Zachary Klaassen

Factors associated with suicide in patients with genitourinary malignancies

Approximately 70% of all suicides in patients aged >60 years are attributed to physical illness, with higher rates noted in patients with cancer. The purpose of the current study was to characterize suicide rates among patients with genitourinary cancers and identify factors associated with suicide in this specific cohort.

Robot-Assisted Anatrophic Nephrolithotomy: Description of Technique and Early Results

PURPOSE To assess the feasibility and report early outcomes of robot-assisted anatrophic nephrolithotomy (RAN) as a treatment modality for patients with complex staghorn calculi. PATIENTS AND METHODS In this single-center prospective study, seven consecutive patients underwent RAN for complex staghorn calculi. After dissection to the renal hilum and clamping of the renal vessels, a nephrotomy was made along the Brodel line and dissection carried through the collecting system to the calculus. The stone was extracted, and the collecting system and parenchyma were closed in layers; no cooling of the kidney was performed. RESULTS The mean patient age was 47±16 years, mean body mass index was 31.9±10.0 kg/m(2), and five of seven patients had complete staghorn calculi. Mean warm ischemia time was 35±7 minutes, mean robotic time was 158±51 minutes, and mean estimated blood loss was 121±39 mL. Mean length of stay was 3.0±1.7 days, and there was one perioperative complication. Five of seven patients had >90% reduction in stone burden, and two (29%) patients were completely stone free. Mean follow-up time was 5.1±4.3 months, and there was no decrease in postoperative estimated glomerular filtration rate compared with preoperative values. CONCLUSIONS Our preliminary experience with RAN demonstrates a safe procedure with encouraging outcomes as a minimally invasive treatment modality for patients with extensive stone burden. Longer follow-up to determine the effect of RAN on renal function is needed.

Comparison of Abiraterone Acetate and Docetaxel with Androgen Deprivation Therapy in High-risk and Metastatic Hormone-naïve Prostate Cancer: A Systematic Review and Network Meta-analysis

CONTEXT Randomized clinical trials have recently examined the benefit of adding docetaxel or abiraterone to androgen deprivation therapy (ADT) in hormone-naïve advanced prostate cancer (PCa). OBJECTIVE To perform a systematic review and network meta-analysis of randomized clinical trials, indirectly evaluating overall survival (OS) for men treated with abiraterone acetate plus prednisone/prednisolone with ADT (Abi-ADT) versus docetaxel with ADT (Doce-ADT) in hormone-naïve high-risk and metastatic PCa. EVIDENCE ACQUISITION Medline, Embase, Web of Science, Scopus, and Clinicaltrials.gov databases were searched in August 2017. We pooled results using the inverse variance technique and random-effects models. The Bucher technique for indirect treatment comparison was used to compare Abi-ADT with Doce-ADT. A priori subgroup and sensitivity analyses were performed. EVIDENCE SYNTHESIS Overall, 6067 patients from five trials were included: 1181 (19.5%) patients who received Doce-ADT, 1557 (25.7%) patients who received Abi-ADT, and 3329 (54.9%) patients who received ADT-alone. There was a total of 1921 deaths: 391 in the Doce-ADT group, 353 in the Abi-ADT group, and 1177 in the ADT-only group. The pooled hazard ratio (HR) for OS was 0.75 (95% confidence interval [CI]: 0.63-0.91, I2=51%, 3 trials, 2951 patients) for Doce-ADT versus ADT-alone and 0.63 (95% CI: 0.55-0.72, I2=0%, 2 trials, 3116 patients) for Abi-ADT versus ADT-alone. The indirect comparison of Abi-ADT to Doce-ADT demonstrated no statistically significant difference in OS between these approaches (HR: 0.84, 95% CI: 0.67-1.06). Findings were similar in various a priori subset analyses, including patients with metastatic disease. Bayesian analyses demonstrated comparable results (HR: 0.83, 95% CI: 0.63-1.16). Despite the lack of statistical significance, Surface Under the Cumulative Ranking Analysis demonstrated an 89% probability that Abi-ADT was preferred. CONCLUSIONS We did not identify a significant difference in OS between Abi-ADT and Doce-ADT for men with hormone-naïve high-risk or metastatic PCa, although Bayesian analysis demonstrates a high likelihood that Abi-ADT was preferred. PATIENT SUMMARY We synthesized the evidence available from studies examining the administration of docetaxel or abiraterone in combination with hormonal therapy for patients with newly diagnosed, advanced prostate cancer. While these studies did not directly compare these agents, we used methodological techniques to indirectly compare them and found no significant difference in overall survival.

