Association of Low Socioeconomic Status With Adverse Prostate Cancer Pathology Among African American Men Who Underwent Radical Prostatectomy.

BACKGROUND: We tested for associations between socioeconomic status (SES) and adverse prostate cancer pathology in a population of African American (AA) men treated with radical prostatectomy (RP). PATIENTS AND METHODS: We retrospectively reviewed data from 2 institutions for AA men who underwent RP between 2010 and 2015. Household incomes were estimated using census tract data, and patients were stratified into income groups relative to the study population median. Pathologic outcomes after RP were assessed, including the postsurgical Cancer of the Prostate Risk Assessment (CAPRA-S) score and a definition of adverse pathology (stage ≥ pT3, Gleason score ≥ 4+3, or positive lymph nodes), and compared between income groups. RESULTS: We analyzed data of 347 AA men. Median household income was $37,954. Low-SES men had significantly higher prostate-specific antigen values (mean 10.2 vs. 7.3; P < .01) and CAPRA-S scores (mean 3.4 vs. 2.5; P < .01), more advanced pathologic stage (T3-T4 31.8% vs. 21.5%; P = .03), and higher rates of seminal vesicle invasion (17.3% vs. 8.2%; P < .01), positive surgical margins (35.3% vs. 22.1%; P < .01), and adverse pathology (41.4% vs. 30.1%; P = .03). Linear and logistic regression showed significant inverse associations of SES with CAPRA-S score (P < .01) and adverse pathology (P = .03). CONCLUSION: In a population of AA men who underwent RP, we observed an independent association of low SES with advanced stage or aggressive prostate cancer. By including only patients in a single racial demographic group, we eliminated the potential confounding effect of race on the association between SES and prostate cancer risk. These findings suggest that impoverished populations might benefit from more intensive screening and early, aggressive treatment of prostatic malignancies.

Obturator Compartment Syndrome Secondary to Pelvic Hematoma After Robot-Assisted Laparoscopic Radical Prostatectomy.

Obturator nerve injury is a known injury after robot-assisted laparoscopic radical prostatectomy (RALP) and patients often present with motor and sensory deficits in the immediate postoperative period. We describe a 65-year-old male who presented with motor deficits, indicative of obturator neurapraxia after RALP upon waking from anesthesia. Work-up revealed an expansile hematoma possibly compressing the obturator nerve. After evacuation of the hematoma, the patient had immediate improvement of his neurologic deficits. Our patient's clinical vignette illustrates the importance of considering postsurgical hematoma in the differential diagnosis when patients present with signs and symptoms of obturator neurapraxia after RALP.

Complications of Minimally Invasive Surgery and Their Management.

Minimally invasive surgery, including both traditional laparoscopic and robot-assisted laparoscopic approaches, has increasingly become the standard of care for urologic abdominal and pelvic surgery. This is a comprehensive review of the contemporary literature regarding complications of laparoscopic and robotic urologic surgery. The review highlights pertinent studies with the goal of providing the minimally invasive urologic surgeon with an up-to-date overview of general and procedure-specific complications and their management.

Multifocal Renal Fungal Abscesses.

We report a case of multiple fungal renal abscesses in a 36-year-old woman with a history of diabetes and intravenous substance use disorder. The patient presented with fever and hematuria, and was found to be bacteremic and fungemic. She was initially managed with broad-spectrum antibiotics and antifungals. She remained febrile and imaging on treatment day 14 showed no improvement of the renal abscesses. Thus, a nephrectomy was performed, after which the patient defervesced and follow-up blood cultures were negative. There is a paucity of literature regarding management of multifocal fungal renal abscesses that fail to respond to medical management.

Oncocytic Adrenocortical Neoplasm Diagnosed after Robot-Assisted Adrenalectomy.

Oncocytic tumors, composed of eosinophilic, mitochondria-rich cells, can occur in several locations throughout the body. These tumors can occur in the adrenal cortex and are rarely malignant. We report a case of a patient presenting with an incidental adrenal mass which was later diagnosed as a oncocytic adrenocortical neoplasm (OAN). The patient is a 53-year-old man found to have a 7.2 cm right adrenal mass, incidentally found by computed tomography (CT). After metabolic workup was negative, a right robotic adrenalectomy (RA) was performed. Pathologic analysis revealed clusters of large cells with abundant eosinophilic and granular cytoplasm, consistent with OAN. This pathology is rare, with only about 150 cases described in the literature. It occurs in females 2.5 times more frequently and more commonly on the left side. Diagnosis is usually made by imaging criteria, typically with CT or magnetic resonance imaging (MRI). Treatment is generally surgical, since OAN can be malignant in some cases. Differentiation between benign and malignant OAN is done based on the Lin-Weiss-Bisceglia criteria and can be difficult. If malignancy is diagnosed, recurrence is common and close surveillance should be performed.

