James Rosoff

Nonneoplastic renal cortical scarring at tumor nephrectomy predicts decline in kidney function.

CONTEXT Evaluating nontumor portions of tumor nephrectomies is useful to diagnose nonneoplastic renal disease. OBJECTIVE To determine the medical renal disease frequency and to assess the prognostic significance of the various renal pathologic variables with long-term follow-up in tumor nephrectomy patients. DESIGN We reviewed nonneoplastic kidney sections of 456 consecutive cases from 1998 to 2008. Seventy-five cases were excluded (19 tumor compression, 25 no nonneoplastic tissue, 22 embolized kidneys, 9 end stage). Special staining, immunofluorescence, and/or electron microscopy was performed where appropriate. Vascular sclerosis was scored from mild to severe; interstitial fibrosis/tubular atrophy and global glomerulosclerosis (GS) were expressed as percentages. Follow-up, minimum 12 months, was evaluated in 156 cases. All renal pathologic variables were compared with regard to change in creatinine level from preoperative assessment to follow-up. RESULTS Of 381 cases, 57 had additional medical renal disease (15%), most frequently diabetic nephropathy (28) and hypertensive nephropathy (11). Postoperative creatinine levels increased significantly in patients with severe arteriosclerosis or arteriolosclerosis, >5% GS, and >10% interstitial fibrosis/tubular atrophy. Seventy-four percent of cases with additional nonneoplastic diagnoses showed severe arteriolosclerosis. Higher corresponding GS was seen in the more affected vascular cases: mean, 5.56% GS for mild versus 23% GS for severe. Three patients progressed to renal failure 1 to 4 years after nephrectomy, 2 with hypertensive nephrosclerosis and 1 with diabetic nephropathy. CONCLUSIONS Medical renal disease was identified in 15% of tumor nephrectomy specimens. The degrees of vascular sclerosis, GS, and interstitial fibrosis/tubular atrophy are predictive of elevated creatinine levels in postnephrectomy patients. Prognostic implications of the nontumor pathology are important in nephrectomized patients.

Negative Multiparametric Magnetic Resonance Imaging of the Prostate Predicts Absence of Clinically Significant Prostate Cancer on 12-Core Template Prostate Biopsy

OBJECTIVE To determine the negative predictive value of multiparametric magnetic resonance imaging (mpMRI), we evaluated the frequency of prostate cancer detection by 12-core template mapping biopsy in men whose mpMRI showed no suspicious regions. METHODS Six hundred seventy patients underwent mpMRI followed by transrectal ultrasound (TRUS)-guided systematic prostate biopsy from December 2012 to June 2016. Of this cohort, 100 patients had a negative mpMRI. mpMRI imaging sequences included T2-weighted and diffusion-weighted imaging, and dynamic contrast enhancement sequences. RESULTS The mean age, prostate-specific antigen, and prostate volume of the 100 men included were 64.3 years, 7.2 ng/mL, and 71 mL, respectively. Overall cancer detection was 27% (27 of 100). Prostate cancer was detected in 26.3% (10 of 38) of patients who were biopsy-naïve, 12.1% (4 of 33) of patients who had a prior negative biopsy, and in 44.8% (13 of 29) of patients previously on active surveillance; Gleason grade ≥7 was detected in 3% of patients overall (3 of 100). The negative predictive value of a negative mpMRI was 73% for all prostate cancer and 97% for Gleason ≥7 prostate cancer. CONCLUSION There is an approximately 3% chance of detecting clinically significant prostate cancer with systematic TRUS-guided biopsy in patients with no suspicious findings on mpMRI. This information should help guide recommendations to patients about undergoing systematic TRUS-guided biopsy when mpMRI is negative.

Laparoendoscopic single-site radical nephrectomy for large renal masses.