First-line Systemic Therapy for Metastatic Renal Cell Carcinoma: A Systematic Review and Network Meta-analysis

CONTEXT In the last decade, there has been a proliferation of treatment options for metastatic renal cell carcinoma (mRCC). However, direct comparative data are lacking for most of these agents. OBJECTIVE To indirectly compare the efficacy and safety of systemic therapies used in the first-line treatment of mRCC. EVIDENCE ACQUISITION Medline, EMBASE, Web of Science, and Scopus databases were searched using the OvidSP platform for studies indexed from database inception to October 23, 2017. Abstracts of conferences of relevant medical societies were included, and the systematic search was supplemented by hand search. For the systematic review, we identified any parallel-group randomized controlled trials assessing first-line systemic therapy. For network meta-analysis, we limited these to a clinically-relevant network based on standard practice patterns. Progression-free survival (PFS) was the primary outcome. Overall survival (OS) and grade 3 and 4 adverse events (AEs) were secondary outcomes. EVIDENCE SYNTHESIS In total, 37 trials reporting on 13 128 patients were included in the systematic review. The network meta-analysis comprised 10 trials reporting on 4819 patients. For PFS (10 trials, 4819 patients), there was a high likelihood (SUCRA 91%) that cabozantinib was the preferred treatment. For OS (5 trials, 3379 patients), there was a 48% chance that nivolumab plus ipilimumab was the preferred option. There was a 67% likelihood that nivolumab plus ipilimumab was the best tolerated regime with respect to AEs. CONCLUSIONS Cabozantinib and nivolumab plus ipilimumab are likely to be the preferred first-line agents for treating mRCC; however, direct comparative studies are warranted. These findings may provide guidance to patients and clinicians when making treatment decisions and may help inform future direct comparative trials. PATIENT SUMMARY There are many treatment options for patients diagnosed with metastatic renal cell carcinoma. We indirectly compared the available options and found that cabozantinib and nivolumab plus ipilimumab are likely to be preferable choices as the first-line treatment in this situation.

Decreasing suicide risk among patients with prostate cancer: Implications for depression, erectile dysfunction, and suicidal ideation screening

OBJECTIVE Prostate cancer is the most common malignancy among males, accounting for 19% of cancers, and the third most common cancer-related cause of death. Suicide rates in the United States have increased among males over the last decade. Further, suicide rates are higher in oncology patients, including patients with prostate cancer, compared to the general population. The objective of this article is to review the current literature and address the relationship between prostate cancer, depression, erectile dysfunction, and suicidal ideation. MATERIALS AND METHODS We reviewed the current literature pertaining to prostate cancer and depression, and prostate cancer and suicide. Furthermore, associations were made between erectile dysfunction and depression. RESULTS Men with prostate cancer at increased risk for suicidal death are White, unmarried, elderly, and men with distant disease. Time since diagnosis is also an important factor, since men are at risk of suicide>15 years after diagnosis. Approximately 60% of men with prostate cancer experience mental health distress, with 10%-40% having clinically significant depression. Additionally, patients that received androgen deprivation therapy (ADT) are 23% more likely to develop depression compared to those without ADT. Longitudinal studies of prostate cancer patients suggest that erectile dysfunction after curative treatment may have a significant psychological effect leading to depression. Herein, a newly proposed screening algorithm suggests for an evaluation with the expanded prostate cancer index composite-clinical practice, patient health questionnaire-9, and an 8-question suicidal ideation questionnaire to assess for health-related quality of life, depression, and suicidal ideation. CONCLUSION The burden of screening for erectile dysfunction, depression and suicidal ideation lies with the entire health care team, as there appears to be an association between these diagnoses, that is, compounded in patients with prostate cancer. The screening algorithm should assist with guiding timely and appropriate psychiatric referral to optimize outcomes in these high-risk patients.

