Tolerance of the human kidney to isolated controlled ischemia.

Tolerance of the human kidney to ischemia is controversial. Here, we prospectively studied the renal response to clamp ischemia and reperfusion in humans, including changes in putative biomarkers of AKI. We performed renal biopsies before, during, and after surgically induced renal clamp ischemia in 40 patients undergoing partial nephrectomy. Ischemia duration was >30 minutes in 82.5% of patients. There was a mild, transient increase in serum creatinine, but serum cystatin C remained stable. Renal functional changes did not correlate with ischemia duration. Renal structural changes were much less severe than observed in animal models that used similar durations of ischemia. Other biomarkers were only mildly elevated and did not correlate with renal function or ischemia duration. In summary, these data suggest that human kidneys can safely tolerate 30-60 minutes of controlled clamp ischemia with only mild structural changes and no acute functional loss.

Perioperative outcomes and oncologic efficacy from a pilot prospective randomized clinical trial of open versus robotic assisted radical cystectomy.

PURPOSE: Robotic assisted laparoscopic radical cystectomy for bladder cancer has been reported with potential for improvement in perioperative morbidity compared to the open approach. However, most studies are retrospective with significant selection bias. MATERIALS AND METHODS: A pilot prospective randomized trial evaluating perioperative outcomes and oncologic efficacy of open vs robotic assisted laparoscopic radical cystectomy for consecutive patients was performed from July 2009 to June 2011. RESULTS: To date 47 patients have been randomized with data available on 40 patients for analysis. Each group was similar with regard to age, gender, race, body mass index and comorbidities, as well as previous surgeries, operative time, postoperative complications and final pathological stage. We observed no significant differences between oncologic outcomes of positive margins (5% each, p = 0.50) or number of lymph nodes removed for open radical cystectomy (23, IQR 15-28) vs robotic assisted laparoscopic radical cystectomy (11, IQR 8.75-21.5) groups (p = 0.135). The robotic assisted laparoscopic radical cystectomy group (400 ml, IQR 300-762.5) was noted to have decreased estimated blood loss compared to the open radical cystectomy group (800 ml, IQR 400-1,100) and trended toward a decreased rate of excessive length of stay (greater than 5 days) (65% vs 90%, p = 0.11) compared to the open radical cystectomy group. The robotic group also trended toward fewer transfusions (40% vs 50%, p = 0.26). CONCLUSIONS: Our study validates the concept of randomizing patients with bladder cancer undergoing radical cystectomy to an open or robotic approach. Our results suggest no significant differences in surrogates of oncologic efficacy. Robotic assisted laparoscopic radical cystectomy demonstrates potential benefits of decreased estimated blood loss and decreased hospital stay compared to open radical cystectomy. Our results need to be validated in a larger multicenter prospective randomized clinical trial.

Active surveillance: pitfalls to consider.

With the pendulum swinging in low risk prostate cancer (PCa) to ideas of overtreatment and overdiagnosis more urologists are looking at Active Surveillance (AS) as a valid option for their low risk PCa patients. AS will undoubtedly hold a place as a management option in men with low risk PCa, however, it is critical to understand its limitations in its current form as highlighted in this article. We conducted a review of multiple computerized databases (Ovid, Medline, Pubmed, CINAHL, Cohrane Library database) with the keywords active surveillance, prostate neoplasm, and low risk PCa. Manual searches were also carried out. Assumptions of AS are discussed and their implications on selecting the appropriate AS candidate. As with any active treatment option offered to patients with PCa, those who are offered AS must be appropriately selected and counseled as to its risks and benefits.

