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INTRODUCTION AND OBJECTIVE:Prognosis for metastatic RCC (mRCC) is variable. Aberrant HIF signaling is associated with progression of RCC. Using primary tumor tissue from Cancer and Leukemia Group B...

The accumulation of data through a prospective, multicenter coordinated registry network is a practical way to gather real world evidence on the performance of novel prostate ablation technologies. Urological oncologists, targeted biopsy experts, industry representatives and representatives of the FDA (Food and Drug Administration) convened to discuss the role, feasibility and important data elements of a coordinated registry network to assess new and existing prostate ablation technologies.A multiround Delphi consensus approach was performed which included the opinion of 15 expert urologists, representatives of the FDA and leadership from high intensity focused ultrasound device manufacturers. Stakeholders provided input in 3 consecutive rounds with conference calls following each round to obtain consensus on remaining items. Participants agreed that these elements initially developed for high intensity focused ultrasound are compatible with other prostate ablation technologies. Coordinated registry network elements were reviewed and supplemented with data elements from the FDA common study metrics.The working group reached consensus on capturing specific patient demographics, treatment details, oncologic outcomes, functional outcomes and complications. Validated health related quality of life questionnaires were selected to capture patient reported outcomes, including the IIEF-5 (International Index of Erectile Function-5), the I-PSS (International Prostate Symptom Score), the EPIC-26 (Expanded Prostate Cancer Index Composite-26) and the MSHQ-EjD (Male Sexual Health Questionnaire for Ejaculatory Dysfunction). Group consensus was to obtain followup multiparametric magnetic resonance imaging and prostate biopsy approximately 12 months after ablation with additional imaging or biopsy performed as clinically indicated.A national prostate ablation coordinated registry network brings forth vital practice pattern and outcomes data for this emerging treatment paradigm in the United States. Our multiple stakeholder consensus identifies critical elements to evaluate new and existing energy modalities and devices.

The natural history of renal cell carcinoma (RCC) is complex and not entirely explained by conventional prognostic factors. In this study we evaluated the prognostic value of carbonic anhydrase IX (CAIX) and Ki67 to predict survival in RCC.Immunohistochemical analysis using a CAIX and a Ki67 monoclonal antibody was performed on tissue microarrays constructed from paraffin embedded specimens from 224 patients treated with nephrectomy for clear cell renal carcinoma. CAIX and Ki67 staining were correlated with clinical factors, pathological features and survival. Median followup was 34 months (range 0.3 to 117) and disease specific survival was the primary end point assessed.Univariate statistical analysis showed that high Ki67 staining and low CAIX staining correlated significantly with poor median survival (21 months, p0.001 and 22 months, p = 0.011, respectively). Each marker was highly significant for stratifying patient groups defined by T stage, Fuhrman grade, nodal status, metastatic status and performance status. On multivariate analysis CAIX and Ki67 were significant predictors of survival with an HR of 1.78 (p = 0.014) and 1.75 (p = 0.009), respectively. Although CAIX and Ki67 staining were inversely correlated (p = 0.009), Ki67 significantly substratified patient subgroups defined by high or low CAIX staining (p = 0.001 and 0.003, respectively). When Ki67 and CAIX were combined into a single parameter, RCC tumors could be stratified into low, intermediate and high risk groups with a median survival of greater than 101, 31 and 9 months, respectively (p0.001). On multivariate analysis the combined parameter consisting of Ki67 and CAIX was a significant predictor of survival (p0.001) and it was able to displace histological grade.Ki67and CAIX are useful prognostic biomarkers for RCC that improve the survival prediction and classification of kidney cancer.

Although cachexia is a common sequela of advanced and metastatic renal cell carcinoma (RCC), cachexia-like symptoms may also represent a paraneoplastic finding. We assessed the prognostic significance of these symptoms in patients with stage T1 RCC.Using the kidney cancer database at our institution 250 patients were identified who underwent partial or radical nephrectomy for T1N0M0 RCC between 1989 and 2001. The prognostic significance of the symptoms present at diagnosis and findings on preoperative laboratory evaluation were examined.Mean and median followup was 33 and 43 months, respectively. Malaise, weight loss, anorexia and hypoalbuminemia were cachexia related findings that were significant predictors of worse disease specific survival (DSS). DSS in patients with 1 vs greater than 1 cachexia related symptoms was not significantly different (p = 0.077). Therefore, any patient with at least 1 cachexia related finding was considered to be positive for cachexia and cachexia occurred in 37 (14.8%). Cachexia was associated with significantly worse recurrence-free survival (HR 3.03, p = 0.032) and DSS (HR 4.39, p = 0.011) even after controlling for tumor size, grade and performance status. The 5-year survival rate in patients with low grade (1 or 2) tumors with and without cachexia was 91% and 81%, respectively. The 5-year survival rate in patients with high grade (3 or 4) tumors with and without cachexia was 75% and 55%, respectively.Cachexia-like symptoms independently predict a worse prognosis in patients with T1 RCC. Patients with cachexia (malaise, weight loss, anorexia and hypoalbuminemia), especially when associated with high grade tumors, should be considered for clinical trials of adjuvant therapies.

