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Purpose: The American Joint Committee on Cancer recognizes 6 rare histological variants of prostate adenocarcinoma. We describe the contemporary presentation and overall survival of these rare variants., Materials and Methods: We examined 1,345,618 patients who were diagnosed with prostate adenocarcinoma between 2004 and 2015 within the National Cancer Database. We focused on the variants mucinous, ductal, signet ring cell, adenosquamous, sarcomatoid and neuroendocrine. Characteristics at presentation for each variant were compared with nonvariant prostate adenocarcinoma. Cox regression was used to study the impact of histological variant on overall mortality., Results: Few (0.38%) patients presented with rare variant prostate adenocarcinoma. All variants had higher clinical tumor stage at presentation than nonvariant (all p <0.001). Metastatic disease was most common with neuroendocrine (62.9%), followed by sarcomatoid (33.3%), adenosquamous (31.1%), signet ring cell (10.3%) and ductal (9.8%), compared to 4.2% in nonvariant (all p <0.001). Metastatic disease in mucinous (3.3%) was similar to nonvariant (p=0.2). Estimated 10-year overall survival was highest in mucinous (78.0%), followed by nonvariant (71.1%), signet ring cell (56.8%), ductal (56.3%), adenosquamous (20.5%), sarcomatoid (14.6%) and neuroendocrine (9.1%). At multivariable analysis, mortality was higher in ductal (HR 1.38, p <0.001), signet ring cell (HR 1.53, p <0.01), neuroendocrine (HR 5.72, p <0.001), sarcomatoid (HR 5.81, p <0.001) and adenosquamous (HR 9.34, p <0.001) as compared to nonvariant., Conclusions: Neuroendocrine, adenosquamous, sarcomatoid, signet ring cell and ductal variants more commonly present with metastases. All variants present with higher local stage than nonvariant. Neuroendocrine is associated with the worst and mucinous with the best overall survival.

Purpose: This study aimed to provide an update and compare perioperative outcomes and complications of intracorporeal and extracorporeal urinary diversion following robot-assisted radical cystectomy using data from the multi-institutional, prospectively maintained International Robotic Cystectomy Consortium database., Materials and Methods: We retrospectively reviewed the records of 2,125 patients from a total of 26 institutions. Intracorporeal urinary diversion was compared with extracorporeal urinary diversion. Multivariate logistic regression models using stepwise variable selection were fit to evaluate preoperative, operative and postoperative predictors of intracorporeal urinary diversion, operative time, high grade complications and 90-day hospital readmissions after robot-assisted radical cystectomy., Results: In our cohort 1,094 patients (51%) underwent intracorporeal urinary diversion. These patients demonstrated shorter operative time (357 vs 400 minutes), less blood loss (300 vs 350 ml) and fewer blood transfusions (4% vs 19%, all p <0.001). They experienced more high grade complications (13% vs 10%, p = 0.02). Intracorporeal urinary diversion use increased from 9% of all urinary diversions in 2005 to 97% in 2015. Complications after this procedure decreased significantly with time (p <0.001). On multivariable analysis higher annual cystectomy volume (OR 1.02, 95% CI 1.01-1.03, p <0.002), year of robot-assisted radical cystectomy (2013-2016 OR 68, 95% CI 44-105, p <0.001) and American Society of Anesthesiologists® score less than 3 (OR 1.75, 95% CI 1.38-2.22, p <0.001) were associated with undergoing intracorporeal urinary diversion. The procedure was associated with a shorter operative time of 27 minutes (p = 0.001)., Conclusions: The use of intracorporeal urinary diversion has increased in the last decade. A higher annual institutional volume of robot-assisted radical cystectomy was associated with intracorporeal urinary diversion as well as with shorter operative time. Although intracorporeal urinary diversion was associated with higher grade complications than extracorporeal urinary diversion, they decreased with time., (Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We sought to investigate the prevalence and variables associated with early oncologic failure., Materials and Methods: We retrospectively reviewed the IRCC (International Radical Cystectomy Consortium) database of patients who underwent robot-assisted radical cystectomy since 2003. The final cohort comprised a total of 1,894 patients from 23 institutions in 11 countries. Early oncologic failure was defined as any disease relapse within 3 months of robot-assisted radical cystectomy. All institutions were surveyed for the pneumoperitoneum pressure used, breach of oncologic surgical principles, and techniques of specimen and lymph node removal. A multivariate model was fit to evaluate predictors of early oncologic failure. The Kaplan-Meier method was applied to depict disease specific and overall survival, and Cox proportional regression analysis was used to evaluate predictors of disease specific and overall survival., Results: A total of 305 patients (22%) experienced disease relapse, which was distant in 220 (16%), local recurrence in 154 (11%), peritoneal carcinomatosis in 17 (1%) and port site recurrence in 5 (0.4%). Early oncologic failure developed in 71 patients (5%) at a total of 10 institutions. The incidence of early oncologic failure decreased from 10% in 2006 to 6% in 2015. On multivariate analysis the presence of any complication (OR 2.87, 95% CI 1.38-5.96, p = 0.004), pT3 or greater disease (OR 3.73, 95% CI 2.00-6.97, p <0.001) and nodal involvement (OR 2.14, 95% CI 1.21-3.80, p = 0.008) was a significant predictor of early oncologic failure. Patients with early oncologic failure demonstrated worse disease specific and overall survival (23% and 13%, respectively) at 1 and 3 years compared to patients who experienced later or no recurrences (log rank p <0.001)., Conclusions: The incidence of early oncologic failure following robot-assisted radical cystectomy has decreased with time. Disease related rather than technical related factors have a major role in early oncologic failure after robot-assisted radical cystectomy., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Bladder dysfunction influences recovery of urinary continence after radical prostatectomy. We performed a multicenter, randomized, double-blind study evaluating solifenacin vs placebo on return to continence in patients who were still incontinent 7 to 21 days after catheter removal after robot-assisted radical prostatectomy., Materials and Methods: A wireless personal digital assistant was given to patients the day of catheter removal. Encrypted answers were transmitted daily to dedicated servers. After a 7 to 21-day treatment-free washout period, patients requiring 2 to 10 pads per day for 7 consecutive days were randomized (1:1) to 5 mg solifenacin daily or placebo. The primary end point was time from first dose to continence defined as 0 pads per day or a dry security pad for 3 consecutive days. Secondary end points included proportion of patients continent at end of study, average change in pads per day number and quality of life assessments., Results: A total of 1,086 screened patients recorded personal digital assistant information. Overall 640 patients were randomized to solifenacin vs placebo and 17 failed to take medication. There was no difference in time to continence (p=0.17). Continence was achieved by study end in 91 of 313 (29%) vs 66 of 309 (21%), respectively (p=0.04). Pads per day change from baseline was -3.2 and -2.9, respectively (p=0.03). Dry mouth was the only common adverse event seen in 6.1% and 0.6%, respectively. Constipation rates were similar. The overall rate of continence in the entire population from screening to end of study was 73%., Conclusions: There was no effect on primary outcome but some secondary end points benefited the solifenacin arm. The study provides level 1B clinical evidence for continence outcomes after robot-assisted radical prostatectomy., (Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Using the Nationwide Emergency Department Sample (NEDS) we examined trends in visits, hospitalization and charges for patients with upper urinary tract stones who presented to the emergency department in the United States., Materials and Methods: All visits with a primary diagnosis of kidney calculus (ICD-9-CM code 592.0), ureter calculus (592.1) or urinary calculus unspecified (592.9) were extracted from NEDS between 2006 and 2009. A weighted sample was used to calculate incidence rates. Temporal trends were quantified by the estimated annual percent change. Patient and hospital characteristics associated with hospitalization were evaluated using logistic regression models adjusted for clustering., Results: Between 2006 and 2009 there were 3,635,054 emergency department visits for upper urinary tract stones. The incidence increased from 289 to 306/100,000 individuals. More men visited than women but women showed significant increases in visits (estimated annual percent change 2.85%, p = 0.018). Total monthly emergency department visits ranged from 5.8% in February to 8.4% in August. Overall 12.0% of patients were hospitalized and the hospitalization rate remained stable (estimated annual percent change -1.02%, p = 0.634). Patients were more likely to be hospitalized if they were female, more ill, seen at an urban teaching or low volume hospital, or had Medicaid or Medicare (each p <0.001). Sepsis was associated with the highest likelihood of hospital admission (OR 69.64, p <0.001). In 2009 charges for emergency department visits increased to $5 billion (estimated annual percent change 10.06%, p = 0.003)., Conclusions: Women showed significant annual increases in emergency department visits for upper urinary tract stones. While emergency department charges increased substantially, hospitalization rates remained stable. Greater use of computerized tomography and medical expulsive therapy could be the reasons for this observation, which warrants further study., (Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We investigated recent trends in the use and perioperative outcomes of percutaneous nephrolithotomy in the United States in a population based cohort., Materials and Methods: We obtained the records of patients treated with percutaneous nephrolithotomy between 1999 and 2009 from the Nationwide Inpatient Sample (NIS). A weighted sample was used to estimate national utilization rates. Trends in age, comorbidity, perioperative complications and in-hospital mortality were analyzed. Temporal trends were quantified by the estimated annual percent change. We evaluated the association between patient and hospital characteristics, including complications, prolonged length of stay and in-hospital mortality, using logistic regression models adjusted for clustering., Results: During 1999 to 2009, percutaneous nephrolithotomy use increased in men and women from 3.0/100,000 and 2.99/100,000 to 