James O. L'Esperance

Rectal cultures before transrectal ultrasound-guided prostate biopsy reduce post-prostatic biopsy infection rates.

OBJECTIVE To test our hypothesis that a targeted rectal screening protocol before transrectal ultrasound (TRUS)-guided biopsy would potentiate streamlined prophylaxis, thereby reducing postbiopsy infectious rates while minimizing unnecessary broad-spectrum antibiotic use. To this end, we instituted preprocedure rectal cultures in an effort to identify fluoroquinolone (FQ)- resistant flora using selective media to optimally direct targeted prophylactic antibiotic administration. The inexorably increasing prevalence of multidrug-resistant microorganisms, notably extended spectrum beta lactamase (ESBL)-producing and FQ-resistant Enterobacteriaceae has increased the post-TRUS prostatic biopsy infection rates, including life-threatening sepsis. METHODS A total of 235 rectal swabs were obtained and plated directly onto MacConkey agar plates containing 10-μg/mL ciprofloxacin. Following the screening procedure, antimicrobial susceptibility results were used to develop a customized antibiotic prophylaxis regimen to be administered before biopsy. Following the biopsy procedure, the patients were seen in follow-up within 7 days, and information was gathered on potential adverse effects, clinical appointments for infections, and potential antibiotics received. RESULTS Thirty-two-patients (14%) had FQ-resistant isolates (most Escherichia coli), and 3 (1.3%) were ESBL-producing isolates. There were no infectious complications identified in this period, (compared with 3 septic complications among 103 biopsies in the 4 months preceding the study). CONCLUSION Rectal cultures obtained before TRUS biopsy, using selective media to identify FQ-resistant Enterobacteriaceae, facilitate targeted antibiotic prophylaxis, and appear to be highly efficacious in reducing infectious complications.

Effect of obesity on prostate-specific antigen recurrence after radiation therapy for localized prostate cancer as measured by the 2006 radiation therapy oncology group-american society for therapeutic radiation and oncology (RTOG-ASTRO) phoenix consensus definition

Given the limited data regarding the impact of obesity on treatment outcomes after external beam radiation therapy (EBRT) for the definitive treatment of prostate cancer, the authors sought to evaluate the effect of obesity as measured by body mass index (BMI) on biochemical disease recurrence (BCR) using the most current 2006 Radiation Therapy Oncology Group‐American Society for Therapeutic Radiation and Oncology (RTOG‐ASTRO) Phoenix consensus definition (prostate‐specific antigen [PSA] nadir + 2 ng/mL).

RENAL Nephrometry Score is Associated With Operative Approach for Partial Nephrectomy and Urine Leak

OBJECTIVE To identify whether RENAL nephrometry score is associated with partial nephrectomy (PN) technique. RENAL nephrometry score quantifies anatomic characteristics of renal tumors. Data are limited regarding clinical utility for surgical planning. METHODS Multicenter analysis of patients undergoing PN for renal masses from March 2003 to May 2011. Cohort was stratified by surgical modality: open partial nephrectomy (OPN), laparoscopic partial nephrectomy (LPN), and robotic-assisted laparoscopic partial nephrectomy (RALPN). Demographic and clinicopathological variables were compared between groups; RENAL score was calculated from preoperative imaging. Factors associated with choice of treatment modality and urine leak were entered into multivariable models. RESULTS One hundred fifty-three patients who underwent OPN, 100 patients who underwent LPN, and 31 patients who underwent RALPN were evaluated, the median tumor size (cm) was significantly larger for OPN (OPN 4.2 vs LPN 2.4 vs RALPN 2.0; P < .001); median operative time (minutes) and ischemia time (minutes) were shorter in OPN (OPN 190 and 25 vs LPN 200 and 29 vs RALPN 195 and 30; P = .042 and P < .001). Mean RENAL score was highest in OPN (OPN 8 vs LPN 6.3 vs RALPN 6.4; P < .001). No significant differences were noted in overall/high-grade complication rates (Clavien, P = .441/.985). On multivariate analysis, there was a 55% increased odds of undergoing OPN for each increase in RENAL score (P < .001). Higher RENAL score was associated with increased odds of urine leak (odds ratios [OR], 1.56; P = .002). CONCLUSION RENAL nephrometry score was associated with type of surgical approach (open vs laparoscopic/robotic) and urine leak. RENAL score may be useful as a decision-making tool in evaluation of patients for nephron-sparing surgery (NSS). Further investigation is requisite.

