Concurrent robotic renal and prostatic surgery: initial case series and safety data of a new surgical technique.

INTRODUCTION: In the era of prostate-specific antigen screening and frequent cross-sectional abdominal imaging, concurrent prostate cancer and renal masses are being identified and treated. Minimizing patient morbidity and cost by avoiding separate surgical procedures is advantageous, provided technical feasibility, and safety data. Our goal was to assess the feasibility and safety of single-setting robotic renal surgery and prostatectomy. We present our initial experience. PURPOSE: To assess the feasibility and safety of single-setting concurrent robot-assisted renal surgery and radical prostatectomy utilizing the same port access scheme. PATIENTS AND METHODS: From February 2009 to June 2009, we performed single-setting concurrent robot-assisted radical nephrectomy/partial nephrectomy and radical prostatectomy on two patients with synchronous kidney tumors and prostate cancer. Identical port sites were used during both aspects of the procedure with the exception of one additional port during prostatectomy. Prostate cancer clinical stage and Gleason scores were T1c and 6 and T2a and 7, respectively. Corresponding renal tumors were 5 cm, respectively. RESULTS: Both operations were performed, with no conversion to open surgery. There were no intraoperative complications and the postoperative course was uneventful in both patients. Discharge was on postoperative day 2 and 3, respectively. Patient 2 had an episode of delayed bleeding on postoperative day 9, treated by selective angio-embolization. Mean operative time for nephrectomy and prostatectomy (135 and 139 minutes, respectively) and estimated blood loss (75 and 100 mL, respectively) were reasonable. We began with the renal portion utilizing a lateral decubitus position before re-positioning into the lithotomy position for the prostatic portion. Clamping time was 34 minutes during partial nephrectomy. CONCLUSION: Single-setting robotic radical/partial nephrectomy and radical prostatectomy is technically feasible and safe in properly selected patients who present with synchronous primary renal and prostate malignancies.

Polymorphisms in hOGG1 and XRCC1 and risk of prostate cancer: effects modified by plasma antioxidants.

OBJECTIVES: To investigate whether polymorphisms in genes involved in the repair of oxidative DNA damage, modulate, and/or interact with antioxidants to influence prostate cancer risk in a population-based case-control study in Central Arkansas. Accumulating evidence indicates that oxidative stress plays a role in prostate carcinogenesis. METHODS: Cases (n = 193) included men aged 40-80 years, diagnosed with prostate cancer in 3 major hospitals in 1998-2003, and controls (n = 197) were matched to cases by age, race, and county of residence. RESULTS: After adjustment for confounders, subjects who were heterozygous or homozygous for the variant allele of the hOGG1 Ser326Cys polymorphism appeared to experience a lower risk of prostate cancer than those who were homozygous for the wild-type allele (odds ratio [OR] (95% confidence interval [CI]): 0.72 (0.46-1.10)]. Conversely, a significant increased risk was observed for individuals who carried 1 or 2 copies of the variant allele of the XRCC1 Arg399Gln polymorphism, compared with those who only harbored the wild-type allele (OR [95% CI]: 1.56 [1.01-2.45]). The above-mentioned associations were generally more pronounced among subjects with low plasma carotenoids or alpha-tocopherol (

Renal cell carcinoma with caval thrombus extending to the right atrium in a horseshoe kidney: a unique surgical challenge.

The surgical anatomy of a horseshoe kidney (HK) is unique in many ways, ranging from its anomalous circulation, shared renal parenchyma between the right and left renal moieties, and its anterior renal pelvis, to the fact that it obscures access to the vena cava and aorta. While renal cell carcinomas (RCCs) are known to occur in HKs, the surgical approach to an RCC with tumour thrombus extending to the right atrium has not been reported in the literature. We report an unusual presentation of RCC and the technical aspects of our successful experience with managing RCC of a HK extending to the inferior vena cava and right atrium.

Granular cell tumour of the ureter: first case reported.

A 33-year-old woman presented with nonspecific, colicky pain of the left lower abdomen. Computed tomography (CT) revealed a 2-cm mass engulfing the mid-left ureter. Ureteroscopy and biopsy revealed normal mucosa, and CT-guided biopsy of the mass was nondiagnostic. The patient underwent laparoscopic exploration. A frozen section taken from the mass revealed a granular cell tumour. We excised the whole involved portion of the ureter and performed end-to-end ureteroureteral anastamosis. The postoperative course was uneventful. Examination of a segment of resected ureter revealed a granular cell tumour diffusely infiltrating the wall of the ureter. There were no features suggesting a malignant phenotype. On follow-up, the patient was found to have developed a stricture at the anastomotic area, which was successfully treated with balloon dilatation. To our knowledge, this is the first reported case of a granular cell tumour involving the ureter.

