Faculty Bibliography

PURPOSE: We investigated whether adding the IIF categorization improved the accuracy of Bosniak renal cyst classification, as evidenced by a low rate of progression in IIF lesions and a high rate of malignancy in category III lesions. MATERIALS AND METHODS: We retrospectively reviewed the records of patients with complex renal cysts categorized as a Bosniak IIF or III. Surveillance imaging and pathological outcomes of category IIF cysts were recorded to determine radiological predictors of progression. Pathological outcomes of category III cysts were recorded to determine the malignancy rate. RESULTS: A total of 112 patients met study inclusion criteria, of whom 81 were initially diagnosed with a category IIF cyst and 31 had a Bosniak category III cyst. At a median followup of 15 months 14.8% of Bosniak IIF lesions progressed in complexity with a median time to progression of 11 months (maximum greater than 4 years). There were no differences in tumor or patient characteristics between cysts that progressed and those that remained stable. In the 33 patients with Bosniak III lesions who underwent surgical extirpation the malignancy rate was 81.8%. Most patients had low stage, low grade disease and remained recurrence-free at a median followup of 6 months. CONCLUSIONS: Adding the IIF category has increased the accuracy and clinical impact of the Bosniak categorization system, as evidenced by a low rate of progression in category IIF cysts and an increased rate of malignancy in surgically treated category III lesions compared to those in historical controls

OBJECTIVE To determine if biopsy characteristics can be used to identify men with unilateral prostate cancer on radical prostatectomy (RP) pathological specimens, thereby selecting candidates for hemi-ablative focal therapy. PATIENTS AND METHODS Of 1458 men who had RP from January 2000 to June 2007, we identified 590 of 880 evaluable patients with unilateral disease on their preoperative biopsy. Charts were reviewed to record preoperative prostate-specific antigen (PSA) level, high-grade prostatic intraepithelial neoplasia (HGPIN), clinical stage, Gleason score, perineural invasion (PNI), prostate volume, number of positive cores, and percentage of positive cores. Final surgical pathology was evaluated for unilateral cancer. Univariate analysis was used (logistic regression method) to identify independent predictors of unilateral disease on the RP specimen. A subset analysis was done in men with low-risk disease, defined as clinical stage T1C, Gleason score <7 and a PSA level of <10 ng/mL. RESULTS Of 590 men with unilateral disease on biopsy, 163 (27.3%) had unilateral disease on the RP specimen. Pathological features, including HGPIN (P = 0.714), Gleason score (P > 0.608), PNI (P = 0.714), number of positive cores (P = 0.076), percentage of cores positive (P = 0.056), prostate volume (P = 0.285), and PSA level (P = 0.062) did not improve the prediction of unilateral disease. When men with unilateral cancer were further stratified to include only those with low-risk disease, 28.4% had unilateral disease on the RP specimen. None of the biopsy or clinical features evaluated were predictors of unilateral disease on the RP specimen. CONCLUSION Unilateral prostate cancer on biopsy predicts unilateral disease on RP pathology in only 27.6% of cases. The predictive ability is not improved by adding biopsy and clinical characteristics. Additional methods are needed to accurately identify men appropriate for focal therapy

PURPOSE: We evaluated the effect of warm ischemia time on early postoperative renal function following laparoscopic partial nephrectomy. MATERIALS AND METHODS: Of 453 patients who were surgically treated for renal tumors between May 2001 and September 2007, and who were identified in our database 128 underwent laparoscopic partial nephrectomy. Of these 128 patients 101 who were evaluable had complete demographic, operative, preoperative and early postoperative data available. Renal function was estimated using the glomerular filtration rate. Warm ischemia time was stratified into 4 interval groups and also analyzed based on different time cutoffs. Ultimately we also tested the relationship between postoperative renal failure, and preoperative factors and warm ischemia time. RESULTS: Warm ischemia time interval analysis was not significant. However, when analyzing the effect of warm ischemia time cutoffs, patients with warm ischemia time greater than 40 minutes had a significantly greater decrease in the glomerular filtration rate (p = 0.03) and a lower glomerular filtration rate postoperatively. The incidence of renal function impairment was more than 2-fold higher in those with a warm ischemia time of greater than 40 minutes than in the other groups (p = 0.077). Warm ischemia time was significant on univariate analysis when only patients with a preoperative glomerular filtration rate of 60 ml per minute per 1.73 m(2) or greater were analyzed. However, this did not hold as an independent predictor of postoperative renal function impairment on multivariate analysis. The preoperative glomerular filtration rate was the only independent predictor of postoperative renal function impairment. CONCLUSIONS: A warm ischemia time of 40 minutes appears to be an appropriate cutoff, after which a significantly greater decrease in renal function occurs after laparoscopic partial nephrectomy. The preoperative glomerular filtration rate was the only independent predictor of an increased risk of renal insufficiency following laparoscopic partial nephrectomy

