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To evaluate whether racial disparities in MRI-Bx usage persisted after correction for socioeconomic, demographic, and clinical factors.This is a retrospective cohort study of patients who received either MRI-Bx or systematic biopsy (SB) within a single academic medical center between January 2018 - June 2020. For each patient, socioeconomic variables including household income, education, percent below poverty, and unemployment were estimated using 2015 American Community Survey census-tract level data. Chi-square analysis was used to examine differences in clinical and demographic characteristics between the two groups. The Benjamini-Hochberg procedure was used to control false discovery rate (FDR) for multiple testing.Eighteen percent of Black men (53/295) received MRI-Bx while 41% (228/561) of white men received MRI-Bx. Patients coming from highly impoverished areas were less likely to receive MRI-Bx, 25% vs 75%, respectively. In multivariate analysis, race remained significantly different across MRI-Bx and SB groups. Clinical factors including family history, DRE, BMI, and prostate volume were not significantly different between patients receiving MRI-Bx and SB.Black men are less likely to receive MRI-Bx than white men, even after adjusting for clinical and socioeconomic characteristics. Further work is necessary to identify and study methods to increase equity in PCa diagnostic testing.

To study the effect of surgeon-administered Transversus Abdominis Plane block (sTAP) on opioid usage and length of stay (LOS).Starting in April 2018, two surgeons at our institution gradually introduced sTAP for radical cystectomy (RC) patients. We performed a retrospective observational cohort analysis of RC patients catalogued in a prospectively maintained database using the Enhanced Recovery After Surgery Interactive Auditing System. Two surgeons adopted the sTAP block technique in April 2018. We included patients undergoing RC for bladder malignancy under Enhanced Recovery After Surgery protocol between January 2017 and August 2020. Primary outcomes included LOS, and postoperative day (POD) 0-3 total opioids consumption measured by morphine milligram equivalents (MME). Multivariable linear or logistic models evaluated the association of TAP with outcomes while controlling for potential confounders.Among 178 patients included in analysis, 84 patients underwent sTAP block and 94 did not. Multivariable analysis demonstrated significantly lower POD 0-3 total opioid usage (106.4 vs 192.2 MME, P = .004), and mean LOS (5.6 vs 7.7 days, P.001) among the sTAP group.sTAP appears to be an effective adjunct to RC care associated with improved LOS, and POD 0-3 opioid consumption. Further studies are needed to optimize TAP block technique and anesthetic composition.

To determine the influence of socioeconomic parameters on urinary stone surgeries.A retrospective cohort study analyzed patients undergoing urolithiasis surgery in our community network hospital in North Carolina from 2005-2018.Of 7731 patients, 2160 (28%), 5,174 (67%), and 397 (5%) underwent SWL, URS, and PCNL, respectively. A higher proportion of Whites underwent URS (67%) and SWL (74%) than PCNL (56%); whereas a larger percentage of Blacks underwent PCNL (24%) than URS (20%) and SWL (15%) groups (P.001). Private insurance payers were greater in the SWL (95%) group than URS (80%) and PCNL (81%) (P.001). The distribution of median income was significantly different amongst the 3 surgeries with higher income classes overutilizing SWL and underutilizing PCNL compared to lower income classes (P.001). In linear regression modeling, the proportion of SWL in a postal code was positively associated with median income (ROur study suggests that socioeconomic status impacts urolithiasis surgical management, underscoring disparity recognition importance in endourologic care and ensuring appropriate surgical care regardless of socioeconomic status.

To elucidate regional trends of infectious complications following transrectal ultrasound prostate biopsy (TRUS-PB) from a national, privately-insured database.Using Market Scan, we identified all men who underwent TRUS-PB from 2010 to 2015. Infectious complications (UTI, prostatitis, sepsis) occurring 30 days after the prostate biopsy from emergency room (ER) visits or hospital admissions constituted the primary outcomes. We analyzed unadjusted and adjusted rates of infectious complications from ER visits and hospital admissions per 100 prostate biopsies by state. Multivariable logistic regression analyses were used to identify patient covariates associated with infectious complications.During the study interval, we identified 193,490 patients who underwent TRUS-PB. The mean age was 57.6 years (SD: 5.0). Over time the unadjusted national rates of infectious complications remained similar from 0.4 ER visits per 100 prostate biopsies in 2010 -0.2 in 2015 (P = 0.83), and 1.2 hospital admissions per 100 prostate biopsies in 2010 to 1.1 in 2015 (P= 0.58). Connecticut had the lowest unadjusted infectious complication rate per 100 biopsies at 0.64, whereas West Virginia had the highest at 2.34. Multivariable analysis revealed higher Elixhauser status and patient age were associated with higher odds of infectious complications (P0.05).While rates of infectious complications attributable to prostate biopsies remain relatively stable, significant variation exists at the state level regarding this adverse outcome.