3.63/100,000 and 4.07/100,000, respectively. Women showed the largest increases in percutaneous nephrolithotomy use with an estimated annual percent change of 4.49% (95% CI 2.7-6.3, p <0.001) vs 2.90% (95% CI 1.5-4.3, p = 0.003) in men. Baseline comorbidity in patients undergoing percutaneous nephrolithotomy increased with time. Overall complications increased from 12.2% to 15.6% (p <0.001), while mortality remained stable at 0.0% to 0.4%. The transfusion rate was 4.0%. Sepsis increased from 1.2% to 2.4% of cases (p <0.001). Patients were at risk for complications if they were older, more ill and treated in more recent years. Age was significantly associated with increased odds of mortality., Conclusions: Percutaneous nephrolithotomy use in the United States has increased and females are now the majority gender. Although mortality remains low, rates of sepsis and overall complications have increased. Broad use of percutaneous nephrolithotomy, especially in older and more ill patients, may account for these changes., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: The use of robot-assisted radical prostatectomy has increased rapidly despite the absence of randomized, controlled trials showing the superiority of this approach. While recent studies suggest an advantage for perioperative complication rates, they fail to account for the volume-outcome relationship. We compared perioperative outcomes after robot-assisted and open radical prostatectomy, while considering the impact of this established relationship., Materials and Methods: Using the NIS (Nationwide Inpatient Sample), we abstracted data on patients treated with radical prostatectomy in 2009. Univariable and multivariable logistic regression analyses were done to compare the rates of blood transfusion, intraoperative and postoperative complications, prolonged length of stay, increased hospital charges and mortality between robot-assisted and open radical prostatectomy overall and across volume quartiles., Results: An estimated 77,616 men underwent radical prostatectomy, including a robot-assisted and an open procedure in 63.9% and 36.1%, respectively. Low volume centers averaged 26.2 robot-assisted and 5.2 open cases, while very high volume centers averaged 578.8 robot-assisted and 150.2 open cases. Overall, patients treated with the robot-assisted procedure experienced a lower rate of adverse outcomes than those treated with the open procedure for all measured categories. Across equivalent volume quartiles robot-assisted radical prostatectomy outcomes were generally favorable. However, the open procedure at high volume centers resulted in a lower postoperative complication rate (OR 0.59, 95% CI 0.46-0.75), elevated hospital charges (OR 0.75, 95% CI 0.64-0.87) and a comparable blood transfusion rate (OR 1.38, 95% CI 0.93-2.02) relative to the robot-assisted procedure at low volume centers., Conclusions: Regionalization has occurred to a greater extent for robot-assisted than for open radical prostatectomy with an associated benefit in overall outcomes. Nonetheless, low volume institutions experienced inferior outcomes relative to the highest volume centers irrespective of approach. These findings demonstrate the importance of accounting for hospital volume when examining the benefit of a surgical technique., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Minimally invasive pyeloplasty might have several advantages compared to open pyeloplasty in the management of ureteropelvic junction obstruction. Nonetheless, minimally invasive pyeloplasty appears to be underused in North America. We examined specific patient and hospital characteristics that may be associated with these disparities., Materials and Methods: The Nationwide Inpatient Sample was used to identify a national estimate of 29,456 patients with ureteropelvic junction obstruction treated with minimally invasive pyeloplasty (laparoscopic or robotic) and open pyeloplasty between 1998 and 2009. The rates of use of minimally invasive and open pyeloplasty were assessed according to year of surgery, and patient and hospital characteristics. The determinants of minimally invasive pyeloplasty were evaluated using logistic regression models adjusted for clustering., Results: Overall 15.3% of patients underwent minimally invasive pyeloplasty between 1998 and 2009. The use of minimally invasive pyeloplasty increased remarkably during the study period from 2.4% to 55.3%, a 23-fold increase. On multivariable logistic regression analysis African-American race (OR 0.584, p = 0.015) and other insurance status (including uninsured patients, OR 0.613, p = 0.013) were associated with a lower rate of minimally invasive pyeloplasty. Patients treated at teaching (OR 1.788, p = 0.003) and/or urban (OR 4.819, p <0.001) institutions were significantly more likely to undergo minimally invasive pyeloplasty., Conclusions: In the last decade there has been a dramatic increase in the use of minimally invasive pyeloplasty in the United States and in 2009 a slight majority underwent minimally invasive pyeloplasty. Nonetheless, treatment disparities exist. African-American patients with other insurance status (including those uninsured) treated at nonteaching, rural hospitals were less likely to undergo minimally invasive pyeloplasty. Efforts should be made to understand these treatment disparities and broaden the availability of minimally invasive pyeloplasty., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Discharge patterns, including rates