systemic therapy was associated with lower CSM and OM. Consequently, N stage should be considered for individual patient counseling and clinical decision-making. Consort diagram of the study population.

Characteristics of incidental prostate cancer in the United States.

BACKGROUND: Data regarding North-American incidental (cT1a/b) prostate cancer (PCa) patients is scarce. To address this, incidental PCa characteristics (age, PSA values at diagnosis, Gleason score [GS]), subsequent treatment and cancer-specific survival (CSS) rates were explored. METHODS: Incidental PCa patients were identified within the Surveillance, Epidemiology, and End Results (SEER) database (2004-2015). Descriptive statistics, annual percentage changes (EAPC), Kaplan-Meier estimates, as well as Cox regression models were used. Bootstrapping technique was used to generate 95% confidence intervals for CSS at 6 years. RESULTS: Of all 344,031 newly diagnosed non metastatic PCa patients, 5155 harbored incidental PCa. Annual rates of incidental PCa increased from 1.9% (2004) to 2.5 % (2015; p = 0.02). PSA values at diagnosis were 0-4 ng/ml in 48% vs. 4-10 ng/ml in 31% vs. > 10 ng/ml in 21%. Of all incidental PCa patients, 64% harbored GS 6 vs. 25% GS 7 vs. 11% GS ≥ 8. Of all incidental PCa patients, 47% were aged < 70, 35% were between 70 and 79 and 18% were ≥ 80 years. Subsequently, 71% underwent no local treatment (NLT) vs. 16% radical prostatectomy (RP) vs. 14% radiotherapy (RT). Proportions of patients with NLT increased from 65 to 81% (p = 0.0001) over the study period (2004-2015). CSS at six years ranged from 58% in GS ≥ 8 patients with NLT to 100% in patients who harbored GS 6 and underwent either RP or RT. CONCLUSION: Incidental PCa in the United States is rare. Most incidental PCa patients are diagnosed in men aged less than 80 years of age. The majority of incidental PCa patients undergo NLT and enjoy excellent CSS.

Regional differences in penile cancer patient characteristics and treatment rates across the United States.

INTRODUCTION: We tested for regional-specific differences in patient, tumor and treatment characteristics as well as cancer-specific mortality (CSM) of squamous cell carcinoma of the penis (SCCP) patients, across the Surveillance, Epidemiology, and End Results (SEER) registries. METHODS: The SEER database (2000-2018) was used to tabulate patient (age at diagnosis, race/ethnicity), tumor (stage, grade, N-stage) and treatment characteristics (proportions of primary tumor surgery, local lymph node surgery, systemic therapy), according to 12 SEER registries. Multinomial regression models, as well as multivariable Cox regression models tested for CSM differences, adjusting for patient, tumor and treatment characteristics. RESULTS: In 5395 SCCP patients, registry-specific patient counts ranged from 2060 (38 %) to 64 (1 %). Differences across registries existed for race/ethnicity, stage, grade and N-stage. Additionally, in stage I-II SCCP patients, proportions of local tumor destruction (LTD) ranged from 19 % to 39 % and from 33 % to 61 % for partial penectomy. In stage III-IV SCCP patients, proportions of partial penectomy ranged from 40 % to 59 % and from 17 % to 50 % for radical penectomy. Local lymph node surgery ranged from 8 % to 24 % and proportions of systemic therapy ranged from 3 % to 14 %. Significant inter-registry differences remained, after adjustment for treatment proportions. Unadjusted five-year CSM ranged from 19 % to 32 %. In multivariable analyses, one registry exhibited significantly higher CSM (SEER registry 10, Hazard Ratio [HR] 1.48), relative to the largest reference registry (SEER registry 1, n = 2060). CONCLUSION: Important regional differences including patient, tumor and treatment characteristics exist for SCCP patients across SEER registries. After multivariable adjustment, no differences in CSM were recorded, with the exception of one registry.