Vigilancia activa: dificultades a considerar / Active surveillance: pitfalls to consider

Las oscilaciones actuales de las ideas acerca del sobrediagnóstico y sobretratamiento del cáncer de próstata (CaP) de bajo riesgo, hay más urólogos que están examinando con atención la vigilancia activa (VA) como una opción válida para sus pacientes con CaP de bajo riesgo. La VA ocupará, sin duda, un lugar como una opción de tratamiento en los hombres con CaP de bajo riesgo. Sin embargo, es fundamental, como se destaca en este artículo, entender las limitaciones que posee en su diseño actual. Se realizó una revisión de varias bases de datos (Ovid, Medline, Pubmed, CINAHL, base de datos de la colaboración Cohrane) empleando las palabras clave: vigilancia activa, neoplasia de próstata y CaP de bajo riesgo. También se llevaron a cabo búsquedas manuales. Trataremos situaciones supuestas acerca de VA y las implicaciones en la selección de los candidatos apropiados. Al igual que con cualquier opción de tratamiento activo que se ofrece a los pacientes con CaP, a los que se les ofrece VA, deben ser adecuadamente seleccionados y asesorados en cuanto a sus riesgos y beneficios(AU)

With the pendulum swinging in low risk prostate cancer (PCa) to ideas of overtreatment and overdiagnosis more urologists are looking at Active Surveillance (AS) as a valid option for their low risk PCa patients. AS will undoubtedly hold a place as a management option in men with low risk PCa, however, it is critical to understand its limitations in its current form as highlighted in this article.We conducted a review of multiple computerized databases (Ovid, Medline, Pubmed, CINAHL, Cohrane Library database) with the keywords active surveillance, prostate neoplasm, and low risk PCa. Manual searches were also carried out. Assumptions of AS are discussed and their implications on selecting the appropriate AS candidate. As with any active treatment option offered to patients with PCa, those who are offered AS must be appropriately selected and counseled as to its risks and benefits.

Efficacy of combined intravesical immunotherapy and chemotherapy for non-muscle invasive bladder cancer.

Intravesical immunotherapy using attenuated bacillus Calmette-Guérin (BCG) strains and intravesical chemotherapy are the modalities most commonly used to treat intermediate- or high-risk patients with non-muscle invasive bladder cancer. BCG has been shown to decrease recurrence rates by up to 67% compared with tumor resection alone, but intensive BCG maintenance regimens are poorly tolerated in a large proportion of patients. Intravesical chemotherapy also decreases the risk of recurrence for these patients, but has diminished efficacy compared with BCG. If BCG dose reduction can be achieved with combined intravesical immunotherapy and chemotherapy, this regimen may improve compliance and thus optimize treatment for these patients by limiting side effects from BCG monotherapy, while at the same time improving oncologic efficacy via the separate anti-tumor mechanisms of these agents. The authors discuss the most recent data regarding combining these agents in an alternating or sequential regimen.

Methods to predict and lower the risk of prostate cancer.

Chemoprevention for prostate cancer (PCa) continues to generate interest from both physicians and the patient population. The goal of chemoprevention is to stop the malignant transformation of prostate cells into cancer. Multiple studies on different substances ranging from supplements to medical therapy have been undertaken. Thus far, only the studies on 5 alpha-reductase inhibitors (the Prostate Cancer Prevention Trial [PCPT] and Reduction by Dutasteride of Prostate Cancer Events [REDUCE] trial) have demonstrated a reduction in the risk of PCa, while results from the Selenium and Vitamin E Cancer Prevention Trial (SELECT) concluded no decreased risk for PCa with selenium or vitamin E.

Prospective evaluation of operating characteristics of prostate cancer detection biomarkers.

