Diagnosis and management of testicular compartment syndrome caused by tension hydrocele

A hydrocele is an abnormal collection of fluid within the tunica vaginalis which may either be congenital or acquired. Hydroceles are usually painless and don\u27t require immediate intervention unless they impact activities of daily living. This case demonstrates a rare complication of hydroceles termed tension hydrocele which presented with scrotal swelling and acute pain. Unlike the classic presentation of hydroceles with minimal pain or discomfort, it is important to recognize tension hydroceles as an extremely rare but possible cause of acute scrotum, which needs to be emergently diagnosed and treated

Pathological Staging of Renal Cell Carcinoma: A Review of 300 Consecutive Cases

Aims: Pathological staging of renal cell carcinoma (RCC) can be challenging compared to other cancer types, as invasion often manifests as finger‐like protrusions into vascular spaces or renal sinus tissue. Although prior studies have shown larger tumour size to be correlated highly with renal sinus invasion, prospective data on evaluating pathological stage are limited. We evaluated a large series reported by one urological pathologist. Methods and results: Three hundred consecutive specimens were reviewed. Tumours larger than 5 cm were routinely sampled extensively or grossly re‐reviewed when no extrarenal extension was identified on initial examination. Apparent multifocal disease was assessed critically for intravascular spread. Retrograde venous invasion was reported in 15 of 300 (5%) cases, 13 of 15 of which were clear cell RCC. Of a total of 163 specimens with clear cell histology, only five of 34 (15%) tumours 7 cm or larger were reported as pT2, all of which had an explanatory comment indicating the absence of definitive extrarenal spread. In contrast, 15 of 20 (75%) pT2 tumours were non‐clear cell histology (papillary, chromophobe and translocation‐associated). Comparing pT3a or higher tumours, the median tumour size in cases with retrograde venous invasion was 8.0 cm, compared to 6.2 cm in cases without retrograde venous invasion (P = 0.005). ConclusionsOur findings support that retrograde venous invasion should be considered carefully before diagnosing multifocal clear cell RCC, which is rare in the sporadic setting. In the absence of vascular invasion, multifocal clear cell papillary RCC can be a mimic. pT2 occurs more frequently with non‐clear cell histology (particularly papillary or chromophobe RCC).https://scholarlycommons.henryford.com/merf2019basicsci/1002/thumbnail.jp

Rare Histological Variants of Prostate Adenocarcinoma (PCa): NCDB Analysis

Introduction and Objective: American Joint Committee on Cancer (AJCC) recognizes five rare histological variants of prostate adenocarcinoma (PCa). Our aim was to describe the contemporary presentation and overall survival (OS) of these rare variants. Methods: From 2004-2015, we selected cases of mucinous, ductal, signet ring cell (SRC), Adenosquamous, and neuroendocrine (NEC) variants of PCa from the National Cancer Database. Characteristics at presentation for each variant were compared with nonvariant PCa. Cox regression was used to study the effect of histological subtype on overall mortality. Results: Less than 1 percent (5062/1345561; 0.38%) patients presented with rare-variant PCa. All variants had a higher clinical T stage at presentation than nonvariant PCa (all p\u3c0.001; Table 1). Metastatic disease was most common with NEC (62.9%), followed by adenosquamous (31.1%), SRC (10.3%), and ductal (9.8%) variants, compared to 4.2% in nonvariant PCa (all p\u3c0.001). Metastatic disease in mucinous (3.3%) was similar to nonvariant PCa (p = 0.15). SRC, mucinous, and ductal variants presented with a significantly higher PSA (Median 9.0, 6.7, and 6.6, respectively vs. 6.2 ng/ml in nonvariant PCa; all p \u3c 0.001), and higher biopsy grade (Grade group ≥ 4 (34.7%, 11.2%, and 27%, respectively vs. 8.6% in nonvariant PCa; all p \u3c 0.001). Estimated 5-year OS was highest in mucinous variant (89.3%), followed by nonvariant (87.2%), ductal (76.4%), SRC (67.0%), adenosquamous (20.5%), and NEC PCa (13.4%). After adjusting for covariates—compared to nonvariant PCa—mortality was significantly higher in ductal, SRC, adenosquamous, and NEC variants (Table 2) Conclusions: There are differences in the presentation and OS among rare variants of PCa. NEC, adenosquamous, signet ring cell, and ductal variants more commonly present with metastatic disease. All variants present with a higher local stage than nonvariant PCa. NEC variant is associated with the worst, and mucinous variant with the best OS.https://scholarlycommons.henryford.com/merf2019basicsci/1004/thumbnail.jp

