Factors associated with downgrading in patients with high grade prostate cancer

ObjectiveTo determine the factors associated with downgrading between biopsy and prostatectomy in the contemporary era using extended-template biopsy techniques.Materials and methodsThe UCSF Urologic Oncology Database was used to identify subjects diagnosed with high grade prostate cancer (primary pattern 4 or 5) in at least one core on extended-pattern biopsy. Multivariable logistic regression analysis was performed to identify independent factors associated with downgrading at radical prostatectomy, defined as a change from primary pattern 4 or 5 to primary pattern 3.ResultsDowngrading occurred in 68 (34%) of 202 subjects who met the study criteria. Fourteen (47%) of 30 subjects with ≤25% of cores that were high grade and 9 (43%) of 21 subjects with <10% of total tissue containing cancer were downgraded. In a multivariable model, patients with mixed grade cores had much higher odds of downgrading than those with all high grade cores (OR 3.0 95% 1.3-7.1), P < 0.01). The proportion (per 10% increment) of positive cores containing high grade cancer (OR 0.8 95% CI 0.7-0.9 P < 0.01) and the percent (per 10% increment) of total tissue containing cancer (OR 0.7 95% CI 0.6-0.9 P = 0.01) were significantly associated with lower odds of downgrading.ConclusionsDowngrading following radical prostatectomy is a common event. Biopsy over-grading may preclude men from active surveillance or lead to unnecessary lymphadenectomy, excess radiation, or prolonged hormone therapy. The proportion of positive biopsy cores that are high grade and the percent of total tissue containing cancer should be incorporated into decision making

Hyperoxaluria after modern bariatric surgery: case series and literature review

Two recent studies have shown that modern bariatric surgery leads to significant hyperoxaluria and risk of nephrolithiasis. However, neither report evaluates the use or effects of stone risk modifying agents in these patients. We sought to determine the impact of medical management on stone risk profile in patients who have undergone Roux-en-y gastric bypass. Twenty-four-hour urine collections of all patients referred to a tertiary clinic for nephrolithiasis in the past 4 years were reviewed. Those patients with severe (>75 mg/day) hyperoxaluria were identified. Retrospective chart review was performed to identify those patients with a history of bariatric surgery. Student’s t-test was used to compare mean urinary parameters between bariatric and non-bariatric patients. Out of all stone formers within our 24-h urine collection database, 39 patients had severe hyperoxaluria (oxalate >75 mg/day). Twenty-six patients had complete information for review. Five patients had a history of bariatric surgery. Compared with non-bariatric patients, those with a history of bariatric surgery had increased use of oral calcium (80 vs. 28%) and citrate supplementation (100 vs. 47%), higher urinary oxalate (129 vs. 91 mg/day) and volume (2.9 vs. 2.4 L/day), lower urinary citrate (390 vs. 800 mg/day) and calcium (155 vs. 235 mg/day), and a decreased supersaturation of calcium oxalate (6.7 vs. 11). Appropriate medical management, in particular oral calcium and citrate supplementation, and perhaps most importantly aggressive fluid intake can mitigate some of the effects of enteric hyperoxaluria caused by fat malabsorption after modern bariatric surgery