Performing urological inpatient procedures as same-day procedures during the COVID pandemic A retrospective feasibility study.

INTRODUCTION: In line with Canadian provincial directives due to the COVID-19 pandemic, certain elective urologic surgical cases that are normally performed as inpatient procedures were performed as same-day discharge procedures to reduce hospitalization and the usage of scarce healthcare resources. Since the pandemic, we began performing laser enucleation of the prostate (LEP), robotic-assisted radical prostatectomy (RARP), and percutaneous nephrolithotomy (PCNL ) as outpatient surgeries. This was supported by recent evidence demonstrating the safety and feasibility of performing these minimally invasive surgeries as same-day procedures. As such, we sought to retrospectively evaluate the clinical outcomes and safety during the COVID-19 era at our institution for same-day discharge LEP, RARP, and PCNL procedures. METHODS: All patients operated for LEP, RARP, or PCNL between May 2020 and March 2022 at two academic institutions were included. Surgeries were classified as planned same-day discharge or inpatient surgery. Same-day discharge patients were compared to inpatients for each procedure type. This comparison assessed the occurrence of same-day failure, postoperative complications, and re-admission rates at 30 days. This study was approved by the scientific ethics committee of the Centre de Recherche de l'Université de Montréal (CRCHUM). RESULTS: A total of 413 subjects were included in this study. Among LEP patients (n=169), 104 (62%) were identified as same-day procedures and 65 (38%) were inpatient. Among RARP patients (n=194), 46 (24%) were identified as same-day procedures and 148 (76%) inpatient. Among PCNL patients (n=50), 38 (76%) were identified as same-day procedures and 12 (24%) were inpatient. Of the patients who underwent planned same-day LEP, RARP, and PCNL, 77.9%, 73.9%, and 71.1% were successfully discharged home, respectively. Patients who underwent LEP as inpatients had a higher incidence of overall postoperative complications compared to same-day LEP (23.1% vs. 8.7%, p=0.017). The rates of 30-day emergency department (ED ) visits and hospital re-admission were similar between inpatient and same-day LEP (9.2% vs. 3.8%, p=0.27; and 4.6% vs. 1.0%, p=0.32, respectively). Inpatient RARP, however, was associated with more 30-day ED visits compared to same-day procedures (17.4% vs. 4.1%, p<0.01). No statistically significant differences were found for postoperative complications (15.2% vs. 6.1%, p=0.097) and re-admission rates (1.4% vs. 4.3%, p=0.51). There were no significant differences on overall postoperative complications, 30-day ED visits, and re-admission rates in inpatient vs. same-day PCNL. CONCLUSIONS: Our results suggest that same-day discharge for LEP, RARP, and PCNL is safe and feasible in select patients, with an acceptable complication rate. These results should be validated in a larger, prospective clinical trial comparing same-day and inpatient procedures.

Clinical Applications of Machine Learning for Urolithiasis and Benign Prostatic Hyperplasia: A Systematic Review.

