Biomedical subjects

Yair Lotan

Publications and source records attributed to Yair Lotan.

At least 37 records · Page 2Linked to original sources

PubMed2006

Nicotinamide adenine dinucleotide staining immediately following radio frequency ablation of renal tumors-is a positive stain synonymous with ablative failure?

PURPOSE: Nicotinamide adenine dinucleotide diaphorase staining is arguably the standard for assessing tissue viability following radio frequency ablation, yet the accuracy of this test is questionable. Thus, it is imperative to examine the reliability of nicotinamide adenine dinucleotide to predict ablation success. To evaluate the observation that immediate nicotinamide adenine dinucleotide staining may not be clinically reliable, we compared results from immediate post-ablation biopsies of renal tumors to radiological and clinical followup. MATERIALS AND METHODS: Laparoscopic radio frequency ablation was performed in 9 patients and 10 tumors using a temperature modulated radio frequency system. Cold cup biopsies were taken immediately following ablation, and processed for nicotinamide adenine dinucleotide and hematoxylin and eosin staining. Patients were then followed using contrast enhanced computerized tomography at regular intervals. RESULTS: Median tumor size was 2.3 cm. Hematoxylin and eosin stain diagnosed 8 renal cell carcinomas and 2 angiomyolipomas. A quarter of the renal cell carcinomas and both angiomyolipomas stained positive for scattered nicotinamide adenine dinucleotide diaphorase activity immediately after RFA. Mean followup for the nicotinamide adenine dinucleotide positive tumors was 28.5 months (range 24 to 30) and for the nicotinamide adenine dinucleotide negative tumors was 25 months (range 18 to 30). There was no evidence of local tumor recurrence in any patient. CONCLUSIONS: Four lesions had nicotinamide adenine dinucleotide diaphorase activity on post-ablation biopsy suggesting retained viable tissue, yet there has been no recurrence during an average 2-year followup. While negative nicotinamide adenine dinucleotide staining is consistent with nonviability, these results suggest that false-positive staining can occur immediately following RFA, making the predictive value of positive nicotinamide adenine dinucleotide diaphorase staining unclear.

Adult↗

PubMed2006

Outcomes of radical cystectomy for transitional cell carcinoma of the bladder: a contemporary series from the Bladder Cancer Research Consortium.

PURPOSE: We present the characteristics and outcomes of a large, contemporary, consecutive series of patients treated with radical cystectomy and pelvic lymphadenectomy for transitional cell carcinoma of the bladder. MATERIALS AND METHODS: We developed a multi-institutional database and collected retrospective and prospective data on 888 consecutive patients with bladder transitional cell carcinoma who were treated with radical cystectomy and pelvic lymphadenectomy at 3 academic centers in the United States between 1984 and 2003. RESULTS: Of the patients 25% had extravesical tumor extension with negative lymph nodes and 23% had lymph node metastasis. The rate of lymph node involvement increased with advancing pathological stage. Mean recurrence-free and bladder cancer specific survival +/- SE was 58% +/- 2% and 66% +/- 2% at 5 years, respectively. On preoperative multivariate analysis clinical tumor stage and neoadjuvant systemic chemotherapy were associated with cancer recurrence, while more advanced age, clinical tumor stage and preoperative carcinoma in situ were associated with bladder cancer specific mortality. On postoperative multivariate analysis pathological tumor stage, lymph node metastasis, lymphovascular invasion, adjuvant radiotherapy and adjuvant chemotherapy were associated with cancer recurrence, while higher pathological tumor stage, more advanced age, lymph node metastasis, lymphovascular invasion and adjuvant radiotherapy were associated with disease specific survival. Patients with metastasis to regional lymph nodes (pT any N1-3) were at significantly higher risk for bladder cancer recurrence and death than patients with extravesical tumor extension (pT3N0), who in turn were at significantly higher risk than patients with organ confined disease (pT2 N0 or less). CONCLUSIONS: The results of this large, contemporary, multi-institutional series show that radical cystectomy and pelvic lymphadenectomy provide durable local control and disease specific survival in patients with localized invasive transitional cell carcinoma.

