Trends in Initial Management of Prostate Cancer in New Hampshire

Purpose Prostate cancer management strategies are evolving with increased understanding of the disease. Specifically, there is emerging evidence that ‘‘low-risk’’ cancer is best treated with observation, while localized ‘‘high-risk’’ cancer requires aggressive curative therapy. In this study, we evaluated trends in management of prostate cancer in New Hampshire to determine adherence to evidence- based practice. Methods From the New Hampshire State Cancer Registry, cases of clinically localized prostate cancer diagnosed in 2004–2011 were identified and classified according to D’Amico criteria. Initial treatment modality was recorded as surgery, radiation therapy, expectant management, or hormone therapy. Temporal trends were assessed by Chi-square for trend. Results Of 6,203 clinically localized prostate cancers meeting inclusion criteria, 34, 30, and 28 % were low-, intermediate-, and high-risk disease, respectively. For lowrisk disease, use of expectant management (17–42 %, p\0.001) and surgery (29–39 %, p\0.001) increased, while use of radiation therapy decreased (49–19 %, p\0.001). For intermediate-risk disease, use of surgery increased (24–50 %, p\0.001), while radiation decreased (58–34 %, p\0.001). Hormonal therapy alone was rarely used for low- and intermediate-risk disease. For high-risk patients, surgery increased (38–47 %, p = 0.003) and radiation decreased (41–38 %, p = 0.026), while hormonal therapy and expectant management remained stable. Discussion There are encouraging trends in the management of clinically localized prostate cancer in New Hampshire, including less aggressive treatment of low-risk cancer and increasing surgical treatment of high-risk disease

Does Travel Time to a Radiation Facility Impact Patient Decision-making Regarding Treatment for Prostrate Cancer? A Study of the New Hampshire State Cancer Registry

Purpose: We sought to determine whether further distance from a radiation center is associated with lower utilization of external beam radiation therapy (XRT). Methods: We retrospectively identified patients with a new diagnosis of localized prostate cancer (CaP) within the New Hampshire State Cancer Registry from 2004 to 2011. Patients were categorized by age, D’Amico risk category, year of treatment, marital status, season of diagnosis, urban/rural residence, and driving time to the nearest radiation facility. Treatment decisions were stratified into those requiring multiple trips (XRT) or a single trip (surgery or brachytherapy). Multivariable regression analysis was performed. Results: A total of 4,731 patients underwent treatment for newly diagnosed CaP during the study period, including 1,575 multitrip (XRT) and 3,156 singletrip treatments. Of these, 87.6% lived within a 30-minute drive to a radiation facility. In multivariable analysis, time to the nearest radiation facility was not associated with treatment decisions (P = .26). However, higher risk category, older age, married status, and winter diagnosis were associated with XRT (P \u3c .05). More recent year of diagnosis and urban residence were associated with single-trip therapy (primarily surgery) (P \u3c .05). There was a significant interaction between travel time and season of diagnosis (P = .03), as well as a marginally significant interaction with urban/rural status (P = .07). Conclusion: Overall, further travel time to a radiation facility was not associated with lower utilization of XRT. These data are encouraging regarding access to care for CaP in New Hampshire

The impact of tumour size on the probability of synchronous metastasis and survival in renal cell carcinoma patients: a population-based study.

To access publisher's full text version of this article, please click on the hyperlink in Additional Links field or click on the hyperlink at the top of the page marked Files. This article is open access.The observed low metastatic potential and favorable survival of small incidentally detected renal cell carcinomas (RCCs) have been a part of the rationale for recommending partial nephrectomy as a first treatment option and active surveillance in selected patients. We examined the relationship between tumor size and the odds of synchronous metastases (SMs) (primary outcome) and disease specific survival (secondary outcome) in a nationwide RCC registry.Retrospective study of the 794 RCC patients diagnosed in Iceland between 1971 and 2005. Histological material and TNM staging were reviewed centrally. The presence of SM and survival were recorded. Cubic spline analysis was used to assess relationship between tumor size and probability of SM. Univariate and multivariate statistics were used to estimate prognostic factors for SM and survival.The probability of SM increased in a non-linear fashion with increasing tumor size (11, 25, 35, and 50%) for patients with tumors of ≤4, 4.1-7.0, 7.1-10.0, and >10 cm, respectively. On multivariate analysis, tumor size was an independent prognostic factor for disease-specific survival (HR = 1.05, 95% CI 1.02-1.09, p < 0.001), but not for SM.Tumor size affected the probability of disease-specific mortality but not SM, after correcting for TNM staging in multivariate analysis. This confirms the prognostic ability of the 2010 TNM staging system for renal cell cancer in the Icelandic population.Landspitali University Hospital Scientific Foundation Memorial Foundation of Bergthora Magnusdottir and Jakob J. Bjarnaso

Erratum: The impact of tumour size on the probability of synchronous metastasis and survival in renal cell carcinoma patients: a population-based study.