The prognostic significance of the level of venous involvement in renal cell carcinoma (RCC) is controversial. It has been suggested that the 1997 TNM classification of venous involvement system should be revised.The records of 226 patients who underwent a nephrectomy and tumor thrombectomy, 117 for renal vein (RV) and 109 for inferior vena cava (IVC) involvement, between 1989 and 2001 were reviewed and compared to those of 654 patients undergoing nephrectomy without venous involvement.In patients with localized RCC (N0M0), the risk of recurrence after nephrectomy was significantly increased in patients with venous thrombus compared to patients without venous thrombus (p = 0.005). However, the difference was not significant in a multivariate analysis including T stage (1, 2, 3 or 4), Fuhrman grade and Eastern Cooperative Oncology Group performance status. In patients with localized RCC disease specific survival was similar (p = 0.536) in patients with RV (T3b) and IVC involvement below the diaphragm (T3b). However, patients with IVC involvement above the diaphragm (T3c) had a significantly worse survival rate even after controlling for Fuhrman grade and Eastern Cooperative Oncology Group performance status in a multivariate analysis (p = 0.020). All patients treated for metastatic RCC had a similar prognosis regardless of the level of venous involvement.For patients with pT3b disease, local tumor stage and grade are better predictors of prognosis than extent of venous involvement. Based on our data we support the current TNM classification of venous involvement with RV and IVC invasion categorized as T3b and IVC involvement above the diaphragm categorized as T3c.

Item does not contain fulltext PURPOSE: Outcome prediction for patients with renal cell carcinoma is based on a combination of factors. In this study a previously published clinical outcome algorithm based on 1997 T stage, Fuhrman grade and performance score is validated using an international database. MATERIALS AND METHODS: A total of 1,060 patients from Nijmegen, the Netherlands (NN), MD Anderson (MDA) and University of California, Los Angeles (UCLA) who had localized renal cell carcinoma were evaluated for outcome prediction using a clinical outcome algorithm previously shown to stratify patients into low, intermediate and high risk groups. Validation was performed by comparing the 3 risk groups separately within the 3 centers as well as by comparing hazard ratios and concordance indices among the 3 centers. RESULTS: Estimated disease specific survival rates at 5 years for the low risk groups were 94% (NN), 92% (MDA) and 93% (UCLA). The 5-year disease specific survival rates for the intermediate risk groups were 65% (NN), 73% (MDA) and 78% (UCLA), while the rates for the high risk groups were 40% (NN), 30% (MDA) and 48% (UCLA). The concordance indices for each of the databases were 79% (NN), 86% (MDA) and 84% (UCLA). CONCLUSIONS: A clinical algorithm that uses only 3 prognostic variables (1997 T stage, Fuhrman grade and performance status) to stratify patients with localized renal cell carcinoma into 3 risk groups has been shown to be applicable to external databases. This algorithm may be useful for patient counseling, surveillance and identification of high risk patients for enrollment in clinical trials.

Purpose: Cryosurgical ablation of the prostate is 1 approach to the treatment of localized prostate cancer. Third generation cryosurgery uses gas driven probes that allow for a decrease in probe diameter to 17 gauge (1.5 mm). The safety, morbidity and preliminary prostate specific antigen (PSA) results of 122 cases are reported.Materials and Methods: A total of 106 patients have undergone percutaneous cryosurgery using a brachytherapy template with at least 12 months of PSA followup. Immediate and delayed morbidities were evaluated. PSA results at 3 and 12 months were recorded, and failure was defined as the inability to reach a nadir of 0.4 ng/ml or less.Results: Complications in patients undergoing primary cryosurgery included tissue sloughing (5%), incontinence (pads, 3%), urge incontinence/no pads (5%), transient urinary retention (3.3%) and rectal discomfort (2.6%). There were no cases of fistulas or infections. Postoperative impotence was 87% in previously potent patients. For patients who u...