Adult↗

PubMed2006

Efficacy of high dose per fraction radiation for implanted human prostate cancer in a nude mouse model.

PURPOSE: SBRT is a new therapeutic paradigm using large dose per fraction treatments (aggressive hypofractionation). While SBRT has shown efficacy for treating patients with lung, liver and spine tumors, to our knowledge there have been no preclinical studies evaluating the efficacy of this treatment for prostate cancer. We investigated the dose-response characteristics of SBRT for treating human prostate cancer in a nude mouse model. MATERIALS AND METHODS: Nude mice were injected subcutaneously into the right flank with C4-2 prostate cancer cells grown in culture. A dose escalation trial was performed to assess toxicity and response. Tumor bearing animals were radiated with 3 fractions (1 per week) for a total dose of 15 Gy in 11, 22.5 Gy in 9 and 45 Gy in 10, while 8 untreated animals served as controls. The mice were weighed, and tumor volume and PSA measurements were performed at baseline and weekly until 4 weeks after treatment. RESULTS: There was no treatment related toxicity. There was a significant difference in the tumor response to higher radiation doses. In the 15 and 22.5 Gy groups mean tumor volume decreased to 58% and 90% of the original volume, respectively, but the rats experienced progressive tumor regrowth within 1 week after the completion of therapy. The 45 Gy group had a mean tumor volume and PSA decrease of greater than 90%, which was sustained 1 month after treatment in all except 2 mice. CONCLUSIONS: SBRT dose level treatments were able to significantly decrease tumor volume and PSA. However, using 15 and 22.5 Gy durable responses were not achieved except in a few mice. The 45 Gy group demonstrated sustained PSA and tumor volume decreases in most mice. These results clearly show an increasing dose-response relationship for a range of hypofractionated dose levels, as used in SBRT.

Animals↗

PubMed2006

Cancer specific outcomes in patients with pT0 disease following radical cystectomy.

PURPOSE: We assessed clinical outcomes in patients found to have no evidence of disease, ie pT0, in the cystectomy specimen following radical cystectomy for transitional cell carcinoma. MATERIALS AND METHODS: Between 1984 and 2003, 955 consecutive patients underwent bilateral pelvic lymphadenectomy and radical cystectomy for bladder cancer at 3 institutions, namely The Johns Hopkins Hospital, University of Texas Southwestern Medical Center and Baylor College of Medicine. Excluding nonTCC histology and patients with missing data resulted in 888 evaluable cases. Primary end points were recurrence-free survival and bladder cancer specific survival. RESULTS: Final pathological evaluation revealed absent transitional cell carcinoma in the cystectomy specimen, ie pT0, in 59 patients (7%), of whom 2 (3%) had pathologically positive lymph nodes. Transurethral resection stage or clinical stage data were available on 56 patients (95%), including Tis in 5 (9%), Ta in 2 (4%), T1 in 18 (32%), T2 in 29 (52%) and T3 in 2 (4%). Overall 6 recurrences (10%) were noted, including cTis in 1 case, cT1 in 1, cT2 in 3 and cT3 in 1. Median followup in patients with pT0 disease was 56 months (range 3 to 183). Three patients (5%) died of bladder cancer and another 4 (7%) died of other causes. Five and 10-year bladder cancer progression-free and cancer specific survival estimates in patients with pT0 disease were 90% and 81%, and 95% and 85%, respectively. CONCLUSIONS: Despite excellent clinical outcomes in the majority of patients with no evidence of tumor on final pathological evaluation not all patients with pT0 disease in the cystectomy specimen are cured of bladder cancer. These events may even occur in patients with nonmuscle invasive or muscle invasive organ confined pathology at staging transurethral resection. Further study is needed to identify prognostic factors in this population.

