Tullika Garg

Preoperative Serum Albumin Is Associated With Mortality and Complications After Radical Cystectomy

To determine the association between preoperative serum albumin and mortality and postoperative complications after radical cystectomy (RC) and urinary diversion.

Resonance® Metallic Ureteral Stents Do Not Successfully Treat Ureteroenteric Strictures

PURPOSE To report the outcomes of patients with ureteroenteric strictures after ileal conduit urinary diversion that were managed with Resonance metallic ureteral stents. PATIENTS AND METHODS Ten ureteroenteric strictures in patients with ileal conduits that were managed with metallic ureteral stenting were retrospectively identified. Charts were examined for patient age, anastomosis type, stricture cause, stricture laterality, complications, and follow-up. RESULTS Nine of 10 (90%) cases resulted in distal stent migration. Mean time to stent migration was 21 days (range 3-60 d). CONCLUSIONS Placement of Resonance metallic stents in patients with ileal conduits is ineffective for management of ureteroenteric strictures because of the high rate of distal migration.

Systematic classification and prediction of complications after nephrectomy in patients with metastatic renal cell carcinoma (RCC)

Study Type – Harm (case series)

Urinary Diversion Practice Patterns Among Certifying American Urologists

PURPOSE We investigated trends in urinary diversion use and surgeon characteristics in the performance of incontinent and continent urinary diversion using American Board of Urology data. MATERIALS AND METHODS Annualized case log data for urinary diversion were obtained from the American Board of Urology for urologists who certified or recertified from 2002 to 2010. We evaluated the association between surgeon characteristics and the performance of any urinary diversion or the type of urinary diversion. RESULTS Of the 5,096 certifying or recertifying urologist case logs examined 1,868 (37%) urologists performed any urinary diversion. The median number of urinary diversions was 4 per year (IQR 2, 6) and 222 urologists (4%) performed 10 or more per year. On multivariate analysis younger urologists, those self-identified as oncologists or female urologists, those who certified in more recent years and those in larger practice areas or outside the Northeast region of the United States were more likely to perform any urinary diversion. Only 9% of the total cohort (471 urologists) performed any continent urinary diversion. The likelihood of performing any continent urinary diversion increased with the number of urinary diversions (p <0.0001). As urinary diversion volume increased, the proportion representing continent urinary diversion also increased (p <0.0005). Surgeons in private practice settings and those in the Northeast were less likely to perform continent urinary diversion. CONCLUSIONS Few urologists perform any urinary diversion. Continent urinary diversion is most frequently done by high volume surgeons. The type of urinary diversion that a patient receives may depend in part on surgeon characteristics.

Burden of Multiple Chronic Conditions among Patients with Urological Cancer

Purpose: We describe age, multiple chronic condition profiles and health system contact in patients with urological cancer. Materials and Methods: Using Geisinger Health System electronic health records we identified adult primary care patients and a subset with at least 1 urology encounter between 2001 and 2015. The Agency for Health Care Research and Quality Chronic Condition Indicator and Clinical Classifications Software tools were applied to ICD‐9 codes to identify chronic conditions. Multiple chronic conditions were defined as 2 or more chronic conditions. Patients with urological cancer were identified using ICD‐9 codes for prostate, bladder, kidney, testis and penile cancer. Inpatient and outpatient visits in the year prior to the most recent encounter were counted to document health system contact. Results: We identified 357,100 primary care and 33,079 urology patients, of whom 4,023 had urological cancer. Patients with urological cancer were older than primary care patients (71 vs 46 years) and they had more median chronic conditions (7 vs 4). Kidney and bladder cancer were the most common chronic conditions (median 8 patients each). Coronary artery disease and chronic kidney disease were common in urological cancer cases compared to mental health conditions in primary care cases. Patients with urological cancer who had multiple chronic conditions had the most health system contact, including 32% with at least 1 hospitalization and 68% with more than 5 outpatient visits during 1 year. Conclusions: Urology patients are older and more medically complex, especially those with urological cancer than primary care patients. These data may inform care redesign to reduce the treatment burden and improve care coordination in urological cancer cases.