Objective To measure differences in post-operative opioid usage and pain scores between pre- and post-Enhanced Recovery after Surgery (ERAS) radical cystectomy (RC) patients in an effort to optimize outcomes. Study design We performed a retrospective cohort study from a single institution from January 1, 2015 to July 31, 2018 among 86 and 108 pre- and post-ERAS RC patients. The primary endpoints were total mean opioid usage (morphine equivalent daily dosing or MEDD) and mean pain scores (Visual Analog Scale) on postoperative days (POD) 1-3. Secondary endpoints were number of opioid pills prescribed at discharge and within 30 days of discharge. Multivariable model selection was carried out with forward selection and backward elimination to identify variables associated with key outcomes. Results Total mean usage of opioids and mean pain scores were significantly lower in post-ERAS vs pre-ERAS patients across POD 1-3, respectively (32.90 MEDD vs 99.86 MEDD, P ≤ .001; 3.51 vs 4.17, P = .003). The median number of opioid pills prescribed at discharge was significantly lower in the post-ERAS group compared to pre-ERAS (30 pills vs 45 pills, P = .046) as well as the median number opioid pills prescribed within 30 days of discharge (40 pills vs 50 pills, P = .001). Conclusion Our study suggests that a dedicated ERAS protocol following RC might be superior to traditional, non-ERAS methods in reducing postoperative opioid use and pain scores.

Objectives To examine (i) the prevalence of comorbidity among invasive bladder cancer (IBC) patients, and (ii) the effect of comorbidity on IBC survival and mortality in Northern Denmark. Comorbidity has shown to be associated with treatment selection and survival in patients who undergo radical cystectomy for IBC. Methods Patients with a diagnosis of IBC from Danish hospitals between 1996 and 2007 within a population of 1.6 million were identified through the Danish National Patient Registry. From hospital diagnosis data, we computed Charlson Comorbidity Index scores (0, 1-2, 3+) for IBC patients and computed absolute survival and relative mortality estimates according to comorbidity level. Results We identified 3997 patients with IBC among whom 1715 (43%) had comorbidities. The prevalence of comorbidity tended to increase during the study period with those having scores 3+ increasing from 8%-12%. Three- and 5-year mortality rates were higher for patients with comorbidity, with mortality rates more than 2-fold higher among those with scores of 3+ and 1.5-fold higher among those with scores of 1-2 compared with no comorbidity. Generally, the same pattern was seen for 1-year relative survival rates. Conclusions Comorbidity was seen among 43% of IBC patients and severe comorbidity was a predictor of poorer survival.

Objectives. To report the results of a Phase II trial of neoadjuvant estramustine and etoposide before radical prostatectomy in patients with locally advanced disease. Methods. Treatment consisted of three cycles of estramustine (10 mg/kg/day) and etoposide (50 mg/m 2 /day) orally on days 1 through 21, repeated every 28 days, followed by radical prostatectomy. The eligibility criteria included locally advanced prostate cancer (clinical Stage T2b/c or T3, prostate-specific antigen [PSA] level of 15 ng/mL or greater, or Gleason score of 8 or higher) without evidence of metastatic disease. The median PSA level was 14 ng/mL (range 5.3 to 50), the median Gleason score was 7 (range 6 to 9), and 44% had Stage T2b/c or T3 disease. The primary endpoint was feasibility of neoadjuvant therapy and radical prostatectomy, including drug and surgery-related toxicities. Secondary endpoints included the pre-prostatectomy PSA level, local response, pathologic outcomes, and time to PSA failure. Results. Eighteen patients were entered and completed all three cycles of therapy, and 16 (89%) underwent radical prostatectomy. A local response occurred in 15 (94%) of 16 patients with palpable tumors, and the serum PSA reached undetectable levels after therapy and before radical prostatectomy in 9 patients (50%). Five patients (28%) experienced grade 3 toxicity (two with deep venous thrombosis, two with neutropenia, and one with diarrhea) and one (6%) experienced grade 4 toxicity (pulmonary embolus) before surgery. The median operative time was 125 minutes, the mean blood loss was 665 mL, and the mean length of stay was 2.5 nights. Five minor surgical complications occurred in 4 patients. The pathologic analysis demonstrated residual carcinoma with squamous metaplasia and androgen deprivation effect in all patients. Five patients (31%) had organ-confined disease and 9 patients (56%) had specimen-confined disease. All patients achieved an undetectable PSA level postoperatively and at a median follow-up of 14 months (range 5 to 20) and without additional therapy, all 14 patients with negative lymph nodes were disease free. Conclusions. This trial confirms the feasibility of radical prostatectomy with acceptable surgical morbidity after neoadjuvant therapy with estramustine and etoposide in patients with locally advanced prostate cancer. However, this regimen is associated with estramustine-induced thromboembolic toxicity. The results of the pathologic analysis suggest a higher than expected rate of organ-confined and specimen-confined disease, but little histologic evidence of antitumor effect beyond that associated with androgen deprivation. Additional study of this paradigm with other drug regimens is warranted.