Evaluating the Role of LVI as an Indicator for Adverse Outcomes in Patients with Upper Tract Urothelial Carcinoma and its Histological Subtypes

Lymphvascular invasion (LVI) is recognized as an adverse prognostic factor in many cancers. Our aim is to assess the prognostic ability of LVI in UTUC urothelial carcinoma (UC) and micropapillary urothelial carcinoma (MPUC) subtypes as a predictor of overall survival (OS) using a large North American cohort. Our cohort included 9750 cM0 UTUC patients who underwent a radical nephroureterectomy (RNU), between 2004 and 2015, within the National Cancer Database (NCDB). The main variable of interest was LVI status, and its interaction with pathological nodal (pN) status. Kaplan-Meier curves were used to estimate the OS. Cox regression analysis tested the impact of LVI status on OS after accounting for covariates. In patients with UC at 5-years post-RNU, the OS rates were 60.2%, 29.9%, 28.9%, and 20.8% in patient with pN0 without LVI, pN0 with LVI, pN+ without LVI, and pN+ with LVI, respectively (p Our report is the first to examine the impact of LVI on OS in a large North American nationwide cohort. It indicates that LVI is associated with reduced OS in patients with UTUC treated surgically

Impact of Hospital Teaching Status on Healthcare Utilization, Length of Stay (LOS), and Cost of Hospitalization of Radiation Cystitis (RC) in the United States

Background: Limited data exist regarding in-hospital use of resources, LOS, and cost of RC-associated admissions in teaching hospital (TH) versus nonteaching hospital (NTH) settings. The goal of this study was to address the above void in literature. Methods:We focused on 13,272 admissions for RC between 2008-2014 within the National Inpatient Sample. Patients with concurrent diagnosis of other bladder conditions (n=914) were excluded. ICD-9 diagnosis and procedure codes were used to study inpatient procedures performed during admission. Type of admissions, receipt of a procedure, type of procedures performed, LOS, and total inflation-adjusted cost were then compared between TH and NTH. Complex survey chi-squared test and analysis of variance procedures were used to account for the NIS sampling design. Results: Of the 12,358 assessable records, 49% were at THs. Patients were more commonly admitted to emergency department at NTH (85%) compared to TH (80%; p\u3c0.001). Weekend admissions were more common at NTH (24%) compared to TH (21%) (p=0.004). Receipt of a procedure during admission was higher in TH (65%) compared to NTH (60%; p\u3c0.001). Number of procedure codes recorded was higher in TH (\u3e= 2 codes; 28.9% in TH vs 24.5% in NTH; p \u3c0.001. More complex procedures like cystectomy were almost exclusively performed at TH (cystectomy 2.4% in TH vs 0.4% in NTH admissions; p \u3c0.001), whereas there was no difference in procedures like blood transfusion (TH 34%; NTH 33%; p=0.3), suprapubic cystostomy (TH 1.3%; NTH 1.4%; p=0.8), and transurethral procedures (TH 14%; NTH 16%; p=0.06). Despite statistically significant difference in LOS between the two groups (Median days (IQR): TH 5 (3-9); NTH 5 (3-8); p\u3c0.001) the difference was not clinically significant. Cost of admission was higher in TH (10,377$TH; 8504$ NTH; p\u3c0.001). Conclusions: In the United States, patients with RC are more frequently admitted to the emergency department in NTH. Patients admitted to TH receive a procedure more often, receive a higher number of procedures, and more complex procedures, compared to NTH. This explains higher cost of admission in TH. Further research is needed to study the readmission rates and outcomes of patients treated in both types of health systems to know the best practices that can reduce morbidity and readmissions.https://scholarlycommons.henryford.com/merf2019qi/1021/thumbnail.jp