PURPOSE: We assessed the independent predictive values of the serum markers free prostate specific antigen, proenzyme prostate specific antigen, neuroendocrine marker and Dickkopf-1 compared to serum prostate specific antigen and other standard risk factors for early prostate cancer detection. MATERIALS AND METHODS: From the prospectively collected SABOR cohort 250 prostate cancer cases, and 250 mean age matched and proportion of African-American race/ethnicity matched controls were selected who had a prior available prostate specific antigen and digital rectal examination. Serum samples were obtained, and free prostate specific antigen, [-2]proenzyme prostate specific antigen, Dickkopf-1 and neuroendocrine marker were measured. AUC, sensitivities and specificities were calculated, and multivariable logistic regression was used to assess the independent predictive value compared to prostate specific antigen, digital rectal examination, family history, prior biopsy history, race/ethnicity and age. RESULTS: The AUCs (95% CI) were 0.76 (0.71, 0.8) for free prostate specific antigen, 0.72 (0.67, 0.76) for [-2]proenzyme prostate specific antigen, 0.76 (0.72, 0.8) for %free prostate specific antigen, 0.61 (0.56, 0.66) for %[-2]proenzyme prostate specific antigen, 0.73 (0.68, 0.77) for prostate health index, 0.53 (0.48, 0.58) for Dickkopf-1 and 0.53 (0.48, 0.59) for neuroendocrine marker. In the 2 to 10 ng/ml prostate specific antigen range the AUCs (95% CI) were 0.58 (0.49, 0.67) for free prostate specific antigen, 0.53 (0.44, 0.62) for [-2]proenzyme prostate specific antigen, 0.67 (0.59, 0.75) for %free prostate specific antigen, 0.57 (0.49, 0.65) for %[-2]proenzyme prostate specific antigen and 0.59 (0.51, 0.67) for phi. Only %free prostate specific antigen retained independent predictive value compared to the traditional risk factors. CONCLUSIONS: Free prostate specific antigen retained independent diagnostic usefulness for prostate cancers detected through prostate specific antigen and digital rectal examination screening. Prostate specific antigen isoforms are highly correlated with prostate specific antigen. Future research is needed to identify new markers associated with prostate cancer through different mechanisms.

Management of post-chemotherapy residual mass in patients with metastatic nonseminomatous germ cell tumors of the testis.

The basis of treatment for advanced germ cell tumors is chemotherapy and surgical resection of residual disease. Surgery has maintained its role in staging and therapeutic management. Despite these advances, much of the outcomes depend on proper patient selection. Complete removal of all post-chemotherapy residual masses remains the standard of care in the treatment of advanced nonseminomatous germ cell tumors both within and outside of the retroperitoneum.

Outcomes following active surveillance of men with localized prostate cancer diagnosed in the prostate specific antigen era.

PURPOSE: We gained insights concerning outcomes associated with men who elect active surveillance for the management of localized prostate cancer. MATERIALS AND METHODS: This is a retrospective case series analysis of 40 patients diagnosed with localized prostate cancer since 1990 who elected active surveillance. RESULTS: A total of 31 patients remained on active surveillance for a median of 48 months (range 12 to 168). The 5-year probability of remaining on active surveillance was 74%. Most patients who abandoned this strategy did so within 33 months of diagnosis (range 12 to 84). An increasing prostate specific antigen and anxiety were the 2 most common reasons. A delay in treatment did not appear to compromise subsequent outcomes. CONCLUSIONS: Men with low grade prostate cancer can elect active surveillance and have excellent long-term results.

Minimally invasive therapy for benign prostatic hyperplasia: practice patterns in Minnesota.