Association of Obesity-Related Hemodilution of Prostate-Specific Antigen, Dihydrotestosterone, and Testosterone

Prostate‐specific antigen (PSA) hemodilution is the leading theory for lower PSA values in obese men. However, testosterone and dihydrotestosterone (DHT), which are necessary for PSA production, are reduced in obese men. We assessed the relationship of body mass index (BMI) and PSA, taking into consideration the effect of testosterone and DHT.

Zero-fragment Nephrolithotomy: A Multi-center Evaluation of Robotic Pyelolithotomy and Nephrolithotomy for Treating Renal Stones

BACKGROUND Robotic pyelolithotomy (RPL) and robotic nephrolithotomy (RNL) may be utilized for treating kidney stones as an alternative to percutaneous nephrolithotomy or flexible ureteroscopy. OBJECTIVE To describe the techniques of RPL and RNL, and present multi-center outcome data for patients undergoing these procedures. DESIGN, SETTING, AND PARTICIPANTS This study was a retrospective analysis of 27 patients undergoing RPL and RNL at five tertiary academic institutions between 2008 and 2014. SURGICAL PROCEDURE RPL and RNL without use of renal ischemia. MEASUREMENTS We assessed stone clearance by visual assessment and postoperative imaging. We also examined other factors, including complications (Clavien grade), estimated blood loss, operative time, and length of stay. RESULTS AND LIMITATIONS Twenty-seven patients underwent 28 procedures for a mean renal stone size of 2.74cm (standard deviation: 1.4, range: 0.8-5.8). The mean stone volume was 10.2cm3. RPL accounted for 26 of these procedures. RNL was performed in one patient, while another underwent combined RPL-RNL. Indications included failed previous endourological management (13), staghorn calculi (five), gas containing stone (one), calyceal diverticulum (one), complex urinary tract reconstruction (two), and patient preference (four). The mean patient age was 35.6 yr and mean body mass index was 25.5kg/m2. Mean operative time/console times were 182min and 128min, respectively. The mean estimated blood loss was 38ml. The mean length of stay was 1.7 d. There was no significant change in preoperative and postoperative serum creatinine levels. The overall complication rate was 18.5% (Clavien 1=3.7%; 2=7.4%; 3b=7.4%). The complete stone-free rate was 96%. CONCLUSIONS RPL and RNL are safe and reasonable options for removing renal stones in select patients. In particular, RPL allows the removal of stones without transgressing the parenchyma, reducing potential bleeding and nephron loss. PATIENT SUMMARY The robotic approach allows for complete removal of the renal stone without fragmentation, thereby maximizing chances for complete stone clearance in one procedure.

Intracavernosal Injection for the Diagnosis, Evaluation, and Treatment of Erectile Dysfunction: A Review