Adult↗

PubMed2006

Clinical outcomes following radical cystectomy for primary nontransitional cell carcinoma of the bladder compared to transitional cell carcinoma of the bladder.

PURPOSE: The effect of bladder cancer histological subtypes other than transitional cell carcinoma (nonTCC) on clinical outcomes remains uncertain. We conducted a multi-institutional retrospective study of patients with bladder cancer treated with radical cystectomy to assess the impact of nonTCC histology on bladder cancer specific outcomes. MATERIALS AND METHODS: A total of 955 consecutive patients underwent radical cystectomy with bilateral pelvic lymphadenectomy for bladder cancer at 3 academic institutions. TCC was present in the radical cystectomy specimen in 888 patients (93%). NonTCC histology was present in 67 patients (7%), including squamous cell carcinoma in 26, adenocarcinoma in 13, small cell carcinoma in 10 and other nonTCC subtypes (ie spindle cell carcinoma, carcinosarcoma and undifferentiated carcinoma) in 18. For patients alive at last followup median followup was 39 and 23 months for patients with TCC and nonTCC histologies, respectively. Bladder cancer specific progression and survival were assessed using Kaplan-Meier and multivariate Cox proportional hazards analyses. RESULTS: Bladder cancer specific progression and mortality did not differ significantly between patients with SCC and TCC histologies. Patients with nonTCC and nonSCC bladder cancer were at significantly increased risk for progression and death compared to patients with TCC or SCC (p <0.001). This association remained statistically significant in patients with organ confined disease (stage pT2 or lower) and patients with nonorgan confined disease (stage pT3 or higher) (p <0.001). In a multivariate analysis nonTCC and nonSCC histology was associated with an increased risk of bladder cancer progression and death (OR 2.272 and 2.585, respectively, p <0.001), even after adjusting for final pathological stage, lymph node status, lymphovascular invasion and neoadjuvant or adjuvant treatments. CONCLUSIONS: NonTCC and nonSCC histological subtype is an independent predictor of bladder cancer progression and mortality in patients undergoing radical cystectomy for bladder cancer. Patients with bladder TCC and SCC share similar stage specific clinical outcomes.

Aged↗

PubMed2006

Radiofrequency ablation of renal tumors: intermediate-term results.

BACKGROUND AND PURPOSE: Needle ablative therapies are being offered to patients presenting with small renal masses, but long-term outcomes are currently unavailable. We report our intermediate-term results (1-4 years) after radiofrequency ablation (RFA) of small (<4-cm) renal masses. PATIENTS AND METHODS: At our institution, all renal tumors treated using RFA since May 2001 have been recorded in a prospective database. During this time, 94 tumors (mean size 2.4 cm; range 1-4.2 cm) in 78 patients were treated using a temperature-based RFA generator by either a percutaneous (59%) or a laparoscopic approach. The patients followed with imaging at 6 weeks, 3 and 6 months, and every 6 months thereafter. Only patients with at least 12 months of follow-up were eligible for this analysis; the mean follow-up was 25 months. RESULTS: Of the 89% of masses that were biopsied, 77% were renal-cell carcinomas (RCC), of which 66% were Fuhrman grade 1, 31% were grade 2, and 3% were grade 3. Three recurrences were noted, for an overall recurrence-free rate of 96.8%. In this patient population with numerous comorbid conditions, there were six deaths but only one related to renal cancer, for a cancer-specific survival rate of 98.5% and an overall survival rate of 92.3%. CONCLUSION: In the intermediate term (1-4 years), the oncologic effectiveness of RFA appears comparable to that of traditional treatments offered for small renal masses. Further studies of larger numbers of patients with longer follow-up are needed.

Adult↗

PubMed2006

The cost of prostate cancer chemoprevention: a decision analysis model.

