Trends in Utilization of Robotic and Open Partial Nephrectomy for Management of cT1 Renal Masses

BACKGROUND

Partial nephrectomy is widely used for surgical management of small renal masses. Use of robotic (RPN) versus open partial nephrectomy (OPN) among various populations is not well characterized.

OBJECTIVE

To analyze trends in utilization of RPN and disparities that may be associated with this procedure for management of cT1 renal masses in the USA.

DESIGN, SETTING, AND PARTICIPANTS

Patients who underwent RPN or OPN for clinical stage T1N0M0 renal masses in the USA from 2010 to 2013 were identified in the National Cancer Data Base. A total of 23 154 patients fulfilled the inclusion criteria.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Univariable and multivariable logistic regression analyses were performed to evaluate differences in receiving RPN or OPN across various patient groups.

RESULTS AND LIMITATIONS

Utilization of RPN increased from 41% in 2010 to 63% in 2013. Black patients (adjusted odds ratio [aOR] 0.91, 95% confidence interval [CI] 0.84-0.98) and Hispanic patients (aOR 0.85, 95% CI 0.77-0.95) were less likely to undergo RPN. RPN was less likely to be performed in rural counties (aOR 0.80, 95% CI 0.66-0.98) and in patients with no insurance (aOR 0.52, 95% CI 0.44-0.61) or patients covered by Medicaid (aOR 0.81, 95% CI 0.73-0.90). There was no significant difference in RPN utilization between academic and non-academic facilities. Patients with higher clinical stage (aOR 0.58, 95% CI 0.55-0.62) and comorbidities (aOR 0.79, 95% CI 0.71-0.88) were also less likely to undergo RPN.

CONCLUSIONS

Utilization of RPN has continued to increase over time; however, there are significant disparities in its utilization according to race and socioeconomic status. Black and Hispanic patients and patients in rural communities and with limited insurance were more likely to be treated with OPN instead of RPN.

PATIENT SUMMARY

The use of robotic surgery in partial nephrectomy for management of small renal masses has increased over time. We found a significant disparity across different racial and socioeconomic groups in use of robotic partial nephrectomy compared to open surgery. Patients living in rural areas, with limited insurance, and multiple medical comorbidities were more likely to undergo open than robotic partial nephrectomy.

Reclassification Rates of Patients Eligible for Active Surveillance After the Addition of Magnetic Resonance Imaging-Ultrasound Fusion Biopsy: An Analysis of 7 Widely Used Eligibility Criteria

OBJECTIVES

To evaluate the impact of adding magnetic resonance imaging-ultrasound (MRI-US) fusion biopsy cores to standard 12-core biopsy in selecting men for active surveillance (AS).

MATERIALS AND METHODS

Among men undergoing a fusion biopsy for evaluation of prostate cancer, we selected men who were eligible for at least 1 of 7 different AS criteria based on the standard biopsy alone. We assessed each patient's eligibility for each AS criterion with and without the inclusion of fusion biopsy cores. The primary end point was the proportion of men who were initially eligible for AS but became ineligible after addition of the fusion biopsy cores.

RESULTS

A total of 100 men were eligible for at least 1 AS criterion. After addition of fusion biopsy cores, the proportion of men who became ineligible for AS varied from 10.3% to 40.7%. Criteria that incorporated an absolute maximum number of cores positive had the highest rates of ineligibility. Using a percentage of cores positive helped to reduce the number of patients who would have been excluded. Combining the targeted biopsy cores into one, or taking the single core with the highest grade or volume did not appear to reduce the proportion of men who became ineligible.

CONCLUSIONS

The addition of fusion biopsy to standard 12-core biopsy significantly increased the number of men who became ineligible for AS. Using the percent of cores positive, instead of an absolute number, allowed fewer exclusions. AS criteria may need to be updated to prevent the unnecessary exclusion of men due to an oversampling of low-risk disease.

Advances in the management of castration resistant prostate cancer

Docetaxel based chemotherapy showed survival benefit and emerged as the mainstay of treatment for castration resistant prostate cancer (CRPC) in 2004. However, therapeutic options have expanded rapidly since 2011. The spectrum of new agents is broad and includes drugs that target the androgen axis (enzalutamide, abiraterone), immunotherapy (sipuleucel-T), bone seeking radionuclides (radium-223), and second line chemotherapy (cabazitaxel). In addition, new agents have been developed to reduce skeletal related events (denosumab). Given that docetaxel was the standard first line treatment for metastatic CRPC, the newer oral agents that affect the androgen axis were initially approved in the post-docetaxel setting. However, subsequent randomized trials have led to their approval in the pre-chemotherapy setting as well. Patients with CRPC are clinically heterogeneous, ranging from patients who are asymptomatic and do not have metastases to those with substantial symptoms and both bony and visceral metastases. CRPC is a clinically challenging disease entity, therefore, with a wide array of treatment options and multiple possible sequencing combinations depending on the individual patient. This review will summarize the findings of the randomized trials that led to the approval of the therapies for CRPC. It will also discuss recent guidelines and provide suggestions for sequencing of drugs based on the best available evidence.