of prolonged length of stay and transfer to a facility, were evaluated in the context of radical cystectomy., Materials and Methods: Within the Nationwide Inpatient Sample we focused on radical cystectomy performed between 1998 and 2007. Multivariable logistic regression analyses predicting the likelihood of prolonged length of stay or transfer to a facility were performed., Results: Overall 11,876 eligible radical cystectomy cases were identified. The rates of prolonged length of stay decreased from 59% in the early period (1998 to 2001) to 50% in the late period (2005 to 2007, p<0.001) while the rates of transfer to a facility remained stable (14%). On multivariable analyses adjusted for clustering, prolonged length of stay was more frequently recorded in patients from low annual caseload hospitals (OR 1.42, p<0.001), as well as in Medicaid and Medicare patients (OR 1.66 and 1.17, respectively, all p<0.01). Similarly rates of transfer to a facility were significantly higher for patients from low annual caseload hospitals (OR 1.81, p<0.001) and for those with Medicaid or Medicare (OR 2.18 and 1.54, respectively, all p<0.001), as well as for patients treated at nonacademic institutions (OR 1.31, p<0.001)., Conclusions: It is encouraging that the rates of prolonged length of stay have decreased while the rates of transfer to a facility remained stable. However, it is worrisome that individuals treated at low annual caseload centers as well as those with Medicare and Medicaid insurance experience less favorable discharge patterns., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Radical prostatectomy outcomes may be better at academic institutions than at nonacademic centers. We examined the effect of academic status on 5 short-term radical prostatectomy outcomes., Materials and Methods: In the Health Care Utilization Project Nationwide Inpatient Sample we focused on radical prostatectomy performed within the 7 most contemporary years (2001 to 2007). We tested the rates of homologous blood transfusions and extended length of stay, as well as intraoperative and postoperative complications stratified according to institutional academic status. Multivariable logistic regression analyses further adjusted for confounding variables., Results: Overall 89,965 radical prostatectomies were identified, yielding a weighted national estimate of 442,811. Of those procedures 58.2% were recorded at academic institutions. Patients at academic institutions had a lower Charlson comorbidity index and more frequently had private insurance (p <0.001). Radical prostatectomy at academic institutions was associated with fewer blood transfusions (5.4% vs 7.4%), fewer postoperative complications (10.1% vs 12.9%) and lower rates of hospital stay above the median (18.0% vs 28.2%). On multivariable analyses institutional academic status exerted a protective effect on postoperative complication rates (OR 0.93, p = 0.02) and on rates of hospital stay in excess of the median (OR 0.91, p <0.001). Similarly radical prostatectomy performed at hospitals with a high annual caseload were less frequently associated with intraoperative (OR 0.8, p = 0.01) and postoperative (OR 0.63, p <0.001) complications, length of stay beyond the median (OR 0.19, p <0.001) and homologous blood transfusions (OR 0.35, p <0.001)., Conclusions: Even after adjusting for annual hospital caseload, radical prostatectomy performed at academic institutions is associated with better outcomes than radical prostatectomy performed at nonacademic institutions. This relationship illustrates averages and does not imply that academic institutions invariably offer better care., (Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Studies have suggested that statin (3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitors) medication use may decrease prostate specific antigen in healthy men. We determined the effect of preoperative statin use on total preoperative prostate specific antigen and the risk of biochemical recurrence in patients with prostate cancer presenting for radical prostatectomy., Materials and Methods: A retrospective review of 3,828 patients undergoing radical prostatectomy from January 2001 to July 2008 at our institution identified 1,031 on statin medications. We compared these 1,031 patients to the remaining 2,797 not on statins preoperatively. We evaluated differences in prostate specific antigen overall, and when patients were stratified by age specific groups, body mass index and Gleason grades on final pathology. We also investigated differences in biochemical recurrence rates., Results: Overall median serum prostate specific antigen was lower in patients on preoperative statins (5.0 vs 5.2 ng/ml, p = 0.002). Median prostate specific antigen was lower in men on statins with Gleason grades 7 or 8/9 disease (p <0.05). Using a multivariate logistic regression model statin therapy was associated with a 4.7% decrease in prostate specific antigen (p <0.001). Statin therapy was not associated with an overall decreased risk of biochemical recurrence (p = 0.73) at a mean followup of 26 months., Conclusions: In this cohort of men presenting for radical prostatectomy serum prostate specific antigen is significantly lower in patients with prostate cancer on preoperative statins compared to those not taking these medications. Prospective studies are required to evaluate if this decrease in prostate specific antigen leads to later detection of prostate cancer or variations in oncological outcomes.