To access publisher's full text version of this article, please click on the hyperlink in Additional Links field or click on the hyperlink at the top of the page marked Files. This article is open access

Over-the-counter alkali agents to raise urine pH and citrate excretion: a prospective crossover study in healthy adults

OBJECTIVE: To assess the effect of two over-the-counter alkalizing agents on 24-hour urinary parameters. MATERIALS AND METHODS: Ten healthy volunteers without a history of kidney stones were recruited to complete a baseline 24-hour urinalysis with a four-day diet inventory. Participants then maintained the same diet on either LithoLyte® (20 mEq two times per day) or KSPtabs (1 tablet two times per day) and submitted another 24-hour urinalysis. The process was repeated with the other supplement. Urinary alkali parameters were compared to baseline, and side effects were elicited with a questionnaire. RESULTS: LithoLyte® intake resulted in a non-significant increase in citrate (597 to 758 mg/day, p=0.058, an increase in urine pH (6.46 to 6.66, p=0.028), and a decrease in urine ammonium (41 to 36 mmol/day, p=0.005) compared to baseline. KSPtabs resulted in an increase in citrate (597 to 797 mg/day, p=0.037) and urine pH (6.46 to 6.86, p=0.037), with a non-significant decrease in ammonium (41 to 34 mmol/day, p=0.059). No significant differences were seen comparing urinary analytes between LithoLyte® and KSPtabs. With Litholyte®, no side effects, mild, moderate, and severe side effects were seen in 50%, 40%, 10%, and 0%, respectively. With KSPtabs, rates were 60%, 20%, 10%, and 10%, respectively. CONCLUSIONS: In healthy participants without a history of kidney stones, LithoLyte® and KSPtabs are effective over-the-counter alkali supplements, with a similar side effect profile to prescription potassium citrate

Endourologic Management of Stent Retained Over 22 Years in Patient with Duplicated Collecting System

Retained and subsequently encrusted stents can lead to a number of complications, the most dire being deterioration of renal function. Limited literature exists concerning endourologic management of stents retained for extreme durations and few that concerns patients with abnormal renal anatomy. A 70-year-old man with history of Crohn\u27s disease and partially duplicated collecting system presented with rising creatinine and was found to have bilateral retained Double-J stents, originally placed before small bowel resection 22 years prior. The patient underwent staged bilateral percutaneous nephrolithotomy with ultimate effective removal of both stents. The patient has had subsequent improvement in renal function and has not required dialysis. Removal of ureteral stents in a timely manner is paramount to prevent long-term retention and complication, but when required retained stents can be safely managed with a well-planned endourologic approach, even if significant deterioration in renal function has occurred

Pre-operative Risk Factors for Sepsis Following PCNL

Purpose/Background: Post-operative sepsis is a rare, potentially devastating, risk of percutaneous nephrolithotomy (PCNL). Knowledge of pre-operative risk factors may identify which patients might benefit most from new management strategies. Methods/Approach: Retrospective chart review was performed on 153 consecutive patients who underwent PCNL at Maine Medical Center between October 2016 and December2018. Patient demographic factors, comorbidities, infection history, culture data, and stone factors were recorded. Post-operative sepsis was defined according to SIRS criteria for severe sepsis. Multivariate logistic regression was used to evaluate categorical variables as risk factors for sepsis. Fischer exact and student t tests were used to evaluate variables in patients with positive pre-op urine culture. Results: 14 of 153 patients developed post-operative sepsis. Septic patients did not differ from others with regards age, gender, BMI, stone laterality, diabetes mellitus or renal function. Infected stone as an indication for PCNL was an independent predictor of sepsis (OR 5.66; p=0.015), as was large stone burden (a Seoul score \u3e= 5 (OR 3.76; p=0.046) or S.T.O.N.E score \u3e= 9 (OR 5.52; p=0.018)). Patients with limited mobility (upper or lower body) were much more likely to become septic (OR 21.4; p=0.002). Any positive pre-op culture was independently associated with sepsis (OR 13.7; p= 0.002),as were gram negative bacteria as a group (OR 5.7; p=0.025) and specifically the proteus species (OR 10.6; p=0.023). Such association was not found for gram positive bacteria. Among 45 patients with positive pre-op cultures, female gender (RR 3.9; p=0.047), infected stone as an indication (RR 3.1; p=0.047), limited lower (RR 3.5; p=0.022) and upper (RR 3.4; p=0.027) body mobility were all associated with post-op sepsis. Negative culture was protective against sepsis (OR 0.073; p= 0.002). Among patients with negative pre-op cultures, 2/109 (1.8%) had post-op sepsis, both with large complex stones (Seoul and S.T.O.N.E scores \u3e=9). Conclusions: Limited patient mobility and large stone burden are strong predictors of post PCNL sepsis. Positive pre-op urine culture, especially those with a gram-negative organism, also correlate with increased risk. Patients without these risk factors have a low chance of sepsis, even not accounting for intra-operative factors. Our results suggest a framework for risk-stratifying patients prior to surgery and the potential for more aggressive antimicrobial intervention in high risk patients, and less aggressive treatment in low risk patients