Diagnosis and Treatment of Non-Muscle Invasive Bladder Cancer: AUA/SUO Guideline

PURPOSE

Although associated with an overall favorable survival rate, the heterogeneity of non-muscle invasive bladder cancer (NMIBC) affects patients' rates of recurrence and progression. Risk stratification should influence evaluation, treatment and surveillance. This guideline attempts to provide a clinical framework for the management of NMIBC.

MATERIALS AND METHODS

A systematic review utilized research from the Agency for Healthcare Research and Quality (AHRQ) and additional supplementation by the authors and consultant methodologists. Evidence-based statements were based on body of evidence strength Grade A, B, or C and were designated as Strong, Moderate, and Conditional Recommendations with additional statements presented in the form of Clinical Principles or Expert Opinions.(1) RESULTS: A risk-stratified approach categorizes patients into broad groups of low-, intermediate-, and high-risk. Importantly, the evaluation and treatment algorithm takes into account tumor characteristics and uniquely considers a patient's response to therapy. The 38 statements vary in level of evidence, but none include Grade A evidence, and many were Grade C.

CONCLUSION

The intensity and scope of care for NMIBC should focus on patient, disease, and treatment response characteristics. This guideline attempts to improve a clinician's ability to evaluate and treat each patient, but higher quality evidence in future trials will be essential to improve level of care for these patients.

Knowledge of the harms of tobacco use among patients with bladder cancer

BACKGROUND

The objective of this study was to determine tobacco use knowledge and attribution of cause in patients with newly diagnosed bladder cancer.

METHODS

A stratified, random sample of bladder cancer survivors diagnosed between 2006 and 2009 was obtained from the California Cancer Registry. Respondents were surveyed about tobacco use, risk factors, and sources of information on the causes of bladder cancer. Contingency tables and logistic regression analyses were used to evaluate tobacco use knowledge and beliefs.

RESULTS

Of 1198 eligible participants, 790 (66%) completed the survey. Sixty-eight percent of the cohort had a history of tobacco use, and 19% were active smokers at diagnosis. Tobacco use was the most cited risk factor for bladder cancer, with active smokers more knowledgeable than former smokers or never smokers (90% vs 64% vs 61%, respectively; P<.001). Urologists were the predominant source of information and were cited most often by active smokers (82%). In multivariate analyses, active smokers had 6.37 times greater odds (95% confidence interval, 3.35-12.09) than never smokers of endorsing tobacco use as a risk factor for bladder cancer, and smokers who named the urologist as their information source had 2.80 times greater odds (95% confidence interval, 1.77-4.43) of believing tobacco use caused their cancer.

CONCLUSIONS

Patients' smoking status and primary source of information were associated with knowledge of the harms of tobacco use and, in smokers, acknowledgment that tobacco use increased the risk of their own disease. Urologists play a critical role in ensuring patients' knowledge of the connection between smoking and bladder cancer, particularly for active smokers who may be motivated to quit.

Increasing use of observation among men at low risk for prostate cancer mortality

PURPOSE

There are growing concerns regarding the overtreatment of localized prostate cancer. It is also relatively unknown whether there has been increased uptake of observational strategies for disease management. We assessed the temporal trend in observation of clinically localized prostate cancer, particularly in men with low risk disease, who were young and healthy enough to undergo treatment.

MATERIALS AND METHODS

We performed a retrospective cohort study using the SEER-Medicare database in 66,499 men with localized prostate cancer between 2004 and 2009. The main study outcome was observation within 1 year after diagnosis. We performed multivariable analysis to develop a predictive model of observation adjusting for diagnosis year, age, risk and comorbidity.

RESULTS

Observation was performed in 12,007 men (18%) with a slight increase with time from 17% to 20%. However, there was marked increase in observation from 18% in 2004 to 29% in 2009 in men with low risk disease. Men 66 to 69 years old with low risk disease and no comorbidities had twice the odds of undergoing observation in 2009 vs 2004 (OR 2.12, 95% CI 1.73-2.59). Age, risk group, comorbidity and race were independent predictors of observation (each p <0.001), in addition to diagnosis year.

CONCLUSIONS

We identified increasing use of observation for low risk prostate cancer between 2004 and 2009 even in men young and healthy enough for treatment. This suggests growing acceptance of surveillance in this group of patients.

Restaging transurethral resection for non-muscle invasive bladder cancer: who, why, when, and how?

The rate of clinical understaging in non-muscle invasive bladder cancer (NMIBC) after an initial transurethral resection (TUR) is significant, particularly for high-grade disease, and this has a major impact on prognosis. A repeat TUR, 2 to 6 weeks following the initial resection, is recommended in appropriately selected cases to avoid diagnostic inaccuracy and improve treatment allocation. This article summarizes the rationale and indications for performing a repeat TUR in NMIBC and also provides information regarding patient selection and technique.

Effect of statin use on biochemical outcome following radical prostatectomy

OBJECTIVE

•To determine the relationship between statin use and biochemical recurrence (BCR) following radical prostatectomy (RP).