Purpose: Several case series have shown that reconstruction of the anterior or posterior periprostatic tissues facilitates early return of urinary continence after radical prostatectomy. We conducted a randomized clinical trial comparing early continence rates in patients undergoing urethrovesical anastomosis with or without periprostatic reconstruction., Materials and Methods: A total of 116 consecutive patients undergoing computer assisted (robotic) prostatectomy performed by 1 of 2 experienced surgeons were randomized to single (without periprostatic reconstruction) or double layer (with periprostatic tissue reconstruction) urethrovesical anastomosis. Urinary loss was measured by pad weight at 1, 2, 7 and 30 days after catheter removal. Patients and data gatherers were blinded to treatment allocation., Results: There were 57 patients randomized to the single and 59 to the double layer anastomosis group. All patients completed the study and followup. Using the conventional definition of urinary continence (0 to 1 pads daily) 26% and 34%, 49% and 46%, 51% and 54%, and 74% and 80% of patients undergoing single layer or double layer anastomoses were continent at 1, 2, 7 and 30 days, respectively (p >0.1). Of the patients in the 2 groups 7% and 15%, 14% and 14%, 16% and 20%, and 47% and 42% had no urinary leakage (0 gm or 0 pads daily) at these intervals, respectively (p >0.1). In each group 1 patient required prolonged catheterization because of cystographic evidence of anastomotic leakage. There were no other complications., Conclusions: Early urinary continence rates were high in patients undergoing single or double layer urethrovesical anastomosis. We found no improvement in early continence rates with reconstruction of the periprostatic tissues.

Purpose: We assessed the incidence of and analyzed factors that contributed to perioperative complications in patients undergoing robotic radical prostatectomy, that is Vattikuti Institute prostatectomy (VIP), at our institution., Materials and Methods: We recorded operative and postoperative data on 300 consecutive patients who underwent VIP at our institution during a 1-year period. All operations were performed by 1 of 2 surgeons (MM or JOP). We reviewed the complications seen in these patients., Results: There was no operative mortality and no case was converted to open surgery. A total of 269 (89.7%) patients were considered to have an ideal postoperative course, ie they were discharged home within 48 hours with no unscheduled office visits or complications. There were 14 unscheduled postoperative visits (4.7%) for transient urinary retention after early catheter removal (13) or hematuria (1). There were 17 complications, of which 16 (5.3%) were related to surgery and 1 was related to anesthesia. A total of 11 complications (3.7%) were minor (grade I) and 5 (1.7%) were major (grade II). Of them 3 (1%) patients required reoperation. There were no grade III or IV complications., Conclusions: In our hands VIP is a safe operation with an overall complication rate of 5.3%, a major complication rate of less than 2% and a surgical re-intervention rate of 1%.