INTRODUCTION Intracavernosal injection (ICI) of a vasoactive agent has been an important part of the diagnosis, evaluation, and treatment of erectile dysfunction (ED) since its initial description by Virag in 1982. AIM To review the literature and summarize the use of ICI and its role in the diagnosis, evaluation, and treatment of ED. METHODS Literature review. MAIN OUTCOME MEASURE To define the role of ICIs utility in the diagnosis, evaluation, and treatment of ED. RESULTS When used in conjunction with color penile Doppler ultrasound for ED evaluation and diagnosis, ICI helps to detect penile vascular abnormalities and allows for differentiation between the multiple vasculogenic causes of impotence, thus helping clinicians to select the optimal treatment modality for each patient. Patients utilizing ICI continue to report high efficacy and satisfaction rates relative to other treatment options despite ICIs designation as a second-line therapy since the introduction of oral phosphodiesterase type 5 inhibitors in 1998. In recent years, ICI has also become an important part of penile rehabilitation programs following radical prostatectomy, as regular use of ICI is thought to increase the rate at which patients experience return of spontaneous erection through preservation of penile tissue integrity and prevention of corporeal smooth muscle atrophy. CONCLUSIONS ICI of vasoactive agents remains an important tool in treating and diagnosing ED, with high patient satisfaction and efficacy rates. However, the dropout rate for ICI therapy remains relatively high, and it may be associated with priapism, ecchymoses, hematoma formation, and penile fibrosis. Patients should be educated on the benefits and limitations of ICI therapy prior to beginning treatment in order to minimize dropout rates. Additional studies are necessary to better understand the possible long-term benefits of ICI therapy and how to most effectively structure the penile rehabilitation program after radical prostatectomy. Belew D, Klaassen Z, and Lewis RW. Intracavernosal injection for the diagnosis, evaluation, and treatment of erectile dysfunction: A review. Sex Med Rev 2015;3:11-23.

Body mass index and comorbidity are associated with postoperative renal function after nephrectomy

ABSTRACT Purpose: To explore the association of body mass index (BMI) and comorbidity with renal function after nephrectomy. Materials and Methods: We retrospectively analyzed 263 patients submitted to partial or radical nephrectomy from 2000-2013. Variables assessed included BMI, Charlson Comorbidity Index (CCI), race, tobacco use, tumor histology, surgical approach, Fuhrman nuclear grade, and tumor (T) classification. Glomerular filtration rate (GFR) was estimated using the Cockroft-Gault equation, adjusted for gender. Logistic regression was performed and included all interaction terms. Results: Median follow-up was 19.6 months (IQR 5.2, 53.7). Median preoperative GFR was 86.2mL/min/1.73m2 and median postoperative GFR was 68.4mL/min/1.73m2. BMI (OR 1.07, 95%CI 1.02-1.11), CCI (OR 1.19, 95%CI 1.04-1.37), and radical nephrectomy (OR 3.09, 95%CI 1.51-6.33) were significantly associated with a decline in renal function of ≥25%. Conclusion: BMI and CCI are associated with postoperative decline in renal function after nephrectomy. Additionally, radical nephrectomy is significantly associated with decreasing renal function compared to partial nephrectomy. These findings highlight the importance of assessing patient comorbidity in the decision making process for patients presenting with a renal mass.

Emerging association between androgen deprivation therapy and male meningioma: significant expression of luteinizing hormone-releasing hormone receptor in male meningioma.

Background:There is emerging data suggesting a potential risk for meningioma growth stimulation in patients on luteinizing hormone-releasing hormone (LHRH) analogs for prostate cancer. We examined the expression of LHRH receptor (LHRH-R), progesterone receptor (PR) and Ki67 labeling index (LI) in specimens from male meningioma (MM) and female meningioma (FM) patients.Methods:A total of 24 MM and 24 FM paraffin blocks were retrieved from our institution between 1991 and 2008. Sections from the paraffin blocks were stained with mouse monoclonal antibodies against LHRH-R, PR and Ki67. All male patients had no previous history of prostate cancer (PCa) or previous history of hormone therapy.Results:LHRH-R positivity was extensive in 92% of MM and 88% of FM samples, with both showing strong intensity (67% and 79%, respectively). PR was positive in 20 of 24 (83%) MM and 23 of 24 (96%) FM samples. MM is less likely to exhibit Ki67 LI >4% compared with FM.Conclusions:The majority of MM and FM samples were strongly positive for LHRH-R expression and PR expression. The emerging association of androgen deprivation therapy and meningioma growth should be recognized in urological practice. Caution should be taken when considering LHRH agonist administration for patients with PCa and concurrent meningioma or previous history of meningioma.