BACKGROUND AND PURPOSE: Benign prostatic hyperplasia (BPH) affects more than 50% of men by the age of 60 and 90% by age 85. Many of these men are not candidates for surgical procedures such as transurethral resection of the prostate (TURP), stimulating the development of less-invasive forms of therapy. We studied the utilization of these newer therapies by urologists practicing in Minnesota. MATERIALS AND METHODS: An anonymous questionnaire was sent to 174 members of the Minnesota Urological Society, of which 58 were available for analysis. A case scenario was presented of a patient with BPH refractory to medical therapy. The options were traditional and minimally invasive therapies. The physician was asked to select whether he or she would offer each option and perform the procedure or refer the patient within or outside the practice. Statistical analysis was performed using chi-square and two-sample t-tests on Minitab software. The results were considered significant at P < 0.05. RESULTS: While 59% of the respondents would offer both minimally invasive and traditional alternatives, 10% would offer only minimally invasive therapy, while 29% would offer only traditional therapy (P = 0.01). The most common minimally invasive therapies offered were transurethral microwave thermotherapy and (55%) and transurethral needle ablation (33%). If they offered a form of minimally invasive therapy, the majority of respondents would perform the procedure themselves. Rural urologists were less likely to offer minimally invasive therapy (43%) than metro physicians (81%; P = 0.035). There was no significant difference in the use of minimally invasive therapies by rural and urban urologists (P = 0.409) or urban and metropolitan urologists (P = 0.119). Urologists completing their training between 1960 and 1980 were less likely to offer minimally invasive therapy. There was no significant difference in the likelihood of offering traditional versus minimally invasive alternatives according to the percent of managed care in the practice. CONCLUSIONS: Urologists closer to the completion of their residency training are more likely to include a minimally invasive technique in their treatment plan, while urologists practicing in rural Minnesota are less likely to offer minimally invasive procedures. Further emphasis should be placed on increasing the availability of minimally invasive techniques in rural settings.

Contemporary management of ureteropelvic junction obstruction: practice patterns in Minnesota.

BACKGROUND AND PURPOSE: Ureteropelvic junction (UPJ) obstruction can be addressed surgically by an open, laparoscopic, endoscopic, or fluoroscopic procedure. Our objective was to establish what surgical alternatives are currently offered by urologists in Minnesota. MATERIALS AND METHODS: A questionnaire was sent to 174 members of the Minnesota Urological Society. Practice settings were characterized as rural, urban, or metropolitan on the basis of the ZIP-code classifications of the Minnesota Ambulance Association and state geographic legislation. Respondents were asked to select initial treatment options for an adult patient with flank pain, decreased renal function, and hydronephrosis secondary to UPJ obstruction. RESULTS: Whereas 60% of the respondents would offer open pyeloplasty, only 12% would offer it as the only treatment option. The two most common minimally invasive therapies offered were the Acucise balloon (48%) and percutaneous antegrade endopyelotomy (48%). Rural urologists were more likely to offer Acucise balloon incision (71%) than were urban (28%; P=0.045) or metropolitan (55%; P=0.412) urologists. CONCLUSIONS: The majority of urologists still offer open pyeloplasty as first-line therapy for UPJ obstruction. Further emphasis should be placed on increasing the availability of endoscopic and laparoscopic procedures.

Nephrolithiasis: "scope," shock or scalpel?

PURPOSE: To evaluate treatment preferences for complex urinary calculi. MATERIALS AND METHODS: A questionnaire was sent to 174 members of the Minnesota Urological Society. Three case scenarios were presented: a 1.5-cm lower-pole calculus with unfavorable anatomy, a 1.4-cm proximalureteral calculus, and a staghorn calculus. The treatment options offered were extracorporeal shockwave lithotripsy (SWL), ureteral stenting, ureteroscopy (URS), percutaneous nephrolithotomy (PCNL), and open surgery. RESULTS: Our survey response rate was 49%. A PCNL for staghorn calculi was more likely to be offered by urologists in metropolitan (100%; P<0.001) and urban (100%; P=0.003) settings than rural settings (57%). Whereas only 22% of urban and metropolitan urologists would offer anatrophic nephrolithotomy, 43% of rural urologists would include this among their treatment options. A PCNL was more likely to be offered by urologists trained after 1980 (100%) than by urologists trained before 1980 (81%; P=0.004). For a large lower-pole calculus with unfavorable anatomy, urologists with >50% managed-care practices were more likely (91%) than urologists with <50% managed-care practices (65%) to select PCNL for such stones (P=0.034). Whereas 82% of metropolitan urologists would select PCNL, 43% of rural urologists would consider SWL as initial therapy. A URS was more likely to be offered by urologists trained after 1980 (16%) than by urologists trained before 1980 (0; P=0.044). For a large proximal-ureteral calculus, metropolitan urologists were most likely (64%) to use stents initially (urban 28%; P=0.014; rural 14%; P=0.017). Rural urologists were more likely to offer SWL (100%) than were metro urologists (55%; P=0.024). CONCLUSIONS: Initial therapy for nephrolithiasis differs significantly according to geographic location, year of residency completion, and the percentage of managed-care patients in a urologist's practice. Future emphasis should be placed on increasing the availability of endoscopic techniques in rural settings.