Purpose: The technique of laparoscopic radical prostatectomy is difficult to master and is associated with a steep learning curve. We hypothesized that a structured approach to establishing a laparoscopic prostatectomy program would diminish complications during the learning process and that robotic technology would be useful in learning the operation., Materials and Methods: A structured laparoscopic radical prostatectomy program was introduced at the Vattikuti Urology Institute on October 23, 2000. One of 2 surgeons with a combined experience of more than 500 laparoscopic radical prostatectomies performed or supervised the first prostatectomies, training a third surgeon with extensive "open" surgical skills but no laparoscopic experience. The "trained" surgeon then started performing the operation independently with robotic assistance. The results of this approach were analyzed at the end of 12 months., Results: We performed 48 laparoscopic radical prostatectomies and 50 robot assisted prostatectomies within the 12-month period. The preoperative and intraoperative demographical variables were comparable in both groups as were the operative times, changes in hemoglobin concentrations, durations of hospitalization, positive margin rates and overall complication rates. All measured parameters were comparable to the "best-in-class" values for laparoscopic radical prostatectomy reported in the literature., Conclusions: A structured approach minimizes complications during the establishment of laparoscopic radical prostatectomy program. Robotic assistance helps skilled "open" surgeons learn the technique of laparoscopic radical prostatectomy.

Purpose: The TNM classification of renal cell carcinoma was recently revised in 1997. The most significant change from the previous edition (1987) is an increase in the size cutoff between T1 and T2 tumors from 2.5 to 7.0 cm. We compared the 1997 and 1987 TNM staging classifications in predicting patient outcome., Materials and Methods: A total of 381 patients who underwent nephrectomy for renal cell carcinoma at our hospital between 1968 and 1994 were identified. Mean patient age was 61 years (range 15 to 89) and mean followup was 64.5 months. All pathological slides were re-reviewed in uniform manner and staged using the 1987 and 1997 TNM classifications. The impact of numerous pathological factors and each staging classification on disease specific survival and freedom from progression were statistically analyzed, and Kaplan-Meier survival curves were generated and compared., Results: The 1997 TNM classification resulted in a redistribution of 170 cases previously classified as stage II (T2N0M0) to stage I (T1N0M0) under the new system. Both classifications were strong predictors of survival on univariate and multivariate analyses, and essentially equivalent in the ability to predict patient outcome. However, comparison of survival curves on Kaplan-Meier life tables revealed better separation of survival for stage I (T1N0M0) and stage II (T2N0M0) cases under the 1997 TNM classification, with survival for TNM stage I essentially remaining unchanged., Conclusions: The 1997 TNM classification of renal cell carcinoma appears to be equivalent to the previous classification in predicting outcome but permits better stratification of cases according to survival and, therefore, may have improved clinical usefulness.

Purpose: We objectively compare the costs associated with the medical and surgical treatment of metastatic prostate cancer., Materials and Methods: We analyzed and compared itemized billing statements for 28 men with metastatic adenocarcinoma of the prostate. Half of the men were treated medically with the luteinizing hormone-releasing hormone analogue leuprolide, while the other half underwent bilateral therapeutic orchiectomy. In addition, differences in hospital cost to treat these men were calculated., Results: During a mean followup of 24 months leuprolide treated patients were charged $500.00 per month of treatment compared to average monthly expenditure of $226.00 for orchiectomy patients during a 23-month interval. By 9 months charges incurred by both groups were equal and by 20 months medically treated patients accumulated urological charges twice that of the surgically treated patients. The true hospital cost to treat these patients followed the same trend, that is the medically treated group cost twice as much to treat by 15 months. For the average stage D2 case leuprolide therapy charges were $9,420, or 63%, more than orchiectomy. Similarly, leuprolide cost the hospital $8,924 more than surgery., Conclusions: Medical management of metastatic prostate cancer is expensive. With broadening applications and androgen deprivation being initiated earlier in the course of disease, the amount spent on medical therapy will continue to escalate. For patients with a life expectancy of more than 9 months orchiectomy is the most cost-effective treatment option.

Purpose: To determine whether autocrine motility factor receptor (AMFR) is detectable in the urine of patients with transitional cell carcinoma (TCC) of the bladder., Materials and Methods: We assayed the urine of 89 patients with bladder pathology and 28 normal controls for AMFR. A monoclonal antibody to AMFR was used., Results: All patients with muscle-invasive TCC tested positive for AMFR. Autocrine motility factor receptor was detectable for 80% of superficial tumors, with a correlation between AMFR and tumor grade. Seventy-five percent of control urines tested negative., Conclusions: Autocrine motility factor receptor is detectable in the urine of patients with TCC. Long-term follow-up and refinements in the assay should define the marker's utility for detection and prognosis.