BACKGROUND: The Prostate Cancer Prevention Trial found reduced prostate cancer prevalence for men treated with finasteride. The public health cost of wide-scale chemoprevention is unclear. We developed a model to help clarify the cost effectiveness of public use of prostate cancer-preventive agents. METHODS: A Markov decision analysis model was designed to determine the lifetime prostate health-related costs, beginning at the age of 50 years, for men treated with finasteride compared with placebo. Model assumptions were based on data from the Prostate Cancer Prevention Trial, a literature review of survival and progression rates for patients treated with radical prostatectomy, and costs associated with prostate cancer disease states. RESULTS: Chemoprevention with finasteride resulted in a gain of 8.7 [corrected] life years per 1,000 men at a cost of $1.107 million [corrected] per life year saved (LYS). However, if finasteride is assumed to not increase the incidence of high-grade tumors, it renders a gain of 16.9 [corrected] life years per 1,000 men at a cost of $578,400 [corrected] per LYS; finasteride must cost $160 per year [corrected] to reach $100,000 [corrected] per LYS. When applied to a population at higher risk (lifetime prevalence >or=40%) [corrected]for developing prostate cancer, the cost of finasteride must be reduced from its current cost ($62/month) to <$15/month [corrected]for the cost effectiveness to fall below $50,000 [corrected] per LYS. CONCLUSIONS: Given the natural history of treated prostate cancer, implementation of chemoprevention would require an inexpensive medication with substantial cancer risk reduction to be cost effective. Targeting populations at higher risk for developing prostate cancer, however, allows for considerable flexibility in the medication cost to make prostate cancer chemoprevention a more attainable goal.

Aged↗

PubMed2005

Pre-operative percent free PSA predicts clinical outcomes in patients treated with radical prostatectomy with total PSA levels below 10 ng/ml.

INTRODUCTION: To evaluate the association of total prostate specific antigen (T-PSA) and percent free PSA (%F-PSA) with prostate cancer outcomes in patients treated with radical prostatectomy (RP). METHODS: Pre-operative serum levels of T-PSA and F-PSA were prospectively measured in 402 consecutive patients treated with RP for clinically localized prostate cancer who had T-PSA levels below 10 ng/ml. RESULTS: T-PSA was not associated with any prostate cancer characteristics or outcomes. Lower %F-PSA was significantly associated with higher percent positive biopsy cores, extracapsular extension, seminal vesicle involvement, lympho-vascular invasion, perineural invasion, positive surgical margins, and higher pathologic Gleason sum. When adjusted for the effects of standard pre-operative features, lower %F-PSA significantly predicted non-organ confined disease, seminal vesicle involvement, lympho-vascular invasion, and biochemical progression. %F-PSA did not retain its association with biochemical progression after adjusting for the effects of standard post-operative features. Based on data from 22 patients with biochemical progression, lower %F-PSA was correlated with shorter T-PSA doubling time after biochemical progression (rho = 0.681, p = 0.010). %F-PSA was lower in patients who failed salvage radiation therapy (p = 0.031) and in patients who developed distant cancer metastases compared to patients who did not (p < 0.001). CONCLUSIONS: Pre-operative T-PSA is not associated with prostate cancer outcomes after RP when levels are below 10 ng/ml. In contrast, pre-operative %F-PSA is associated with adverse pathologic features, biochemical progression, and features of aggressive disease progression in patients treated with RP and T-PSA levels below 10 ng/ml. %F-PSA may improve pre-operative predictive models for predicting clinical outcomes of patients diagnosed with prostate cancer nowadays.

Adult↗

PubMed2005

Lymphovascular invasion is independently associated with overall survival, cause-specific survival, and local and distant recurrence in patients with negative lymph nodes at radical cystectomy.

