Faculty Bibliography

OBJECTIVE: To report outcomes of MRI-ultrasound fusion (MRF-TB) and 12-core systematic biopsy (SB) over a 26-month period in men with prior negative prostate biopsy. METHODS: Between 6/12 and 8/14, 210 men presenting to our institution for prostate biopsy with >/=1 prior negative biopsy underwent multiparametric MRI followed by MRF-TB and SB and were entered into a prospective database. Clinical characteristics, MRI suspicion scores (mSS), and biopsy results were queried from the database and the detection rates of Gleason >/=7 prostate cancer (PCa) and overall PCa were compared between biopsy techniques using McNemar's test. RESULTS: Fifty-three (31%) of 172 men meeting inclusion criteria (mean age 65+/-8 years; mean PSA 8.9+/-8.9) were found to have PCa. MRF-TB and SB had overall cancer detection rates (CDR) of 23.8% and 18.0% (p=0.12), respectively, and CDR for Gleason score (GS)>/=7 disease of 16.3% and 9.3% (p=0.01), respectively. Of 31 men with GS>/=7 disease, MRF-TB detected 28 (90.3%) while SB detected 16 (51.6%) (p<0.001). Using UCSF-CAPRA criteria, only one man was re-stratified from low-risk to higher risk based on SB results compared to MRF-TB alone. Among men with mSS<4, 80% of detected cancers were low-risk by UCSF-CAPRA criteria. CONCLUSIONS: In men with previous negative biopsies and persistent suspicion for PCa, SB contributes little to the detection of GS>/=7 disease by MRF-TB, and avoidance of SB bears consideration. Based on the low likelihood of detecting GS>/=7 cancer and overall low-risk features of PCa in men with mSS<4, limiting biopsy to men with mSS>/=4 warrants further investigation.

PURPOSE: The impact of cardiopulmonary bypass in level III-IV tumor thrombectomy on surgical and oncologic outcomes is unknown. We determine the impact of cardiopulmonary bypass on overall and cancer specific survival, as well as surgical complication rates and immediate outcomes in patients undergoing nephrectomy and level III-IV tumor thrombectomy with or without cardiopulmonary bypass. MATERIALS AND METHODS: We retrospectively analyzed 362 patients with renal cell cancer and with level III or IV tumor thrombus from 1992 to 2012 at 22 U.S. and European centers. Cox proportional hazards models were used to compare overall and cancer specific survival between patients with and without cardiopulmonary bypass. Perioperative mortality and complication rates were assessed using logistic regression analyses. RESULTS: Median overall survival was 24.6 months in noncardiopulmonary bypass cases and 26.6 months in cardiopulmonary bypass cases. Overall survival and cancer specific survival did not differ significantly in both groups on univariate analysis or when adjusting for known risk factors. On multivariate analysis no significant differences were seen in hospital length of stay, Clavien 1-4 complication rate, intraoperative or 30-day mortality and cancer specific survival. Limitations include the retrospective nature of the study. CONCLUSIONS: In our multi-institutional analysis the use of cardiopulmonary bypass did not significantly impact cancer specific survival or overall survival in patients undergoing nephrectomy and level III or IV tumor thrombectomy. Neither approach was independently associated with increased mortality on multivariate analysis. Greater surgical complications were not independently associated with the use of cardiopulmonary bypass.