Introduction: Previous systematic reviews related to machine learning (ML) in urology often overlooked the literature related to endourology. Therefore, we aim to conduct a more focused systematic review examining the use of ML algorithms for the management of benign prostatic hyperplasia (BPH) or urolithiasis. In addition, we are the first group to evaluate these articles using the Standardized Reporting of Machine Learning Applications in Urology (STREAM-URO) framework. Methods: Searches of MEDLINE, Embase, and the Cochrane CENTRAL databases were conducted from inception through July 12, 2021. Keywords included those related to ML, endourology, urolithiasis, and BPH. Two reviewers screened the citations that were eligible for title, abstract, and full-text screening, with conflicts resolved by a third reviewer. Two reviewers extracted information from the studies, with discrepancies resolved by a third reviewer. The data collected were then qualitatively synthesized by consensus. Two reviewers evaluated each article according to the STREAM-URO checklist with discrepancies resolved by a third reviewer. Results: After identifying 459 unique citations, 63 articles were retained for data extraction. Most articles consisted of tabular (n = 32) and computer vision (n = 23) tasks. The two most common problem types were classification (n = 40) and regression (n = 12). In general, most studies utilized neural networks as their ML algorithm (n = 36). Among the 63 studies retrieved, 58 were related to urolithiasis and 5 focused on BPH. The urolithiasis studies were designed for outcome prediction (n = 20), stone classification (n = 18), diagnostics (n = 17), and therapeutics (n = 3). The BPH studies were designed for outcome prediction (n = 2), diagnostics (n = 2), and therapeutics (n = 1). On average, the urolithiasis and BPH articles met 13.8 (standard deviation 2.6), and 13.4 (4.1) of the 26 STREAM-URO framework criteria, respectively. Conclusions: The majority of the retrieved studies effectively helped with outcome prediction, diagnostics, and therapeutics for both urolithiasis and BPH. While ML shows great promise in improving patient care, it is important to adhere to the recently developed STREAM-URO framework to ensure the development of high-quality ML studies.

WATER vs WATER II 3-Year Update: Comparing Aquablation Therapy for Benign Prostatic Hyperplasia in 30-80 cc and 80-150 cc Prostates.

OBJECTIVE: To compare the outcomes of Aquablation for small-to-moderate (30-80cc) prostates with the outcomes for large (80-150 cc) prostates at 3-year follow up. METHODS: WATER is a prospective, double-blind, multicenter, international clinical trial comparing the safety and efficacy of Aquablation and TURP in the treatment of LUTS/BPH in men 45-80 year with a prostate of 30cc-80cc. WATER II is a prospective, multicenter, single-arm international clinical trial of Aquablation in men with a prostate of 80cc-150cc. We compare 36-mo outcomes amongst 116 WATER and 101 WATER II study subjects undergoing Aquablation. RESULTS: International Prostate Symptom Score (IPSS) scores improved from 22.9 and 23.2 at baseline in WATER and WATER II, respectively, to 8.0 and 6.5 at 36-month, with 36-mo reductions of 14.4 and 16.3 points, respectively (P = .247). At baseline, urinary flow rate (Qmax) was 9.4 and 8.7 cc/sec in WATER and WATER II, improving to 20.6 and 18.5 cc/sec, respectively (P = .552) at 36-mo. Improvements in both IPSS and Qmax were immediate and sustained throughout follow-up. At 3 year, 98% and 94% of treated patients were BPH medication-free in WATER and WATER II, respectively (P = .038). At 3yr, 96% and 97% of treated patients were free from surgical retreatment in WATER and WATER II, respectively (P = .613). CONCLUSIONS: Three-year follow-up demonstrates that Aquablation therapy leads to sustained outcomes, few irreversible complications, and low retreatment rates for the treatment of LUTS/BPH independently of prostate volume.

Assessment of hepatocellular carcinoma treatment response with LI-RADS: a pictorial review.

Computed tomography (CT) and magnetic resonance imaging (MRI) play critical roles for assessing treatment response of hepatocellular carcinoma (HCC) after locoregional therapy. Interpretation is challenging because posttreatment imaging findings depend on the type of treatment, magnitude of treatment response, time interval after treatment, and other factors. To help radiologists interpret and report treatment response in a clear, simple, and standardized manner, the Liver Imaging Reporting and Data System (LI-RADS) has developed a Treatment Response (LR-TR) algorithm. Introduced in 2017, the system provides criteria to categorize response of HCC to locoregional treatment (e.g., chemical ablation, energy-based ablation, transcatheter therapy, and radiation therapy). LR-TR categories include Nonevaluable, Nonviable, Equivocal, and Viable. LR-TR does not apply to patients on systemic therapies. This article reviews the LR-TR algorithm; discusses locoregional therapies for HCC, treatment concepts, and expected posttreatment findings; and illustrates LI-RADS treatment response assessment with CT and MRI.