Analysis of Ureteral Stent Compression Force and its Role in Malignant Obstruction

PURPOSE Extrinsic ureteral obstruction can be a challenging entity for the urologist since half of the ureteral stents placed for malignant obstruction fail. We evaluated the resistance to radial compression of various stents. MATERIALS AND METHODS Silhouette(R) 4.6Fr, 6Fr and 8Fr, Sof-Curl Tecoflex 6Fr, Resonance 6Fr, Polaris Ultra 6Fr and 7Fr, and Percuflex 6Fr and 8Fr stents were tested. The force needed to compress the stent to 50% of its original external diameter was measured at 3 locations along the stent length, including proximal, middle and distal. Statistical analysis was performed. RESULTS Statistically greater force was required to compress the Resonance and Silhouette stents compared to all others tested. These results were maintained at all 3 locations along the stent. Only the Polaris 6Fr stent differed in resistance to compression along the stent length. CONCLUSIONS The significantly higher forces required to compress the Resonance and Silhouette stents may translate into improved success in patients with malignant ureteral obstruction.

Testis cancer: a 20-year epidemiological review of the experience at a regional military medical facility.

PURPOSE Testis cancer is the most common solid malignancy in the young adult population and the incidence in this population is increasing. We present a 20-year epidemiological review of testis cancers treated at our institution. MATERIALS AND METHODS The records of testis cancer cases diagnosed between January 1988 and June 2007 were reviewed. Patient demographics, cancer histology and stage, adjuvant therapy, temporal trends and survival data are presented. Our experience was compared to trends published in the SEER (Surveillance, Epidemiology and End Results) database and the National Cancer Database. RESULTS A total of 338 testis cancers (330 germ cell tumors) were diagnosed during the study period. Median patient age at diagnosis was 26.6 years vs 34 in the SEER database. We observed a temporal increase in stage I tumors (57% to 75%) and a decrease in the proportion of seminomas (52% to 43%) during the study period. In terms of adjuvant therapy for stage I seminoma the use of radiotherapy decreased (91% to 75%), while the use of chemotherapy increased (1.5% to 7.5%). For stage I nonseminomatous germ cell tumors the use of adjuvant chemotherapy increased (12% to 20%), while the use of staging retroperitoneal lymph node dissection decreased (88% to 63%). Five-year cancer specific survival was 97.7%. CONCLUSIONS We are seeing an increase in localized disease at diagnosis, an increase in surveillance for stage I disease and 5-year survival in excess of 95%, similar to data in SEER and the National Cancer Database. However, unlike in SEER and the National Cancer Database, our patients are younger, we are seeing less seminoma and we are performing significantly more staging retroperitoneal lymph node dissection.

Second Prize: Recurrence Rates After Percutaneous and Laparoscopic Renal Cryoablation of Small Renal Masses: Does the Approach Make a Difference?

BACKGROUND AND PURPOSE As radiologic detection of small renal masses increases, patients are increasingly offered percutaneous renal cryoablation (PRC) or transperitoneal laparoscopic renal cryoablation (TLRC). This multicenter experience compares these approaches. PATIENTS AND METHODS Between September 1998 and May 2010, review of our PRC and TLRC experience was performed. Patients with ≥ 12-month follow-up were included for analysis. Post-treatment surveillance consisted of laboratory studies and imaging at regular intervals. Treatment failure was considered if persistent mass enhancement or interval tumor growth was radiographically evident. Repeated biopsy and re-treatment were recommended in the event of recurrence. RESULTS Sixty-one patients underwent PRC and 84 patients underwent TLRC. No significant differences were noted with respect to demographic factors. Mean tumor size was 2.7 ± 1.1 cm (PRC) and 2.5 ± 0.8 (TLRC) cm (P = 0.090). Mean follow-up was 31.0 ± 15.9 months (PRC) and 42.3 ± 21.2 (TLRC) months (P = 0.008), with local tumor recurrence noted in 10/61 (16.4%) PRC and 5/84 (5.9%) TLRC (P = 0.042). For PRC, disease-free survival (DFS) and overall survival (OS) were 93.7% and 88.9%, respectively, with four patients having evidence of disease at last follow-up. DFS and OS were 91.7% and 89.3% for TLRC, with seven patients having evidence of disease at last follow-up. DFS (P = 0.654) and OS (P = 0.939) were similar. CONCLUSIONS In this multicenter study of well-matched cohorts, PRC had higher primary treatment failure rates than TLRC. While no differences were noted between DFS and OS, analysis is limited by intermediate follow-up. Further study is necessary to discern reasons for the higher recurrence rates in PRC and to determine what long-term consequences exist.