Hematuria with electroconvulsive therapy: a case report.

We report a case of hematuria developing during the administration of electroconvulsive therapy. The patient had preexisting hypertension and was on anticoagulant therapy. Diagnostic evaluation revealed the source of bleeding to be the right kidney. The bleeding was transient and not life threatening. Other than acute renal insufficiency that resolved, there did not appear to be any permanent loss of organ function or health related to this event. Although the cause of the bleeding in this patient is unknown, it is suspected that a vascular anomaly, in conjunction with hypertension and anticoagulation, led to gross hematuria. It appears that hematuria has not previously been reported with electroconvulsive therapy and would be considered a very rare complication.

Plasma carotenoids and prostate cancer: a population-based case-control study in Arkansas.

Carotenoids possess antioxidant properties and thus may protect against prostate cancer. Epidemiological studies of dietary carotenoids and this malignancy were inconsistent, partially due to dietary assessment error. In this study, we aimed to investigate the relation between plasma concentrations of carotenoids and the risk of prostate cancer in a population-based case-control study in Arkansas. Cases (n = 193) were men with prostate cancer diagnosed in 3 major hospitals, and controls (n = 197) were matched to cases by age, race, and county of residence. After adjustment for confounders, plasma levels of lycopene, lutein/zeaxanthin, and beta-cryptoxanthin were inversely associated with prostate cancer risk. Subjects in the highest quartile of plasma lycopene (513.7 microg/l) had a 55% lower risk of prostate cancer than those in the lowest quartile (140.5 microg/l; P trend = 0.042). No apparent association was observed for plasma alpha-carotene and beta-carotene. Further adjustment for the other 4 carotenoids did not materially alter the risk estimates for plasma lycopene, lutein/zeaxanthin, and beta-cryptoxanthin but appeared to result in an elevated risk with high levels of plasma alpha-carotene and beta-carotene. The results of all analyses did not vary substantially by age, race, and smoking status. This study added to the emerging evidence that high circulating levels of lycopene, lutein/zeaxanthin, and beta-cryptoxanthin are associated with a low risk of prostate cancer.

Expression of CD138 (Syndecan-1) in renal cell carcinoma is reduced with increasing nuclear grade.

CD138/Syndecan-1 is a cell-surface heparan sulfate proteoglycan expressed on most epithelial cells, and decreased CD138 expression is associated with increased invasive and metastatic potential in carcinomas. CD138 expression has not been investigated previously in renal neoplasms. Formalin-fixed, paraffin-embedded tissue sections of 50 renal cell carcinomas (RCCs) (40 clear-cell RCCs of various nuclear grades, 10 of which harbored metastases; 6 papillary RCCs, 4 chromophobe RCCs) and 4 oncocytomas were stained immunohistochemically for CD138 using the monoclonal antibody B-B4 (CD138). Staining intensity and distribution were scored and results related to histologic type, nuclear grade, and local stage (pT). Immunoreactivity was membranous in all clear-cell RCCs, chromophobe RCCs, and oncocytomas and was located at the basal aspect of cytoplasm in papillary RCCs. In clear-cell RCCs, the extent of CD138 immunoreactivity decreased with increasing nuclear grade (P<0.001). No significant correlation was found between CD138 immunoreactivity and histologic type (P=0.2) or local stage (P=0.7). Metastatic foci showed a mild to moderate decrease in intensity compared with primary tumor. Decreased expression of CD138 may have a role in more aggressive behavior of clear-cell RCC.

Metastatic renal cell carcinoma to prostate.

Clinically apparent renal cell carcinoma that has metastasized to the prostate is a rare finding. When identified, it has been associated with widespread metastatic disease and short-term survival. We present a case of metachronous renal cell carcinoma found only in the prostate with the longest reported interval of 9 years between radical nephrectomy and clinically apparent disease.

CYP3A43 Pro(340)Ala polymorphism and prostate cancer risk in African Americans and Caucasians.