Is there a role for small-diameter ureteral access sheaths? Impact on irrigant flow and intrapelvic pressures.

OBJECTIVES: To evaluate irrigant flows and intrapelvic pressures with small-diameter access sheaths. Ureteral access sheaths improve irrigant flow and decrease intrarenal pelvic pressures during flexible ureteroscopy. However, no comparisons of individual sheaths have been conducted. Previous studies have demonstrated more favorable results with the 12F sheath than with the 10F sheath. METHODS: Ureteral access sheaths were tested ex vivo in porcine kidneys. An 18F angiocatheter was placed in the renal pelvis and connected to a Hewlett Packard Gauss Pressure transducer. Irrigant was maintained at 100 mm Hg pressure. Irrigant flow and intrapelvic pressures were measured with three flexible ureteroscopes at baseline and using each of four 10F sheaths, with the sheaths positioned in the middle ureter and the ureteroscopes positioned in the renal pelvis. The pressure at which irrigant efflux through the sheath occurred and the rate of irrigant efflux through the access sheath were measured. RESULTS: Intrapelvic pressures measured greater than 40 mm Hg, and irrigant flows remained at less than 15 mL/min when the Olympus URF-P3 and Storz 11274AAU flexible ureteroscopes were tested with all four sheaths. The intrapelvic pressures, irrigant inflow, and irrigant efflux with the Wolf 7325.172 (7.5F) flexible ureteroscope were optimized in combination with the Cook Peelaway 10F and Applied Access 10F sheaths. CONCLUSIONS: Small ureteral access sheaths should be used only with the Wolf 7325.172 flexible ureteroscope. The Cook Peelaway (10F) and Applied Access (10F) sheaths offered the greatest increase in irrigant flow and decrease in intrapelvic pressures.

Minimally invasive therapy for renal cell carcinoma: is there a new community standard?

OBJECTIVES: To evaluate current practice use of laparoscopic and minimally invasive therapies in the treatment of renal cell cancer. METHODS: A questionnaire was sent to 174 members of the Minnesota Urological Society. The first case scenario described a 6-cm lesion not amenable to nephron-sparing surgery. The second case scenario described a 3-cm lower pole exophytic mass amenable to nephron-sparing surgery. The treatment options included traditional therapy (open partial or radical nephrectomy) and minimally invasive therapy (laparoscopic radical or partial nephrectomy or renal cryoablation). RESULTS: Our survey response rate was 49%. For the first scenario, 86% of respondents would offer open radical nephrectomy; however, 57% would offer laparoscopic surgery. Of those urologists offering laparoscopic surgery, 14% would refer outside their practice and 43% would use a hand-assisted approach. Sixty-four percent of the metropolitan and 56% of the urban respondents would offer a form of minimally invasive therapy; only 29% of rural respondents offered these options. For the second scenario, 90% of respondents would offer open partial nephrectomy and 45% a minimally invasive therapy; however, 24% of these would refer outside their practice. Thirty-eight percent of respondents would offer laparoscopic partial nephrectomy and 22% of respondents would offer renal cryoablation. Urologists completing residency after 1990 were more likely to offer a minimally invasive option (65%) compared with urologists completing residency before 1990 (31%). CONCLUSIONS: Minimally invasive therapy for renal cell cancer is evolving into a community standard of care, with urologists relying heavily on outside referrals to access minimally invasive alternatives. Younger urologists living in metropolitan and urban areas are more likely to offer minimally invasive therapy. Additional emphasis should be placed on increasing the availability of minimally invasive techniques in rural settings.