Identification of epigenetic interactions between miRNA and DNA methylation associated with gene expression as potential prognostic markers in bladder cancer

BackgroundOne of the fundamental challenges in cancer is to detect the regulators of gene expression changes during cancer progression. Through transcriptional silencing of critical cancer-related genes, epigenetic change such as DNA methylation plays a crucial role in cancer. In addition, miRNA, another major component of epigenome, is also a regulator at the post-transcriptional levels that modulate transcriptome changes. However, a mechanistic role of synergistic interactions between DNA methylation and miRNA as epigenetic regulators on transcriptomic changes and its association with clinical outcomes such as survival have remained largely unexplored in cancer.MethodsIn this study, we propose an integrative framework to identify epigenetic interactions between methylation and miRNA associated with transcriptomic changes. To test the utility of the proposed framework, the bladder cancer data set, including DNA methylation, miRNA expression, and gene expression data, from The Cancer Genome Atlas (TCGA) was analyzed for this study.ResultsFirst, we found 120 genes associated with interactions between the two epigenomic components. Then, 11 significant epigenetic interactions between miRNA and methylation, which target E2F3, CCND1, UTP6, CDADC1, SLC35E3, METRNL, TPCN2, NACC2, VGLL4, and PTEN, were found to be associated with survival. To this end, exploration of TCGA bladder cancer data identified epigenetic interactions that are associated with survival as potential prognostic markers in bladder cancer.ConclusionsGiven the importance and prevalence of these interactions of epigenetic events in bladder cancer it is timely to understand further how different epigenetic components interact and influence each other.

Improving safety in robotic surgery: Intraoperative crisis checklist

TULLIKA GARG, MD, MPH, WASSIM M. BAZZI, MD, JONATHAN L. SILBERSTEIN, MD, NADEEM ABU-RUSTUM, MD, MARIO M. LEITAO JR, MD, AND VINCENT P. LAUDONE, MD* Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York Department of Urology, Tulane University Medical Center, New Orleans, Louisiana Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York

The effects of alternative splicing on miRNA binding sites in bladder cancer

Eukaryotic organisms have developed a variety of mechanisms to regulate translation post-transcriptionally, including but not limited to the use of miRNA silencing in many species. One method of post-transcriptional regulation is through miRNAs that bind to the 3′ UTRs to regulate mRNA abundance and influence protein expression. Therefore, the diversity of mRNA 3′ UTRs mediating miRNA binding sites influence miRNA-mediated regulation. Alternative polyadenylation, by shortening mRNA isoforms, increases the diversity of 3′ UTRs; moreover, short mRNA isoforms elude miRNA-medicated repression. Because no current prediction methods for putative miRNA target sites consider whether or not 1) splicing-informed miRNA binding sites and/or 2) the use of 3′ UTRs provide higher resolution or functionality, we sought to identify not only the genome-wide impact of using exons in mRNA 3′ UTRs but also their functional connection to miRNA regulation and clinical outcomes in cancer. With a genome-wide expression of mRNA and miRNA quantified by 395 bladder cancer cases from The Cancer Genome Atlas (TCGA), we 1) demonstrate the diversity of 3′ UTRs affecting miRNA efficiency and 2) identify a set of genes clinically associated with mRNA expression in bladder cancer. Knowledge of 3′ UTR diversity will not only be a useful addition to current miRNA target prediction algorithms but also enhance the clinical utility of mRNA isoforms in the expression of mRNA in cancer. Thus, variability among cancer patient’s variability in molecular signatures based on these exon usage events in 3′ UTR along with miRNAs in bladder cancer may lead to better prognostic/treatment strategies for improved precision medicine.

Aerococcus urinae: An Emerging Cause of Urinary Tract Infection in Older Adults with Multimorbidity and Urologic Cancer

Aerococcus urinae is a rare organism isolated from urine cultures. We present a case of an 80 year-old male with bladder cancer and multimorbidity who developed A. urinae infection. A. urinae may cause simple and complicated UTIs, bacteremia, and endocarditis in older adults with multimorbidity, chronic urinary retention, or indwelling catheters. A. urinae treatment should employ penicillin, amoxicillin, and nitrofurantoin. Due to increasing antibiotic resistance, urine culture should include antibiotic susceptibility testing. Prompt and culture-specific treatment is critical to avoid clinical progression of the infection.

Clear cell adenocarcinoma of female urethra: A case report

Primary malignancies of the female urethra are rare, accounting for less than 1% of genitourinary malignancies. Clear cell adenocarcinoma of the urethra (CCAU) occurs more infrequently, accounting for 0.003% of malignancies of the female urogenital tract. Definitive clinical diagnosis of CCAU is difficult and must be differentiated from tumors of the vagina. Currently, there is limited understanding of the causes of CCAU and there is no established standard of care for treatment. Immunohistochemistry and pathologic analysis can be used to identify the origin of the tumor.