OBJECTIVE: To determine if adjustment of prostate-specific antigen velocity (PSAV) for variation improves prediction of cancer in men with previous negative prostate biopsy. PATIENTS AND METHODS: Records of men undergoing prostate biopsy between 1999 and 2004 by a single urologist were reviewed to identify men with at least three follow up PSA measurements. Patients with atypia, high grade prostatic intraepithelial neoplasia or cancer on baseline biopsy were excluded. Men were rebiopsied if perceived to have rising PSA. Men with cancer, no cancer, or no repeat biopsy were compared for PSAV and a new parameter, PSAV%/Variation. PSAV was calculated by linear regression, and adjusted to percent change (PSAV%). Diagnostic accuracy was assessed by receiver operating characteristic curve. RESULTS: Of 118 men who met inclusion criteria, 32 had repeat biopsies. Nine biopsies were positive (group 1) and 22 were negative (group 2). The PSAV%, PSAV, and PSAV%/Variation for groups 1 versus 2 was 22.9% and 1.7% (p = 0.004), 1.12 versus 0.4 ng/ml/year (p = 0.007), and 1.07 verus 0.03 (p < 0.001), respectively. PSAV%/Variation had the largest area under the curve (0.881), compared with PSAV (0.744) and PSAV% (0.784). At cut off of 0.77, specificity was 86.4% and sensitivity was 87.5% for PSAV%/Variation. At the same sensitivity level, the specificities of PSAV% and PSAV were 77.3% and 63.6%, respectively. CONCLUSION: Correction for variation could potentially make PSAV a more reliable parameter in patients with prior negative biopsy. The results of our preliminary study warrant further analysis in a larger prospective cohort

PURPOSE: We describe the literature base pertaining to adrenalectomy at radical nephrectomy and present a pragmatic approach based on primary tumor and disease characteristics. MATERIALS AND METHODS: Literature searches were performed via the National Center for Biotechnology Information databases using various keywords. Articles that pertained to the concomitant use of adrenalectomy with radical nephrectomy were surveyed. RESULTS: The incidence of solitary, synchronous, ipsilateral adrenal involvement, ie that which is potentially curable with ipsilateral adrenalectomy along with nephrectomy, is much lower than previously thought at 1% to 5%. Evidence to date supports increased size and T stage, multifocality, upper pole location and venous thrombosis as risk factors for adrenal involvement. Cross-sectional imaging is now accurate at demonstrating the absence of adrenal involvement but still carries a significant risk of false-positives. The morbidity of adrenalectomy is minimal except in those patients with metachronous contralateral adrenal metastasis in whom the impact of adrenal insufficiency can be devastating. Disease specific and overall survival of those undergoing radical nephrectomy, with or without adrenalectomy, are similar. The survival of patients with widespread metastatic disease is historically poor regardless of whether adrenalectomy is performed. There is evidence for a survival advantage in patients with isolated adrenal metastasis, although this group comprises no more than 2% of those undergoing surgery for renal tumors. CONCLUSIONS: The apparent benefit of ipsilateral adrenalectomy does not support it as a standard practice in all patients with normal imaging. However, it should be considered in select cases in which there are risk factors for adrenal involvement

The androgen receptor (AR) directs diverse biological processes through interaction with coregulators such as AR trapped clone-27 (ART-27). Our results show that ART-27 is recruited to AR-binding sites by chromatin immunoprecipitation analysis. In addition, the effect of ART-27 on genome-wide transcription was examined. The studies indicate that loss of ART-27 enhances expression of many androgen-regulated genes, suggesting that ART-27 inhibits gene expression. Surprisingly, classes of genes that are up-regulated upon ART-27 depletion include regulators of DNA damage checkpoint and cell cycle progression, suggesting that ART-27 functions to keep expression levels of these genes low. Consistent with this idea, stable reduction of ART-27 by short-hairpin RNA enhances LNCaP cell proliferation compared with control cells. The effect of ART-27 loss was also examined in response to the antiandrogen bicalutamide. Unexpectedly, cells treated with ART-27 siRNA no longer exhibited gene repression in response to bicalutamide. To examine ART-27 loss in prostate cancer progression, immunohistochemistry was conducted on a tissue array containing samples from primary tumors of individuals who were clinically followed and later shown to have either recurrent or nonrecurrent disease. Comparison of ART-27 and AR staining indicated that nuclear ART-27 expression was lost in the majority of AR-positive recurrent prostate cancers. Our studies show that reduction of ART-27 protein levels in prostate cancer may facilitate antiandrogen-resistant disease

OBJECTIVES: To report a technique of stomal creation before abdominal wall transposition of the conduit that reduces asymmetry, retraction, and stenosis of the stoma. The ileal conduit remains the most common form of urinary diversion. Despite extensive experience with the procedure, a significant rate of stomal complications is still observed. METHODS: Unlike the traditional approach, after the segment of the distal ileum is selected and excluded from the bowel continuity, the stoma is prepared intracorporeally. The critical elements of this technique include defatting of the distal mesentery, placement of everting sutures immediately adjacent to the bowel mesentery in a diamond configuration, full-thickness locking sutures to fix the eversion, and fascial fixation sutures on abdominal wall transposition. RESULTS: The technique of early stomal maturation has been performed in 45 consecutive ileal conduit procedures. To date, early stomal retraction with poor appliance fit has been observed in 1 patient who underwent simultaneous abdominal wall reconstruction, requiring early revision of the stoma. The remaining stomas have demonstrated excellent protrusion with no requirement for revision owing to stenosis or retraction. CONCLUSIONS: To date, we have experienced excellent outcomes with the technique, independent of body habitus or mesenteric thickness. The usual tendency of the stoma to be flush at the position of the mesentery is avoided, and symmetric protrusion of the stoma appears to allow a better stomal appliance fit. The effect on long-term complication rates remains to be defined