To determine the number, variability, and distribution of pelvic lymph nodes to better understand the utility of the node count as a surrogate for the dissection extent. Although pelvic lymph node dissection (PLND) at radical cystectomy for bladder cancer is critical for disease control and staging, debate regarding the measurement of dissection adequacy remains. Many have proposed minimum node counts, yet an anatomic study assessing the number and variability of lymph nodes in the PLND templates is lacking.Super-extended PLND was performed on 26 human cadavers, and the lymph nodes within each of 12 dissection zones were enumerated by a single pathologist. We calculated the mean, standard deviation, and range of nodal yield within each dissection region. The super-extended and standard dissection templates were compared using the paired t test.Super-extended PLND yielded a mean of 28.5 ± 11.5 lymph nodes, with a total node count range of 10-53 nodes. In contrast, the nodal yield within the standard template was 18.3 ± 6.3 nodes, with a range of 8-28 nodes (P.001). No significant differences were seen in lymph node counts when stratified by age, sex, or cause of death.Using a cadaveric model and a single pathologist to eliminate many of the factors affecting the nodal yield in surgical series, we found substantial interindividual differences, with counts ranging from 10 to 53 nodes. These results have demonstrated the limited utility of lymph node count as a surrogate for the dissection extent and illustrated the challenges associated with implementing a surgical standard for minimum lymph node counts.

An infected urachal cyst is an uncommon finding in adults. We report the first case of a sigmoid–urachal–cutaneous fistula that resulted from rupture of an infected urachal cyst in an adult male. Definitive management consisted of resection of the urachus with a bladder cuff, along with removal of the affected bowel segments and bowel anastomosis.

Objectives To report a prospective trial of lycopene supplementation in biochemically relapsed prostate cancer. Methods A total of 36 men with biochemically relapsed prostate cancer were enrolled in a dose-escalating, Phase I-II trial of lycopene supplementation. Six consecutive cohorts of 6 patients each received daily supplementation with 15, 30, 45, 60, 90, and 120 mg/day for 1 year. The serum levels of prostate-specific antigen (PSA) and plasma levels of lycopene were measured at baseline and every 3 months. The primary endpoints were PSA response (defined as a 50% decrease in serum PSA from baseline), pharmacokinetics, and the toxicity/tolerability of this regimen. Results A total of 36 patients were enrolled. The median age was 74 years (range 56 to 83), with a median serum PSA at entry of 4.4 ng/mL (range 0.8 to 24.9). No serum PSA responses were observed, and 37% of patients had PSA progression. The median time to progression was not reached. Toxicity was mild, with 1 patient discontinuing therapy because of diarrhea. Significant elevations of plasma lycopene were noted at 3 months and then appeared to plateau for all six dose levels. The plasma levels for doses between 15 and 90 mg/day were similar, with additional elevation only at 120 mg/day. Conclusions Lycopene supplementation in men with biochemically relapsed prostate cancer is safe and well tolerated. The plasma levels of lycopene were similar for a wide dose range (15 to 90 mg/day) and plateaued by 3 months. Lycopene supplementation at the doses used in this study did not result in any discernible response in serum PSA.

Objectives To examine the relationship between the percentage of positive biopsies (PPBs) and freedom from biochemical recurrence (FFBR) in men treated with low-dose-rate prostate brachytherapy (LDRPB) alone. The PPBs has been associated with FFBR in men treated with radical prostatectomy and external beam radiotherapy for prostate cancer. Methods This report concerns 108 men treated with LDRPB alone between November 1997 and December 1999. All patients had clinically localized prostate cancer confirmed by biopsy. All men were treated with iodine-125 to 144 Gy. FFBR was estimated using the product-limit method. Putative covariates for FFBR, including T stage, Gleason score, pretreatment prostate-specific antigen level, minimal dose received by 90% of the target volume, and PPBs, were examined using the proportional hazards regression model. Results The median follow-up was 61 months. Of the 108 men, 13 developed evidence of biochemical relapse at a median of 25 months. The 5-year estimate of FFBR was 87% (95% confidence interval 81% to 93%) for the entire cohort. On univariate analysis, prostate-specific antigen, T stage, minimal dose received by 90% of the target volume, and PPBs were associated with FFBR. In the multivariate model, the PPBs was the only variable that predicted for FFBR (P = 0.002). The 5-year estimate of FFBR was 95% for patients with less than 50% PPB disease versus 63% in patients with more than 50% PPB disease (P Conclusions The PPBs is an important independent predictor of FFBR after LDRPB alone. The FFBR after LDRPB in the group of patients with more than 50% PPBs was poor.

