Faculty Bibliography

OBJECTIVE To determine if preoperative variables, including gender, age and tumour size, influence the decision for active surveillance of renal masses, as due to the increasing detection of incidental renal masses within the ageing population there is a need to identify reliable means of selecting patients who require therapy. PATIENTS AND METHODS We retrospectively identified all renal masses resected at our institution between 1 December 1999, and 1 October 2005. The size of tumour, patient age and gender were compared between those with and without malignancy on final pathology. The influence of these variables in predicting malignancy, high grade, and high stage were assessed by univariate and multivariate analysis using logistic regression models, with a significance level of P < 0.05. Subsets were analysed for the groups of patients with tumours of </=3 or >3 cm and those aged </=75 or >75 years. RESULTS Among 466 of 501 patients with evaluable data, univariate analysis showed that both male gender and increasing size positively predicted malignancy (odds ratio 1.13 and 1.40, respectively), but age, treated as a continuous variable, did not. On multivariate analysis both remained independent predictors of malignancy (odds ratio 1.13 and 1.40, respectively). Size was the only independent predictor of high-stage and high-grade disease on both univariate and multivariate analysis. Among 156 patients with tumours of </=3 cm, on multivariate analysis, male gender was only weakly associated with the risk of malignancy, whereas size remained strongly predictive (odds ratio 1.98, P = 0.076; and 2.16, P = 0.015, respectively). Neither male gender, size nor age increased the risk of high-stage or high-grade disease in this cohort. Patients who were aged >75 years had a greater risk of high-stage disease than those aged <75 years (odds ratio 2.64, P = 0.008). On multivariate analysis, age >75 years remained an independent predictor of malignancy and high-stage, along with size (odds ratio 2.75, P = 0.014; and 1.35, P < 0.001). CONCLUSIONS Increased size of tumour increases the risk of malignancy and the likelihood of high-stage and high-grade disease. Among patients aged >75 years there was a higher risk of malignancy and high-stage disease than in those aged </=75 years. As such, the decision for observation should not be based upon age alone, and should be approached with caution in patients aged >75 years, particularly for larger lesions

BACKGROUND:: Procedures performed in the office offer potential cost savings. Recent analyses suggest, however, that a fee-for-service system may incentivize subscale operations and, thus, contribute to excessive spending. The authors of this report sought to characterize changes in the practice of office-based and hospital-based endoscopic bladder surgery after 2005 increases in Medicare reimbursement. METHODS:: All office and hospital-based endoscopic surgeries that were performed in a faculty practice from 2002 through 2007 were identified using billing codes for procedures, diagnoses, and procedure locations and then analyzed using the chi-square test and logistic regression. Costs were estimated based on published Medicare reimbursements for office and hospital-based surgeries. RESULTS:: In total, 1341 endoscopic bladder surgeries were performed, including 764 in the office and 577 in the hospital. After 2005, the odds ratio (OR) for office surgery occurring among all cystoscopies and for surgery occurring in the office versus the hospital was 2.01 (95% confidence interval [CI], 1.71-2.37) and 2.29 (95% CI, 1.83-2.87), respectively. Among all treated lesions that were associated with a diagnosis of bladder cancer and nonbladder cancer, the OR for a procedure occurring in the office versus the hospital was 1.36 (95% CI, 1.07-1.73) and 1.99 (95% CI, 1.52-2.60), respectively. The likelihood of repeat surgery on the same lesion increased after 2005 (OR, 2.86; 95% CI, 1.46-5.62), and the likelihood of an office surgery leading to a bladder cancer diagnosis at the next visit declined (OR, 0.29; 95% CI, 0.16-0.51). The overall estimated expenditure increased by 50%. CONCLUSIONS:: After 2005, more bladder lesions were identified and treated in the office. In a single group practice, office treatment of bladder cancer did not fully explain this new practice pattern, suggesting a lowered threshold for office intervention. Cancer 2010. (c) 2010 American Cancer Society