PURPOSE: We hypothesized that bladder cancer patients with associated lymphovascular invasion (LVI) are at increased risk of occult metastases. METHODS: A multi-institutional group (University of Texas Southwestern [Dallas, TX], Baylor College of Medicine [Houston, TX], Johns Hopkins University [Baltimore, MD]) carried out a retrospective study of 958 patients who underwent cystectomy for bladder cancer between 1984 and 2003. Of patients with transitional-cell carcinoma (n = 776), LVI status was available for 750. LVI was defined as the presence of tumor cells within an endothelium-lined space. RESULTS: LVI was present in 36.4% (273 of 750) overall, involving 26% (151 of 581) and 72% (122 of 169) of node-negative and node-positive patients, respectively. Prevalence of LVI increased with higher pathologic stage (9.0%, 23%, 60%, and 78%, for T1, T2, T3, and T4, respectively; P < .001). Using multivariate Cox regression analyses including age, stage, grade, and number of pelvic lymph nodes removed, LVI was an independent predictor of local (HR = 2.03, P = .049), distant (HR = 2.60, P = .0011), and overall (HR = 2.02, P = .0003) recurrence in node-negative patients. LVI was an independent predictor of overall (HR = 1.84, P = .0002) and cause-specific (HR = 2.07, P = .0012) survival in node-negative patients. LVI maintained its independent predictor status in competing risks regression models (P = .013), where other-cause mortality was considered as a competing risk. LVI was not a predictor of recurrence or survival in node-positive patients. CONCLUSION: LVI is an independent predictor of recurrence and decreased cause-specific and overall survival in patients who undergo cystectomy for invasive bladder cancer and are node-negative. These patients represent a high risk group that may benefit from integrated therapy with cystectomy and perioperative systemic chemotherapy.

Age Distribution↗

PubMed2005

International comparison of cost effectiveness of medical management strategies for nephrolithiasis.

Although medical therapy is known to reduce the risk of kidney stone recurrence, the cost effectiveness of medical prophylaxis is controversial. We evaluated medical treatment strategies including dietary measures (conservative), empiric medical therapy (empiric) or directed medical therapy (directed) based on comprehensive metabolic evaluation (CME) for patients with recurrent kidney stones, and compared the costs of these strategies using cost data from ten different countries. We previously established rates of stone formation in recurrent stone-formers, risk reduction of medical therapy, sensitivity of CME and rates of spontaneous stone passage from a comprehensive literature search (Lotan et al. 2004 J Urol 172: 2275). The costs of medication, surgical therapy, emergency room visits and CME for ten different countries were obtained from a published report of an international cost survey (Chandhoke 2002 J Urol 168: 937) as well as from our own county hospital in the US. Medication costs in the US were obtained from two national pharmacy chains. A decision tree model was created to compare the costs of different treatment strategies assuming cost accrual for metabolic evaluation, medical therapy and surgery or emergency room visits. For medical therapy, we assumed the distribution of medication use described in the published report, consisting of potassium citrate (60%), thiazide (30%) and allopurinol (10%). A nearly 20-fold difference in the costs of shock-wave lithotripsy, ureteroscopy and medication was found among different countries. From the model (US dollars/patient/year), conservative therapy alone was the most cost effective approach followed by empiric and directed medical therapy in all countries except in the UK. In the UK, the cost of drug therapy (estimated at dollar 29/patient/year) resulted in empiric therapy being the most cost effective strategy for recurrent stone formers. The low likelihood of surgical intervention, as well as the low relative cost of surgery to medication, contributed to the higher cost of empiric and directed medical therapy strategies. Of note, despite the higher cost, drug treatment strategies were associated with significantly lower stone recurrence rates. We found that drug treatment strategies are more costly than conservative treatment but produce good control of stone formation. In all but one country (UK), dietary therapy was the most cost effective approach due to the relatively low cost of surgery compared with medication. The differential resource allocation to different components of a healthcare system (i.e. subsidized medication versus surgical treatment) in different countries determines the cost effectiveness of various treatment strategies.

Cost-Benefit Analysis↗

PubMed2005

Implications of the prostate cancer prevention trial: a decision analysis model of survival outcomes.