Bladder preserving strategies for muscle invasive bladder cancer have evolved from single modality to multimodality treatment approaches with improved results.We review the rationale for a multimodality approach to treat invasive bladder cancer and the results of some recent multimodality bladder sparing treatments. In addition, we compare this approach to radical cystectomy.Multimodality bladder sparing treatment involves combined transurethral bladder resection, external beam radiation with concurrent radiosensitizers and cisplatin based chemotherapy. With this approach overall 5-year survival is 48% to 63% and overall 5-year survival with the bladder intact is 36% to 43%. Survival with this approach is comparable to that in series of patients treated with primary radical cystectomy. The primary impetus for a multimodality bladder sparing approach is the improved quality of life associated with retaining the native bladder. However, the multimodality bladder sparing approach involves a complex treatment schedule associated with significant morbidity and mortality. Cystectomy is eventually required after attempted bladder preservation in 34% to 45% of cases and the rate of superficial recurrence is approximately 28%.Multimodality bladder sparing treatment is a viable option at centers with a dedicated multidisciplinary team. However, primary radical surgery remains the standard of care for invasive bladder cancer.

Purpose: Patients who have extensive stricture disease, those in whom hypospadias repair fails and those who sustain significant urethral trauma pose a reconstructive challenge for genitourinary surgeons. We developed an additional reconstructive option for men with a severely diseased urethra when grafting procedures and local tissue flaps have failed or are otherwise contraindicated.Materials and Methods: A genitourinary reconstructive team performed novel intestinal free flap substitution urethroplasty in 2 patients. A segment of jejunum is harvested on a vascular pedicle and plicated into an appropriate size urethral substitute. Microvascular anastomoses allow this segment to remain viable and functional. The technical aspects of repair and surgical considerations are detailed.Results: The 2 patients have a satisfactory functional and cosmetic outcome. At short followup the urethral lumen remained patent and the intestinal urethra remained viable and intact. Both patients have good urinary streams and...

INTRODUCTION AND OBJECTIVES: Associations of the diffusion of laparoscopic partial nephrectomy with patient safety remain uncharacterized. We compared the frequency of adverse patient safety events occurring in laparoscopic versus open partial nephrectomy over a 10-year period. METHODS: We utilized the Nationwide Inpatient Sample (NIS), a 20% sample of inpatient discharges in the U.S., from 1998 to 2008. All raw data was weighted to produce national estimates. We identified discharges with a principal diagnosis of kidney surgery by ICD-9CM codes. The primary outcome was occurrence of any Patient Safety Indicator (PSIs validated measures developed by the Agency for Healthcare Research and Quality to describe adverse outcomes related to patient safety. We used multivariate logistic regression to compare PSIs occurring in laparoscopic and open partial nephrectomy. RESULTS: The prevalence of both open and laparoscopic partial nephrectomy increased steadily during the study period (Figure 1). Compared to open, patients undergoing laparoscopic partial nephrectomy had lower Charlson Index morbidity scores (p 0.001) and were more likely to undergo surgery at urban (p 0.001) and teaching (p 0.001) hospitals. Among the 62,853 open partial nephrectomies and 5,828 laparoscopic partial nephrectomies performed, PSIs occurred in 4,084 (6.5%) and 270 (4.6%) (p 0.019) cases, respectively. On multivariate analysis, there were no significant differences in the probability of at least one PSI between open and laparoscopic partial nephrectomy [Odds Ratio (OR) 0.778, 95% CI 0.579–1.046, p 0.096)]. The probability of any PSI was 38% higher for Charlson 3 compared to 3 (OR 1.38, 95% CI 1.2 to 1.6, p 0.001). CONCLUSIONS: Laparoscopic and open partial nephrectomy demonstrated similar risks of adverse patient safety events as defined by PSIs. These data suggest that, as it has diffused into clinical practice, laparoscopy has remained a relatively safe technique for performing partial nephrectomy.

850 INTERNATIONAL ROBOT-ASSISTED CYSTECTOMY CONSORTIUM (IRCC): IMMEDIATE ONCOLOGIC RESULTS AFTER ONE HUNDRED AND SIXTY TWO CASES Khurshid A Guru*, Raj S Pruthi, Zubair M Butt, Eric Wallen, Fred Muhletaler, James L Mohler, Hans Stricker, Hyung L Kim, Peter N Wiklund, James O Peabody, Mani Menon. Buffalo, NY, Chapel Hill, NC, Detroit, MI, and Stockholm, Sweden.. INTRODUCTION AND OBJECTIVE: Radical cystectomy