OBJECTIVE: The purpose of this study was to compare a 3D T2-weighted imaging sequence with a conventional multiplanar 2D turbo spin-echo T2-weighted sequence in terms of tumor detection and staging of prostate cancer, as well as image quality. MATERIALS AND METHODS: Before prostatectomy, 38 men (mean age, 60 years) with prostate cancer underwent MRI of the prostate with multiplanar 2D turbo spin-echo T2-weighted sequences (total acquisition time, approximately 11 minutes 4 seconds) and a 3D T2-weighted sampling perfection with application optimized contrasts sequence with different flip angle evolutions (SPACE) (acquisition time, approximately 3 minutes 52 seconds). Two blinded observers in consensus reviewed 2D turbo spin-echo T2-weighted images and SPACE images for detection of peripheral zone cancer, extracapsular extension, and seminal vesicle invasion. The observers also assessed subjective image quality and measured the signal-to-noise ratio (SNR) of normal peripheral zone and tumor-to-peripheral zone contrast. Prostatectomy was used as the reference standard. The diagnostic accuracy of the two sequences was assessed with generalized estimating equations and McNemar tests. The agreement between sequences was assessed with kappa coefficients. A paired Wilcoxon signed rank test was used to compare the subjective image quality, SNR, and tumor-to-peripheral zone contrast of the two sequences. RESULTS: For tumor detection and diagnosis of extracapsular extension, there was substantial agreement between the two sequences (kappa = 0.79, kappa = 0.76) with no difference in sensitivity, specificity, positive predictive value, negative predictive value, accuracy (p = 0.25-1), or image quality (p = 0.937). Images obtained with the 2D turbo spin-echo sequence had a significantly higher SNR ratio for normal peripheral zone (p = 0.0010), but SPACE images had significantly greater tumor-to-peripheral zone contrast (p < 0.0001). CONCLUSION: In comparison with conventional multiplanar 2D turbo spin-echo MRI of the prostate, 3D T2-weighted SPACE MRI was associated with substantial time saving (nearly 8 minutes), had similar image quality and accuracy in the diagnosis of tumor and extracapsular extension, and had better tumor conspicuity

Laparoscopic partial nephrectomy (LPN) was first described in 1992. Its increased use in recent years is a product of overall trends in surgery to minimize operative morbidity, as well as the downward stage migration of renal tumors detected incidentally through widespread medical imaging. Today the indications for LPN have expanded to include larger and higher stage tumors. This review focuses on techniques that will be helpful to the practicing urologist and examines the most up-to-date reports regarding the oncologic and functional outcomes in LPN. Alternative approaches and emerging techniques are also discussed

Angiomyolipoma with epithelial cysts (AMLEC) is a rare variant of angiomyolipoma with minimal fat that contains epithelial-lined cysts and may mimic a cystic renal cell carcinoma. While 17 cases have been described in the pathology literature since this entity was first described in 2006, the radiologic appearance was not demonstrated in any of these cases. We report the CT and MRI appearance of AMLEC found incidentally in a patient with lupus nephritis

Open radical prostatectomy (ORP) is the reference standard for the surgical management of localized prostate cancer. With wider availability of minimally invasive radical prostatectomy techniques, there is a debate regarding the standard treatment of the management of localized prostate cancer. Therefore, we reviewed the current status of laparoscopic radical prostatectomy (LRP) and robotic-assisted laparoscopic radical prostatectomy (RALRP) as compared with ORP. Because no prospective, randomized trials comparing the different techniques have been performed, outcomes must be assessed from published series by centers that focus on ORP, LRP, and RALRP. Aside from reducing the amount of blood loss, current data suggest that the most significant outcomes (cure, continence, and potency) are no better with LRP or RALRP than with conventional ORP. Therefore, in experienced hands, ORP remains the gold standard procedure. However, there is a trend toward consistently better outcomes following RALRP in comparison with LRP. In the end, individual patient outcomes can be maximized by choosing the best modality based on the patient's comorbid medical conditions, cancer characteristics, and surgeon experience. Future studies are needed to further investigate long-term cancer control as well as functional outcomes for RALRP series

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