PURPOSE: To assess the estimated effect of finasteride prevention of prostate cancer on overall survival. METHODS: Data for our decision tree model came from men in the two arms (finasteride or placebo) of the Prostate Cancer Prevention Trial (PCPT) and from clinically localized prostate cancer patients studied for long-term survival outcomes. Our model compared survival outcomes for men treated with finasteride or placebo. Prostate cancer rates were based on the 7-year period prevalence of prostate cancer detected in the PCPT; survival probabilities were abstracted from the long-term outcome studies. We assessed variability in the PCPT and long-term survival studies to test the variability of our model. RESULTS: Survival advantages for a finasteride-treated (v those not treated with finasteride) population include gains of 1.7 months in 15-year cause-specific survival (assuming finasteride-altered Gleason scores and prostate cancer prevalence rates in the PCPT), of up to 3 months for cancers treated conservatively or surgically (assuming finasteride does not alter Gleason scores), and of 0.35 months (assuming the rate of cancers detected by for-cause biopsies in the PCPT), which increased to 1.7 months when assuming a 30% rate of biopsy-detected cancer in the PCPT placebo group. Model-variability analyses support several survival benefits associated with finasteride (eg, the uniform benefits assuming finasteride does not alter Gleason scores) but question certain others (eg, in 15-year recurrence-free survivals assuming finasteride does alter Gleason scores). CONCLUSION: Finasteride can impart survival benefits according to our model, especially when we assume that finasteride does not alter Gleason scores.

Aged↗

PubMed2005

Urinary levels of tumor-associated trypsin inhibitor (TATI) in the detection of transitional cell carcinoma of the urinary bladder.

OBJECTIVE: To assess whether urinary levels of tumor-associated trypsin inhibitor (TATI) would aid in the detection of bladder transitional cell carcinoma (TCC); and to compare diagnostic performance of urinary TATI with that of nuclear matrix protein 22 (NMP22) and barbotage cytology. METHODS: We determined TATI and NMP22 levels in voided urine from 181 subjects: 153 with previous bladder cancer, 20 with urologic pathology other than bladder cancer, and eight healthy volunteers. TATI was analyzed continuously and categorically on the basis of its quartile distribution. We also measured urinary creatinine and barbotage cytology in 173 and 154 patients, respectively. RESULTS: Urinary TATI levels were significantly higher in TCC patients with evidence of tumor on cystoscopic evaluation (n = 96) than in control subjects (n = 85; p < 0.001). Higher levels of TATI were associated with positive cytology assay results (p = 0.018), higher NMP22 levels (p < 0.001), and invasive tumor stage (p = 0.026). The area under the receiver operating characteristics (ROC) curve (AUC) of TATI for the detection of TCC was 0.712 (95%CI: 0.637-0.786). The overall AUCs for TATI and NMP22 were not statistically different from each other (p = 0.174). In the >75% sensitivity region of the ROC curves, TATI was consistently more specific than NMP22. TATI, NMP22, and cytology were independently associated with bladder cancer (p = 0.049, p = 0.040, and p < 0.001, respectively). Adjustment of TATI for urinary creatinine levels did not affect any of the outcomes. CONCLUSIONS: Urinary level of TATI may add independent information to urinary cytology and NMP22 in the detection of bladder TCC. TATI seems to outperform NMP22 for bladder TCC detection.

Adult↗

PubMed2005

Conservative management of priapism in acute spinal cord injury.