Impact of tumour morphology on renal function decline after partial nephrectomy

To examine the association of renal morphology with renal function after partial nephrectomy (PN).

Prospective quality‐of‐life outcomes for low‐risk prostate cancer: Active surveillance versus radical prostatectomy

For patients with low‐risk prostate cancer (PCa), active surveillance (AS) may produce oncologic outcomes comparable to those achieved with radical prostatectomy (RP). Health‐related quality‐of‐life (HRQoL) outcomes are important to consider, yet few studies have examined HRQoL among patients with PCa who were managed with AS. In this study, the authors compared longitudinal HRQoL in a prospective, racially diverse, and contemporary cohort of patients who underwent RP or AS for low‐risk PCa.

Impact of statins on nephrolithiasis in hyperlipidemic patients: a 10-year review of an equal access health care system.

AIM To investigate the impact of statin medications on urinary stone formation in hyperlipidemic patients. MATERIAL AND METHODS We searched outpatient military electronic health records from the Southwestern United States to identify adult patients with hyperlipidemia and urolithiasis. Military facilities serve active duty members, retirees, and their immediate family members. We created two predictor variables - with and without statin. The outcome variable was a diagnosis of urolithiasis. RESULTS The inception cohort included 57,232 subjects with hyperlipidemia and 1,904 subjects with nephrolithiasis. Patients taking statin medications had significantly less stone formation compared to patients not taking statin medications (3.1% vs. 3.7%, univariate OR = 0.83, 95% CI 0.76 - 0.91, p < 0.001). Statins patients were significantly older (59 vs. 45 years, p < 0.001), more likely to be female (38% vs. 34%, p < 0.001) and have co-morbidities (obesity, hypertension, diabetes, heart disease; all p < 0.001). Multivariate analysis indicated that statin medications had a protective effect against stone formation (OR = 0.51, 95% CI 0.46 - 0.57, p < 0.001), after adjusting for age, sex, and comorbidities. The risk of nephrolithiasis was not only additive for diabetes mellitus, hypertension, and obesity; more importantly it was attenuated with addition of statin use. CONCLUSION Statin medications are associated with reduced risk of urinary stones. This is the first study to demonstrate the impact of statins on nephrolithiasis. Further prospective studies are necessary to validate these findings that treatment of hyperlipidemia reduces stone risk formation.

Racial/Ethnic Patterns in Prostate Cancer Outcomes in an Active Surveillance Cohort

Introduction. Concern regarding overtreatment of prostate cancer (CaP) is leading to increased attention on active surveillance (AS). This study examined CaP survivors on AS and compared secondary treatment patterns and overall survival by race/ethnicity. Methods. The study population consisted of CaP patients self-classified as black or white followed on AS in the Center for Prostate Disease Research (CPDR) multicenter national database between 1989 and 2008. Secondary treatment included radical prostatectomy (RP), external beam radiation therapy or brachytherapy (EBRT-Br), and hormone therapy (HT). Secondary treatment patterns and overall survival were compared by race/ethnicity. Results. Among 886 eligible patients, 21% were black. Despite racial differences in risk characteristics and secondary treatment patterns, overall survival was comparable across race. RP following AS was associated with the longest overall survival. Conclusion. Racial disparity in overall survival was not observed in this military health care beneficiary cohort with an equal access to health care.