PURPOSE To report our operative experience and short-term outcomes for the laparoendoscopic single-site (LESS) management of large renal tumors and tumors of advanced stage. PATIENTS AND METHODS Ten consecutive patients underwent LESS-radical nephrectomy (RN) for large (≥ 7 cm) and/or locally advanced tumors (>T(2)). Intraoperative, postoperative, and short-term follow-up data were analyzed. RESULTS Median surgical time was 146 minutes (range 73-164 min), and median estimated blood loss was 100 mL (range 25-400 mL). No procedure needed conversion to open RN or hand-assisted laparoscopic RN. The median hospital stay was 47 hours (range 42 hours-12 days). One (10%) patient had a minor complication (postoperative fever treated with antibiotics) and one (10%) patient had a major complication (small bowel obstruction necessitating reoperation). Of the 10 tumors, 2 were pathologic stage T(1b), 4 were pathologic stage T(2), and 4 were stage T(3a). At a median follow-up of 12.3 months (range 1-16 mos), six (60%) patients were alive without evidence of recurrence, and 4 (40%) patients were alive with disease. Of those four patients, all four had known metastatic disease before surgery. CONCLUSION LESS-RN for large or advanced stage renal masses is a technically challenging operation. In experienced hands, however, it is a safe and feasible therapeutic option for the management of these tumors.

Association of Human Development Index with global bladder, kidney, prostate and testis cancer incidence and mortality

To describe contemporary worldwide age‐standardized incidence and mortality rates for bladder, kidney, prostate and testis cancer and their association with development.

Paratesticular fibrous pseudotumour

A 38-year-old man presented with a 2-year history of an enlarging scrotal nodule. Scrotal ultrasound revealed two soft tissue masses separate from the testicle in the right scrotum measuring 1.7 and 0.8 cm. The patient underwent excision of the scrotal nodules, revealing firm, white tissue with a smooth, nodular surface. On histology, the lesions appeared fibrous with scattered capillaries and areas of inflammatory infiltrate consistent with paratesticular fibrous pseudotumour. On a follow-up ultrasound at 6 months, he had no evidence of recurrence.

Three testicles in one hemiscrotum: an unusual presentation of polyorchidism.

Polyorchidism, or more than one testicle in a hemiscrotum, is a relatively rare phenomenon. It is often associated with several other conditions, including inguinal hernia, testicular maldescent, testicular torsion, hydrocele or hypospadias. In this report, we describe a patient who presented with three testicles in one hemiscrotum, which is a highly unusual presentation for an already uncommon condition. We also review the relevant literature as it relates to the need for surveillance due to the increased risk for malignancy.

Recurrent nephrolithiasis associated with atazanavir use

A 64-year-old man with HIV on antiretroviral therapy (including atazanavir, a protease inhibitor) presented with left flank pain, nausea and vomiting. A kidney stone was suspected, and a CT scan demonstrated left hydronephrosis but failed to demonstrate nephrolithiasis or extrinsic compression. The patient had a ureteral stent placed which relieved his symptoms. A few months later, he underwent left ureteroscopy and a large ureteral calculus was found. The stone was removed and analysis showed 43% atazanavir and 57% calcium oxalate. Several months later, the patient developed flank pain on the opposite side. A renal ultrasound suggested right-sided nephrolithiasis and he subsequently underwent ureteroscopy with laser lithotripsy of two stones. Stone analysis showed that they were composed of 100% atazanavir. This case highlights the fact that patients treated with protease inhibitors remain at risk for developing nephrolithiasis. Ultrasonography can be a useful diagnostic tool in the setting of these radiolucent calculi.

Perivascular epithelioid cell tumour of the bladder.

A 39-year-old woman presented with a long history of pelvic pain and urinary urgency. Prior workup by her primary care doctor had been negative. The patients gynaecologist ultimately referred her to a urologist following an ultrasound that revealed a possible bladder mass. MRI of the abdomen and pelvis demonstrated a 4 cm soft tissue lesion arising from the bladder. Cystoscopy showed an atypical mass on the anterior bladder wall, and pathological examination of the TURBT (transurethral resection of the bladder tumour) specimen revealed a perivascular epithelioid cell tumour (PEComa) with involvement of the detrusor muscle. The patient underwent a robotically assisted laparoscopic partial cystectomy. Final pathology confirmed a PEComa with negative margins. The patient had an uncomplicated postoperative course and is doing well following surgery. A surveillance cystoscopy at 6 months showed no evidence of recurrence. This case underscores the variability of clinical presentation of PEComas while proposing an appropriate method of surgical management.