Increasing stone complexity does not affect fluoroscopy time in percutaneous nephrolithotomy.

Background: The aim of this work was to assess whether stone complexity with the Guy\u27s stone score (GSS) is associated with increased intraoperative fluoroscopy time. Methods: We retrospectively reviewed records of 261 consecutive patients undergoing percutaneous nephrolithotomy between 2007 and 2015. Of these, 203 had both preoperative computed tomography for accurate staging and full intraoperative fluoroscopy and radiation dosimetry data were available. Stone complexity was assessed using GSS. A correlation between fluoroscopy time (FT) and GSS was assessed in a univariate and multivariate fashion, including parameters such as age, sex, body mass index (BMI), and number of accesses. Results: The overall mean FT was 3.69 min [standard deviation (SD) 2.77]. The overall mean Guy\u27s score was 2.5 (SD 1). There was a statistically significant correlation between operative time and FT ( Conclusions: In the setting of conscious efforts to reduce intraoperative radiation exposure, increasing stone complexity, as classified by GSS, did not correlate with FT on univariate or multivariate analysis. Thus, treatment of more complex stones may be undertaken without concern that there is an inevitable need for significantly increased fluoroscopy exposure to the patient or operating room staff

Predicting Polymicrobial Stone in Patients Undergoing PCNL

Purpose/Background: Numerous studies have shown discordance between voided urine culture (UC) and stone culture (SC). This study sought to determine the correlation between polymicrobial stones and sepsis following percutaneous nephrolithotomy, and given poor concordance between UC and SC, other predicting factors for polymicrobial stones in patients undergoing PCNL. Methods/Approach: Retrospective chart review was performed on 153 consecutive patients who underwent PCNL at Maine Medical Center between October 2016 and December2018. Patient demographic factors, comorbidities, infection history, culture data, stone factors and surgical factors were recorded. Sepsis was defined by SIRS criteria for severe sepsis. Multivariate logistic regression was used to evaluate categorical variables. Results: 17 of 153 (11%) patients were found to have polymicrobial stones. Of those, 7 (41%) developed post-operative sepsis as compared to 3/33 (9%) in single organism stones and 4/103 (4%) in sterile stones. Presence of polymicrobial stone was significantly associated with post-op sepsis (OR 18, p=0.001). Diabetes (OR 7.7; p=0.003), neurogenic bladder (OR 11.7; p=0.001) a history of urosepsis (OR 6.5; p=0.005), stone diameter \u3e= 26mm (OR 3.8; p= 0.026), and infected stone as indication (OR 9.08; p=0.001) were all independently associated with polymicrobial stone. Limited upper or lower extremity mobility (OR 31; p\u3c0.001), neurologic disease (OR 8.95; p=0.001) (specifically multiple sclerosis (MS) (OR 6.3; p=0.040)) and contractures were associated with polymicrobial stones. While indication for PCNL because of infected stone, or having any positive pre-op urine culture had high specificity and negative predictive value for predicting polymicrobial stone, positive predictive value was low (0.27 and 0.19, respectively) (Table 1). However, combining these with information on DM, MS, spina bifida, ileal conduit or limited lower extremity mobility resulted in high positive predictive values, negative predictive value and specificity (Table 1). Conclusions: Patients with polymicrobial stones have a substantially higher risk of post PCNL sepsis compared to stones with a single or no microbe species. There are a number of easily identifiable patient attributes significantly associated with polymicrobial stones. These allow for simple risk stratification to help identify PCNL patients at risk for polymicrobial stone and sepsis and have the greatest benefit in modified treatment strategies such as broader peri-operative antibiotics