OBJECTIVES: To perform a retrospective chart review of priapism as a complication of spinal cord injury and review the management and follow-up. Priapism is a known complication of acute spinal cord injury, but little has been written concerning the management of this condition. METHODS: A retrospective chart review (1992 through 2002) was performed for all patients with a diagnosis of priapism. Of these patients, 6 had priapism in the setting of acute spinal cord injury without pelvic trauma. We reviewed the management of the priapism in these cases, and follow-up was attempted in each case. RESULTS: Of the 6 patients with spinal cord injury-related priapism, 4 had spinal cord injury located at C5-C7, 1 at C5-C6, and 1 at T12. The prolonged erections were managed conservatively in 4 patients and irrigated with intracorporeal phenylephrine in 2. All patients with corporal blood gas measurement (n = 4) had nonischemic priapism. All 4 patients who underwent no intervention had the priapism resolve within 5 hours. Four patients (two treated conservatively and two who underwent irrigation) had recurrent episodes during the same admission that resolved spontaneously. Long-term outcomes were obtained by telephone from all 6 patients. Of the 6 patients, 5 had maintained spontaneous erections to date (range 3 to 10 years). CONCLUSIONS: The results of our study have shown that priapism related to acute spinal cord injury is nonischemic and may be managed conservatively because of the high likelihood of resolution. Corporal blood gas measurement is important because the results can guide further management decisions. Our results suggests that conservative management of priapism related to spinal cord injury has a low rate of causing long-term erectile dysfunction.

Acute Disease↗

PubMed2005

Correlation of office-based cystoscopy and cytology with histologic diagnosis: how good is the reference standard?

OBJECTIVES: To evaluate the accuracy of cystoscopy and cytology in predicting the histopathologic features of suspicious cystoscopic lesions. METHODS: We reviewed the bladder biopsy records at two institutions from July 2001 to July 2004. Intraoperative biopsies were performed for positive (papillary or sessile) (n = 155) and equivocal (n = 101) lesions found during office cystoscopy. The specimens were submitted for histopathologic analysis, and the results were correlated with the preceding office-based cystoscopy and cytology findings. RESULTS: Malignancy was found in 27 (26.7%) of 101 equivocal lesions and 128 (82.5%) of 155 sessile or papillary lesions. Of the 72 biopsies performed for equivocal lesions in patients with a history of transitional cell carcinoma (TCC), 24 (33%) had malignancy compared with 3 (10.3%) of 29 biopsies performed in patients without a history of TCC. For patients with no history of TCC and equivocal lesions, cytology was able to identify all neoplasms (100% sensitivity) and negative cytology always predicted a normal biopsy result (100% negative predictive value). However, for patients with a history of TCC and equivocal lesions, cytology had a sensitivity and negative predictive value of 81.8% and 88.2%, respectively. CONCLUSIONS: Our findings suggest that patients without a history of TCC who have an equivocal lesion at cystoscopy may avoid an unnecessary operation if they have normal cytology findings. A large number of patients with equivocal cystoscopic findings undergo unnecessary biopsies in the operating room, and future studies should be performed to assess the value of other bladder markers in predicting oncologic status in this setting.

Cystoscopy↗

PubMed2005

Cost comparison of laparoscopic versus radical retropubic prostatectomy.

OBJECTIVES: To determine the cost of laparoscopic radical prostatectomy (LRP) versus open radical retropubic prostatectomy (RRP) in an actual clinical setting, we analyzed the cost data from a single institution comparing LRP and RRP. LRP is increasing in prevalence, yet questions remain regarding its higher cost versus open RRP. METHODS: A chart and cost review was performed for consecutive patients undergoing LRP (n = 30) and RRP (n = 67) between May 2003 and August 2004. The clinical characteristics, operative techniques, and radiographic and pathologic information were recorded. Detailed cost information for room and board, laboratory, pharmacy, radiology, operating room, surgical supplies, anesthesia, recovery room, electrocardiography, and respiratory services were obtained. RESULTS: The total cost of the procedure was significantly more for LRP than for RRP (6,760 dollars versus 5,253 dollars, P < 0.001). Most of this difference was due to surgical supply (1,202 dollars LRP versus 145 dollars RRP, P < 0.001) and operating room costs (1,601 dollars LRP versus 1,141 dollars RRP, P < 0.001). The room and board and pharmacy costs were significantly lower for LRP than for RRP because of the shorter mean length of stay (1.73 days versus 2.37 days, P < 0.001). The laboratory/pathology and radiology costs were not significantly different. No significant difference was found in the Gleason score, preoperative prostate-specific antigen level, subject age, positive surgical margins, lymph node involvement, or seminal vesicle involvement between the two groups. CONCLUSIONS: At a single institution, the actual LRP costs were significantly greater than the costs for RRP, and this was predominantly due to the higher surgical supply and operating room costs.