Long-term differences in urinary, bowel and sexual function among men treated with surgery versus radiation for prostate cancer

Surgery and radiation have both been shown to increase the long-term disease-specificsurvivalrateformenwithclinically localized prostate cancer. Although both modalities have demonstrated favorable effects on cancer control, questions regarding quality of life (QoL) and functional outcomes remain incompletely answered. To date, no randomized prospective trials have been performed comparing the two treatmentmodalitiesandsoindirectcomparisons of long-term functional outcomes have served as a substitute to aid in patient counselinganddecision-making. Asthereisapaucity of long-term data comparing functional outcomes after radical prostatectomy and external beam radiation therapy, a recent article by Resnick et al., 1 has attempted to provide additional information about this topic in terms of continence, erectile function and bowel function. Utilizing the Prostate Cancer Outcomes Study cohort, a population-based cohort of men diagnosed with prostate cancer in the prostate-specific antige n( PSA) era, the authors compared rates of urinary incontinence, erectile dysfunction, and bowel urgency at 2, 5 and 15 years after primary therapy. They showed that men undergoing prostatectomy had higher rates of incontinence and erectile dysfunction at 2 and 5 years, but these rates were similar to those in the radiotherapy group at 15 years. More specifically, men were approximately five times more likely to have urinary continence issues if they underwent prostatectomy versus radiotherapy and almost three and a half times more likely to develop erectile dysfunction in the short- to intermediate-term following primary treatment. As expected, rates of bowel urgency were higher in the radiotherapy group at 2 and 5 years, but not significantly different from the surgery group at 15 years. In addition, the authors note that the rate of incontinence and erectile function progressively worsened over time, regardless of primary treatment modality. At 15 years of follow-up, the prevalence of erectile dysfunction was approximately 87% in the prostatectomy group, and 94% in the radiotherapy group, a non-significant difference. Interestingly, only approximately 40% of patients in either group reported being bothered by this. Withoutanappropriatecontrolgroup,itishard to distinguish the relative contribution of intervention or age to the overall decline in sexual function. Short-term studies have shown that men undergoing prostatectomy have larger declines in sexual and urinary function than age-matched controls, 2 but no such untreated

What's in a Number? Examining the Effect of a Dedicated Research Year on H-Index and Fellowship Decision-making

OBJECTIVE To assess the effect of a dedicated research year on the h-indices of residents and the pursuit of fellowship within a heterogeneous group of urology programs. We previously demonstrated that urology residents with a dedicated research year produce more than 2 times the number of publications than their counterparts in 5-year programs. However, we did not give consideration to the impact of these publications. MATERIALS AND METHODS We obtained information on the publication output and pursuit of fellowship of graduates from the New York Section urology residency programs from 2009 to 2013. Data on peer-reviewed publications were obtained by PubMed query and h-index was documented from the Scopus database. RESULTS During the 5-year study period, 148 individuals (116 M, 32 F) graduated from New York Section urology programs. The mean h-index was 4.6 for residents in 5-year programs compared with 8.1 for those in 6-year programs (P < .001). Residents with a dedicated research year were more likely to pursue fellowship training (79.3% vs 58.8%, P = .023) with no difference in the pursuit of accredited fellowship programs. Those residents who went on to fellowship training had a significantly higher h-index (6.2 vs 3.6, P = .001). CONCLUSION Urology residents with a dedicated research year have almost 2 times the h-indices of their counterparts. Residents who pursue fellowship training also have higher h-indices. Residents who completed a dedicated research year were more likely to pursue fellowship training, although the accreditation status of these programs was variable.