Renal transposition during minimally invasive partial nephrectomy: a safe technique for excision of upper pole tumors.

Minimally invasive partial nephrectomy (MIPN) for upper pole masses, particularly for those located posteriorly, is challenging because of difficult visualization during tumor resection and renorrhaphy. Complete renal transposition facilitates access to and excision of upper pole renal masses during MIPN. Sixteen patients with upper pole renal masses underwent laparoscopic or robot-assisted partial nephrectomy with renal transposition from October 2009 to March 2012 with a mean follow-up of 22 months. Mean operative time was 242.6 minutes, and mean warm ischemic time was 14.7 minutes. No patient needed an intraoperative or postoperative blood transfusion. Five (31%) patients had a postoperative complication (four Clavien grade I, one Clavien grade II). There were no delayed complications, positive surgical margins, or tumor recurrences. Mean postoperative eGFR change within 3 months was -9.4%. These results show that complete renal transposition can be safely used to facilitate excision of upper pole tumors.

Patterns of care and outcomes of radiotherapy for lymph node positivity after radical prostatectomy.

OBJECTIVE: To evaluate the use and outcomes of adjuvant radiation therapy (ART) for men with lymph node (LN)-positive disease after radical prostatectomy (RP) using a population-based approach. PATIENTS AND METHODS: Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data from 1995 to 2007 was used to identify 577 men with LN metastases discovered during RP and absence of distant metastases, of which 177 underwent ART ≤1 year of RP. Propensity score models were used to compare overall mortality and prostate cancer-specific mortality (PCSM) for men that did and those that did not receive ART. RESULTS: Men in both groups received adjuvant androgen-deprivation therapy at similar rates after propensity weighting adjustments (33.6% vs 33.7%, P = 0.977). ART was not associated with differences in overall (5.09 vs 3.77 events per 100 person-years, P = 0.153) or PCSM (2.89 vs 1.31, P = 0.090) relative to men who did not receive ART. CONCLUSIONS: ART after RP in men with LN-positive prostate cancer was not associated with improved overall or disease-specific survival, in contrast to previous single-centre studies. Prospective randomised studies are needed to assess the effectiveness of ART in this patient population.

Stepwise approach for nerve sparing without countertraction during robot-assisted radical prostatectomy: technique and outcomes.

BACKGROUND: Although subtle technical variation affects potency preservation during robot-assisted laparoscopic radical prostatectomy (RARP), most prostatectomy studies focus on achieving the optimal anatomic nerve-sparing dissection plane. However, the impact of active assistant/surgeon neurovascular bundle (NVB) countertraction on sexual function outcomes has not been studied or quantified. OBJECTIVE: To illustrate technique and compare sexual function outcomes for nerve sparing without (NS-0C) versus with (NS-C) assistant and/or surgeon NVB countertraction. DESIGN, SETTING, AND PARTICIPANTS: This is a retrospective study of 342 NS-0C versus 268 NS-C RARP procedures performed between August 2008 and February 2011. SURGICAL PROCEDURE: RARP. MEASUREMENTS: We used the Expanded Prostate Cancer Index Composite (EPIC) sexual function and potency scores, estimated blood loss (EBL), operative time, and positive surgical margin (PSM). RESULTS AND LIMITATIONS: In unadjusted analysis, men undergoing NS-0C versus NS-C were older, had worse baseline sexual function, higher biopsy and pathologic Gleason grade, and higher preoperative prostate-specific antigen (PSA) levels (all p ≤ 0.023). However, NS-0C versus NS-C was associated with higher 5-mo sexual function scores (20 vs 10; p < 0.001), and this difference was accentuated for bilateral intrafascial nerve sparing in preoperatively potent men (35.8 vs 16.6; p < 0.001). Similarly, 5-mo potency for preoperatively potent men was better with bilateral intrafascial NS-0C versus NS-C (45.0% vs 28.4%; p = 0.039). However, no difference in sexual function or potency was observed at 12 mo. In adjusted analyses, NS-0C versus NS-C was associated with improved 5-mo sexual function (parameter estimate: 10.90; standard error: 2.16; p < 0.001) and potency (odds ratio: 1.69; 95% confidence interval, 1.01-2.83; p = 0.046). NS-0C versus NS-WC was associated with shorter operative times (p = 0.001) and higher EBL (p = 0.001); however, there were no significant differences in PSM. Limitations include the retrospective, single-surgeon study design and smaller numbers for 12-mo comparison. CONCLUSIONS: Reliance on countertraction to facilitate dissecting NVB away from the prostate leads to neuropraxia and delayed recovery of sexual function and potency. Subtle technical modification to dissect the prostate away from the NVB without countertraction enables earlier return of sexual function and potency.

Robotic assisted laparoscopic ureteral reimplantation in children: case matched comparative study with open surgical approach.