Aged↗

PubMed2005

Gastrointestinal hemorrhage as first manifestation of metastatic testicular tumor.

We report a case of a man with a testicular mixed germ cell tumor in whom the first symptom was severe anemia secondary to upper gastrointestinal bleeding from a metastatic pure choriocarcinoma. He underwent ileal enterectomy, radical orchiectomy, and several cycles of chemotherapy (cisplatin, etoposide, and bleomycin). He died within 41 days of diagnosis.

Choriocarcinoma↗

PubMed2005

Nomograms including nuclear matrix protein 22 for prediction of disease recurrence and progression in patients with Ta, T1 or CIS transitional cell carcinoma of the bladder.

PURPOSE: We developed and validated nomograms that accurately predict disease recurrence and progression in patients with Ta, T1, or CIS transitional cell carcinoma (TCC) of the bladder using a large international cohort. METHODS: Univariate and multivariate logistic regression models targeted histologically confirmed disease recurrence, and focused on 2,542 patients with bladder TCC from 10 participating centers. Variables consisted of pre-cystoscopy voided urine Nuclear Matrix Protein 22 (NMP22) assay, urine cytology, age and gender. Resulting nomograms were internally validated with bootstrapping. Nomogram performance was explored graphically with Loess smoothing plots. RESULTS: Overall 957 patients had recurrent TCC. Tumor grade and stage was available for 898 patients, including 24% grade I, 43% grade II, and 33% grade III; 45% stage Ta, 32% T1 and/or CIS, and 23% T2 or greater. Bootstrap corrected predictive accuracy for any TCC recurrence was 0.842; grade III Ta/T1 or CIS was 0.869; and T2 or higher stage TCC of any grade was 0.858. Virtually perfect performance characteristics were observed for the nomograms predicting any TCC recurrence or grade III Ta/T1 or CIS. The nomogram predicting T2 or higher stage TCC overestimated the observed probability for predicted values greater than 45%. CONCLUSIONS: We developed and internally validated nomograms that incorporate urinary NMP22, cytology, age and gender to predict with high accuracy the probability of disease recurrence and progression in patients with Ta, T1, and/or CIS bladder TCC. These nomograms could provide a means for individualizing followup in patients with Ta, T1, CIS bladder TCC.

Adolescent↗

PubMed2005

Application of novel hemostatic agent during laparoscopic partial nephrectomy.

PURPOSE: We determined if QuikClot, a novel hemostatic agent made of a granulated mineral substance, could be used to control renal parenchymal bleeding and collecting system leakage during open and laparoscopic partial nephrectomy. MATERIALS AND METHODS: After obtaining renal hilar vascular control 2 domestic female pigs underwent bilateral open and 4 underwent unilateral laparoscopic partial nephrectomy. After excision of the lower pole without cautery the hemostatic agent was applied to the cut surface of the kidney and hilar vascular control was released. Additional QuikClot was added until complete hemostasis was achieved. One week postoperatively the animals were sacrificed and the operated kidneys were harvested for ex vivo retrograde pyelograms and histopathological analysis. RESULTS: All partial nephrectomies were performed without complication. Mean operative and warm ischemia times were 62 and 16 minutes, respectively. An average of 23% of renal mass by weight was resected with a mean blood loss of 73 ml per procedure. No cautery, additional hemostatic agents or techniques were used. No animal had clinical or radiographic evidence of urinoma or delayed hemorrhage. Histopathological analysis showed preservation of the renal parenchyma immediately beneath the QuikClot layer. CONCLUSIONS: In the porcine model QuikClot allowed the resection of large renal segments, while providing reliable hemostasis and closure of the renal collecting system. No deleterious effect on underlying renal parenchyma or surrounding tissues was observed.

Animals↗