Objectives To present the results of a Phase II trial of thalidomide and interferon-alpha in renal cell carcinoma. Methods Patients with metastatic clear cell renal cell carcinoma and no prior systemic therapy were accrued. Interferon-alpha was administered at 5 million units subcutaneously three times per week. Thalidomide was started at 100 mg/day for 2 weeks and then escalated 200 mg every 2 weeks to 1000 mg or until grade 3-4 toxicity developed. Patients were assessed radiographically at baseline and after 12 weeks. Steady-state thalidomide plasma concentrations were determined. Results Thirty patients were enrolled. The median age was 62 years. Seventeen patients (57%) had undergone nephrectomy before therapy. One patient died during therapy. Of the 30 patients, 29 had at least grade 2 toxicity and 17 patients had at least grade 3. At 12 weeks, no patient had a complete response, 2 had a partial response (6.7%), 8 had stable disease (26.7%), and 11 (including 1 patient with an initial partial response) had disease progression (36.7%). Nine patients were removed from the study before 12 weeks. The median follow-up was 49.6 weeks (range 2.4 to 123.7). The median time of participation in the study was 11.1 weeks (range 1.4 to 63.9). At last follow-up, 2 patients were receiving the study therapy, 1 with stable disease at 64 weeks and 1 with a partial response at 53 weeks. The median survival was 68 weeks. A linear relationship was found between the thalidomide plasma concentration and dose. No relationship was apparent between the concentration and either treatment-related toxicity or response. Conclusions Interferon-alpha and thalidomide as front-line therapy for metastatic renal cell carcinoma showed limited activity. The objective response rate was 7%. One third of patients experienced toxicity that required discontinuation of thalidomide. Randomized controlled studies are needed to determine any objective benefit of this regimen over either drug alone.

Objectives To evaluate the utility of routine intraoperative frozen-section histologic analysis during partial nephrectomy to ensure negative surgical margins. Partial nephrectomy has gained acceptance for surgical treatment of small renal cancers. Many surgeons send specimens for intraoperative frozen section histologic analysis to ensure negative margins. Methods We reviewed the records of 78 patients who underwent partial nephrectomy for presumed malignancy. Patient demographics, intraoperative findings, and pathologic and clinical outcomes were analyzed. Results Seventy-nine partial nephrectomies were performed in 78 patients. Frozen sections were obtained intraoperatively in 76 cases. In 1 case (1.3%), a single margin was interpreted as positive for carcinoma, prompting deeper resection. The final histopathologic finding was interpreted as angiomyolipoma rather than carcinoma. The final pathologic examination revealed renal cell carcinoma in 52 (66%) of 79 cases. The mean oncologic follow-up was 16.2 months. One local recurrence was noted (1.9%). It arose in the resection bed 19 months after removal of a 4.5-cm tumor (pathologic Stage T3a). Both intraoperative frozen section margins and final pathologic margins were negative in this case. One patient developed pulmonary metastases and represented the only metastatic recurrence, as well as the only cancer-related death in our cohort (1.9%). Conclusions Our data suggest that when partial nephrectomy is performed with attention to excising a perimeter of grossly normal-appearing parenchyma, sending specimens for intraoperative frozen section analyses may provide an unnecessary expense without providing meaningful, reliable information. Additional studies, including larger cohorts and extended follow-up, are needed to support these results.

69-year-old woman of the Jehovah’s Witness faith was found to have a mass on a computed tomography bone density scan done for osteoporosis. Computed tomography demonstrated a 10-cm right renal mass with a tumor thrombus extending to the level of the hepatic veins (Fig. 1). Both the computed tomography and magnetic resonance imaging scans demonstrated fat within the tumor, consistent with an angiomyolipoma or a liposarcoma (Fig. 2). No metastatic disease was evident. A right radical nephrectomy was performed with a retroperitoneal lymphadenectomy and level II thrombectomy using a thoracoabdominal approach 1 (Fig. 3). Erythropoietin was given preoperatively, and her starting hematocrit was 50%. Vascular control was obtained intraoperatively by mobilizing the liver off the inferior vena

A 46-year-old man was referred for evaluation of a 13-cm renal mass. Right radical nephrectomy was performed. Pathologic evaluation revealed inflammatory myofibroblastic tumor (IMT) and renal cell carcinoma. To our knowledge, only 28 cases of IMT associated with the kidney have been reported in published studies. This is the first reported case of IMT associated with malignancy in the urogenital tract. Some investigators have suggested that biopsy-proven IMT can be managed conservatively, but the findings of this report have demonstrated the need for radical nephrectomy in this patient population to rule out associated malignancy.