PURPOSE: Surgical treatment may be required in some patients with vesicoureteral reflux. With the recent development of robotic assistance, laparoscopic treatment of vesicoureteral reflux has gained popularity. We sought to evaluate our initial experience with pediatric robotic assisted laparoscopic intravesical and extravesical ureteral reimplantation, and to compare outcomes with the open technique. MATERIALS AND METHODS: A retrospective chart review was performed on all patients who underwent robotic assisted laparoscopic ureteral reimplantation between 2007 and 2010. Comparisons were made with a case matched cohort of patients who underwent the open technique. The groups were compared using t tests for numerical variables and chi-square comparisons or Fisher's exact test for categorical variables. A Kaplan-Meier model was used to compare success rates. RESULTS: A total of 19 patients underwent intravesical and 20 underwent extravesical robotic assisted laparoscopic ureteral reimplantation during the study period. They were compared to 22 patients undergoing intravesical and 17 undergoing extravesical open ureteral reimplantation. Although the robotic assisted approach was associated with a longer operative time (p <0.001), children undergoing intravesical robotic assisted reimplantation had a shorter duration of urinary catheter drainage, fewer bladder spasms and a shorter hospital stay compared to those undergoing the intravesical open technique (p <0.01). There were no significant differences in these parameters when comparing extravesical robotic assisted reimplantation to the extravesical open technique. Overall success rates were similar among patients who underwent robotic assisted laparoscopic ureteral reimplantation and open reimplantation (p >0.5). CONCLUSIONS: Robotic assisted laparoscopic ureteral reimplantation offers similar success rates to the gold standard, open ureteral reimplantation. Future large scale studies will be required to define further the costs and benefits of robotic assisted laparoscopic ureteral reimplantation in the surgical treatment of vesicoureteral reflux.

Efficacy and survival associated with cystoscopy and clot evacuation for radiation or cyclophosphamide induced hemorrhagic cystitis.

PURPOSE: We assessed the outcome of patients with hemorrhagic cystitis severe enough to require cystoscopy and clot evacuation. MATERIALS AND METHODS: We retrospectively evaluated the records of 33 patients with cyclophosphamide or radiation induced hemorrhagic cystitis treated with cystoscopy. RESULTS: Mean followup of living patients was 76 months. Of 33 patients 20 (61%) had resolution of hematuria after single cystoscopy unrelated to hemorrhagic cystitis etiology. Only 4 of 11 patients (36%) had resolution after 2 or more cystoscopies, and all were in the radiation induced hemorrhagic cystitis group (4 of 6, 67%) with none in the cyclophosphamide induced hemorrhagic cystitis group (0 of 5, p = 0.02). Hematuria was refractory to cystoscopy in 9 patients and ileal conduits were created in 4. Kaplan-Meier overall survival at 1, 2 and 5 years was 58%, 51% and 43%, respectively, with survival tending to be worse in patients who received cyclophosphamide for bone marrow transplantation induction. Of the 18 deaths 3 were due to complications of hemorrhagic cystitis, 13 were due to the disease underlying the hemorrhagic cystitis and 2 were unrelated. CONCLUSIONS: The response of hemorrhagic cystitis to single cystoscopy and clot evacuation is reasonable but response to subsequent cystoscopy (unless the hemorrhagic cystitis is radiation induced) is less likely, so alternate interventions should be considered if hematuria does not resolve after initial cystoscopy. Patients with hemorrhagic cystitis requiring cystoscopy have a poor prognosis even if hematuria resolves, although most deaths are related to the disease underlying the hemorrhagic cystitis rather than its direct result.

Peroxynitrite inhibits enterocyte proliferation and modulates Src kinase activity in vitro.

Overproduction of nitric oxide (NO) or its toxic metabolite, peroxynitrite (ONOO-), after endotoxemia promotes gut barrier failure, in part, by inducing enterocyte apoptosis. We hypothesized that ONOO- may also inhibit enterocyte proliferation by disrupting the Src tyrosine kinase signaling pathway, thereby blunting repair of the damaged mucosa. We examined the effect of ONOO- on enterocyte proliferation and Src kinase activity. Sprague-Dawley rats were challenged with LPS or saline, whereas intestinal epithelial cell line cells were treated with ONOO- or decomposed ONOO- in vitro. Enterocyte proliferation in vivo and in vitro was measured by 5-bromo-2'-deoxyuridine (BrdU) or [3H]thymidine incorporation. Src kinase activity in cell lysates was determined at various times. LPS challenge in vivo and ONOO- treatment in vitro inhibited enterocyte proliferation. ONOO- treatment blunted the activity of Src and its downstream target, focal adhesion kinase, in a time-dependent manner. ONOO- blocked mitogen (FBS, EGF)-induced enterocyte proliferation and Src phosphorylation while increasing Src nitration. Thus ONOO- may promote gut barrier failure not only by inducing enterocyte apoptosis but also by disrupting signaling pathways involved in enterocyte proliferation.