The human cytochrome P450 3A subfamily of enzymes is involved in the metabolism of steroid hormones, carcinogens, and many drugs. A cytosine-to-guanine polymorphism in CYP3A43 results in a proline-to-alanine substitution at codon 340. Although the functional significance of this polymorphism is unknown, we postulate that the substitution of proline, an alpha-imino acid, with alanine, an amino acid, could be of biochemical significance. In a case-control study with 490 incident prostate cancer cases (124 African Americans and 358 Caucasians) and 494 controls (167 African Americans and 319 Caucasians), we examined the association between CYP3A43 Pro(340)Ala polymorphism and prostate cancer risk. When all subjects were considered, there was a 3-fold increase in risk of prostate cancer among individuals with the CYP3A43-Ala/Ala genotype (odds ratio, 3.0; 95% confidence interval, 1.2-7.2) compared with those with the CYP3A43-Pro/Pro genotype after adjusting for age, race, and smoking. The prevalence of the polymorphism was significantly higher in African Americans than Caucasians (45% versus 13%). In African Americans, there was a 2.6-fold increase in prostate cancer risk among individuals with the CYP3A43-Ala/Ala genotype (odds ratio, 2.6; 95% confidence interval, 1.0-7.0) compared with those with the CYP3A43-Pro/Pro genotype. Among Caucasians, the small number of homozygotes precluded computing risk estimates; there were only three individuals with the CYP3A43-Ala/Ala genotype. Our results suggest that the CYP3A43-Pro(340)Ala polymorphism contributes to prostate cancer risk.

Radical prostatectomy and postoperative radiation in patients with adenocarcinoma of prostate of intermediate and high risk for recurrence.

OBJECTIVE: To report on the outcome of patients with intermediate and high risk of recurrence who underwent radical prostatectomy (RP). METHODS: Eighty-five consecutive patients categorized as intermediate (17.5%) and high risk (82.5%) of failure after definitive therapy for carcinoma of prostate according to the National Comprehensive Cancer Network (NCCN) underwent RP between 1989 and 1997. Median preoperative PSA was 26 ng/ml (range 15 ng/ml-91 ng/ml). Fifty-nine patients (70%) received three months neoadjuvant hormone therapy. Thirty-six patients (42%) underwent early (three to four months after RP) adjuvant radiation for pT3 disease and/or positive surgical margins. RESULTS: The median follow-up was 58 months (range 12-104 months). There was no difference in the biochemical recurrence rate between the intermediate and high-risk group of patients. The overall relapse rate was 33%. Cancer-specific mortality was 3.5%. Patients with T1c tumors had a significantly lower biochemical recurrence rate (bRR) (7%) compared to palpable tumors (p = 0.03). Age above 65 was a significant negative prognostic factor with respect to biochemical recurrence (p = 0.01). Adjuvant radiation was associated with biochemical recurrence rates of 25% vs. 40% in patients who were not radiated (p = 0.05). CONCLUSIONS: In the intermediate and high-risk groups of patients with nonpalpable prostate cancer, RP and adjuvant RT may provide a biochemical recurrence-free rate (bRFR) comparable to that reported in other series with RP alone on patients in the low-risk groups. We encourage the multimodality treatment approach incorporating adjuvant postoperative radiation in these patients.

Association of SULT1A1 phenotype and genotype with prostate cancer risk in African-Americans and Caucasians.

Exposure to heterocyclic amines may increase prostate cancer risk. Human sulfotransferase 1A1 (SULT1A1) is involved in the bioactivation of some dietary procarcinogens, including the N-hydroxy metabolite of the food-borne heterocyclic amine, 2-amino-1-methyl-6-phenylimidazo(4,5-b) pyridine. This study compares a polymorphism in the SULT1A1 gene, SULT1A1 enzyme activity, meat consumption, and the risk of prostate cancer in a population based case-control study. Prostate cancer patients (n = 464) and control individuals (n = 459), frequency matched on age and ethnicity, provided informed consent, answered a survey, and provided a blood sample. Platelets were isolated for phenotype analysis, and DNA was isolated from lymphocytes for genotype determination. Meat consumption was assessed using a dietary questionnaire. Caucasians homozygous for the SULT1A1*1 high activity allele were at increased risk for prostate cancer [odds ratio (OR), 1.68; 95% confidence interval (CI), 1.05-2.68] compared with individuals homozygous for the low-activity allele. The association between SULT1A1 genotype and prostate cancer risk in African-Americans did not reach significance (OR, 1.60; 95% CI, 0.46-5.62). When SULT1A1 activity was considered, there was a strong association between increased SULT1A1 activity and prostate cancer risk in Caucasians (OR, 3.04; 95% CI, 1.8-5.1 and OR, 4.96; 95% CI, 3.0-8.3, for the second and third tertiles of SULT1A1 activity, respectively) compared with individuals in the low enzyme activity tertile. A similar association was also found in African-American patients, with ORs of 6.7 and 9.6 for the second and third tertiles of SULT1A1 activity (95% CI, 2.1-21.3 and 2.9-31.3, respectively). When consumption of well-done meat was considered, there was increased risk of prostate cancer (OR, 1.42; 95% CI, 1.01-1.99 and OR, 1.68; 95% CI, 1.20-2.36 for the second and third tertiles, respectively). When SULT1A1 activity was stratified by tertiles of meat consumption, there was greater risk of prostate cancer in the highest tertile of meat consumption. These results indicate that variations in SULT1A1 activity contributes to prostate cancer risk and the magnitude of the association may differ by ethnicity and be modified by meat consumption.