PATIENTS AND METHODS

•A retrospective analysis was performed on 3198 RP patients between 1990 and 2008. •Exclusion criteria were neo-adjuvant or adjuvant therapy, follow-up <2 years, and insufficient pathological or prostate-specific antigen (PSA) data. •Statin use was determined from the patient's record. Clinical and pathological variables were compared between statin users and non-users. •Kaplan-Meier and multivariate Cox regression analyses were performed to determine the effect of statin use on BCR.

RESULTS

•A total of 1261 patients fit criteria for analysis. There were 281 (22%) statin users. Mean age was 60 years and median follow-up was 36 months (mean 43 months). •Statin users had a lower median preoperative PSA (6.4) compared with non-users (7.1) (P < 0.05). In all, 80% of statin users had a pathological Gleason sum ≥7 compared with 67% of non-users (P < 0.05). •On multivariate analysis, statin use was an independent predictor of BCR (hazard ratio 1.54, P < 0.05). Statin users had a lower 5-year BCR-free survival compared with non-users (75% vs 84%, P < 0.05).

CONCLUSIONS

•Statin users are at an increased risk for BCR following RP. This finding may be due to the reduction in preoperative PSA potentially delaying diagnosis and/or masking aggressive disease. •Further studies are necessary to elucidate the impact of statin medications following prostate cancer therapy.

Endoscopic management of vesicoureteral reflux in adult women

OBJECTIVE

• To describe our endoscopic management of adult women with vesicoureteral reflux (VUR) and associated outcomes.

PATIENTS AND METHODS

• We retrospectively identified 19 adult women who presented for the endoscopic treatment of VUR from November 2001 to January 2008. • Each patient was diagnosed with VUR by voiding cystourethrogram or nuclear cystourethrogram after an episode of pyelonephritis or recurrent urinary tract infections with renal scarring on ultrasound. • A dimercaptosuccinic acid renal scan was performed prior to treatment. All patients underwent endoscopic treatment with dextranomer/hyaluronic acid copolymer (Deflux). Patients with bilateral VUR received bilateral injections during the same procedure. • Follow-up imaging was obtained and success was strictly defined as no degree of VUR. Patients with residual VUR received repeat endoscopic treatment.

RESULTS

• Nineteen patients with a mean age of 22 years old (range 18-33 years old) underwent endoscopic treatment for VUR. A total of 79% (15/19) had pre-existing risk factors for VUR, including prior open anti-reflux surgery (26%), family history of VUR (26%) and childhood diagnosis of VUR (26%). • Imaging revealed that 47% (9/19) had renal scarring and 26% (5/19) had bilateral VUR. The success rate was 79% (19/24) after one treatment, 92% (22/24) after 5 patients received a second treatment, and 96% (23/24) after 2 patients received a third treatment. There were no perioperative complications.

CONCLUSION

• Endoscopic management of VUR is both safe and effective in adult women.

ACE2 and angiotensin 1-7 are increased in a human model of cardiovascular hyporeactivity: pathophysiological implications

BACKGROUND

ACE and ACE2 produce angiotensin II (Ang II), a vasopressor that induces cardiovascular remodeling, and Ang 1-7, a vasodilator with an antiremodeling effect. While Ang 1-7 has antiarrhythmic properties, at higher concentration it may induce ventricular tachycardia and sudden death. ACE2, therefore, may play an essential role in blood pressure homeostasis, in the long-term complications of hypertension (cardiovascular remodeling), and in the induction of cardiac electric abnormalities. This study evaluated the levels of ACE2 and Ang 1-7 in Bartter's/Gitelman's patients (BS/GS) who have elevated Ang II and endogenous blockade of Ang II type 1 receptor signaling compared with healthy subjects (C) and essential hypertensives (EH). BS/ GS patients were also considered because of their predisposition to cardiac arrhythmias, which has yet to be completely clarified.

METHODS

Mononuclear cell ACE2 and Ang 1-7 were evaluated using western blot.

RESULTS

One-way ANOVA showed that ACE2 and Ang 1-7 levels were significantly different between the three groups (p=0.0074 and p=0.0001, respectively). Post-hoc analysis (Tukey's HSD) showed that both ACE2 (1.59+/-0.63) and Ang1-7 (2.26+/-1.18) were significantly elevated in BS/GS compared with either C (0.98+/-0.45; p=0.008; 1.12+/-0.48, p=0.002, respectively) or EH (1.06+/-0.24; p=0.043; 0.72+/-0.28; p=0.0001, respectively). ACE2 and Ang 1-7 directly correlated only in BS/GS (r=0.91, p<0.0003).

CONCLUSIONS

The elevated ACE2 and Ang 1-7 in BS/ GS patients mirror those in hypertensives and are in line with the clinical, hemodynamic and pathophysiological characteristics of BS/GS, likely contributing to them. In consideration of the clinical picture of these syndromes, the opposite of hypertension, the results of this study further strengthen the importance of the ACE2/Ang 1-7 system in the regulation of vascular tone and cardiovascular biology.