Simultaneous generation of multiple mitochondrial DNA mutations in human prostate tumors suggests mitochondrial hyper-mutagenesis.

Multiple somatic mitochondrial DNA mutations are frequently reported in human tumors, but the process leading to homoplasmic transformation and accumulation of multiple mutations in the same tumor cell lineage remains a mystery. We address possible mechanisms responsible for the generation of multiple mitochondrial (mt)DNA mutations observed in a high frequency of prostate tumors using sensitive mutant-specific PCR coupled with laser capture microdissection. Analysis of prostate tumors with multiple mtDNA mutations in the control region indicates that the mutations are locally confined, that the multiple mutations exist on the same molecules and that more than one mtDNA mutant species co-exists in the same neoplastic lesion. These results suggest an unusually rapid process in mtDNA mutagenesis during tumor progression. On the basis of prostate tumor cell kinetics, we propose a unique process of mitochondrial hyper-mutagenesis, probably mediated by cellular oxidative stress, to account for a burst of multiple mtDNA mutations in human prostate tumors.

Multi-institutional long-term experience with conservative surgery for invasive penile carcinoma.

PURPOSE: Invasive squamous cell carcinoma of the penis occurs on the glans, prepuce, glans and prepuce, coronal sulcus and shaft. Penile squamous cell carcinoma subsequently invades local structures, corpora cavernosa and the urethra, and metastasizes to the inguinal lymph nodes. Invasive squamous cell carcinoma of the penis usually requires total or partial penectomy. We studied the effect of primary tumor resections tailored to the anatomical extent of the cancer with preservation of uninvolved structures in select patients with invasive penile squamous cell carcinoma. MATERIALS AND METHODS: A total of 30 patients between 39 and 82 years old were treated with unconventional conservative surgical excision of the primary penile lesion. More than 130 patients were excluded from the study because they were treated with partial or total penectomy, Mohs' surgery or more extensive surgery. The 30 patients underwent preoperative biopsy with careful mapping of the extent of the disease. Patient age, tumor extent and grade, operative details, outcome and length of followup were analyzed. RESULTS: Tumor size ranged from 1.5 to 8 cm. in diameter. Tumors were well differentiated in 19 patients, moderately differentiated in 5 and poorly differentiated in 6. A total of 17 patients underwent ilioinguinal lymphadenectomy, 12 of whom had pathologically positive lymph nodes. Inguinal radiation was used in 2 patients. Chemotherapy was given to 7 patients with extensive inguinal lymphadenopathy and to 2 of 5 with pathologically positive lymph nodes. Followup ranged from 12 to 360 months. A total of 21 patients had no evidence of disease at last followup. Tumor resection with no sacrifice of function was performed in 2 patients in whom 3 small recurrences developed. One patient with numerous tumors had 2 small recurrences, which were completely excised with no further recurrence. Of the 7 patients with advanced lymphadenopathy 5 and of 5 patients with pathologically positive lymph nodes at presentation 1 died of the cancer but had no local recurrence in the penis. CONCLUSIONS: In a minority of patients with anatomically suitable penile cancer conservative surgical techniques are safe and provide equal tumor control compared to conventional resections. The anatomical situation and tumor characteristics should dictate the choice of treatment for the primary penile lesion. Inguinal lymph nodes should be managed by appropriately established guidelines but should not influence the extent of primary penile lesion resection.

Extensive somatic mitochondrial mutations in primary prostate cancer using laser capture microdissection.

Prostate cancer is the second leading cause of cancer deaths among men in the United States,but the precise molecular events leading to prostate carcinogenesis are not well understood. We isolated histologically defined cell populations from prostate cancer and its preinvasive lesions using laser capture microdissection, and performed genetic analysis on the mitochondrial genome, a sensitive cytoplasmic DNA. An extremely high incidence of somatic mutation (90% of prostatectomy cancer specimens) was found in the control region (the displacement loop) of mitochondrial DNA. The massive induction of lesion-associated mutations suggests active mitochondrial mutagenesis in both prostate cancer and its preinvasive lesions. Inspection of these mutations provides new insights into prostate cancer genetics and reveals unique patterns of somatic mutations in prostatic neoplastic lesions.