Inpatient morbidity and cost of cytoreductive radical prostatectomy in the United States

INTRODUCTION AND OBJECTIVES: Clinical trials are currently examining the role of local therapy in metastatic prostate cancer (mPCa). While the safety of RP in localized disease is proven, few studies have looked at perioperative complications and cost of cytoreductive RP (cRP). We used the National Inpatient Sample (NIS) to study the inpatient morbidity, and cost of cRP in the United States (US). METHODS: Analyzing the NIS dataset from 2008-2014, we identified 90,662 patients (weighted estimate 449,025 in the US) who underwent RP for non-metastatic disease, and 1,173 patients (weighted estimate 5,835) who underwent cRP for mPCa (see Fig. 1). Outcomes of interest were inpatient complications, individual complications, hospital stay, and total cost. Covariates included age, race, Charlson Comorbidity score, insurance status, rural/semi-urban/urban location, income, hospital location (rural/urban), teaching status, geographical location of hospital, and hospital volume. Multivariable logistic regression was used to evaluate the effect of metastatic disease on morbidity after adjusting for covariates. RESULTS: Inpatient complication rates were 14.9% (13,688/91,835) overall, 14.9% (13,464/90,662) in the non-metastatic group, and 19.1% (224/1,173) in the cRP group (p = 0.01). On multivariable analysis, metastasis was an independent predictor of inpatient complications (OR 1.329; 95% CI: 1.077-1.640; p = 0.01). The cRP group also had higher rates of blood transfusion (6.9% [82/1,173] vs 4.3% [3,869/90,662]; p \u3c 0.001), longer hospital stay (median 1.25 vs 0.97 days; p \u3c 0.001), and higher cost (median $14,123 vs$11,591; p \u3c 0.001) compared to the non-metastatic group (see table 1). Majority of cRP was performed in urban teaching hospitals. CONCLUSIONS: cRP is associated with higher inpatient morbidity, longer hospital stay, and higher cost compared to RP for non-metastatic disease. This information may be valuable for informed decision-making in practice and before recruiting patients in clinical trials on this subject. Source of Funding: Nonehttps://scholarlycommons.henryford.com/merf2019hvc/1006/thumbnail.jp

Feasibility of Omitting Outer Renorrhaphy During Robotic Partial Nephrectomy

Introduction: Reconstruction technique after robotic partial nephrectomy (RPN) is a modifiable factor with possible impact on ischemia time, bleeding, renal function, and incidence of pseudoaneurysms. We sought to evaluate the feasibility of omitting cortical (outer) renorrhaphy (CR) in a multi-institutional setting.Methods: We analyzed 1453 patients undergoing RPN, from 2006-2018, within the Vattikuti Collective Quality Initiative database, which captures that data from 14 centers in 9 countries. Patients having surgery for bilateral tumors(n=73) were excluded. The CR and no-CR groups were compared in terms of operative and ischemia time, blood loss, major (Clavien≥3) complications, surgical margins, hospital stay, change in estimated glomerular filtration rate (eGFR), and need of angioembolization. Inverse probability of treatment weighting (IPTW) with a Firth correction for center code was done to account for selection bias.Results: CR was omitted in 120 patients; 1260 patients underwent both inner (base) layer renorrhaphy and CR. There was no difference in intraoperative complications (7.4% in CR; 8.9% in no-CR group;p=0.6) or postoperative major complications (1% and 2.8% in the CR and no-CR groups, respectively;p=0.2). Estimated blood loss was 100 mL (IQR 50-200) in both treatment groups(p=0.6). Angioembolization was needed in 0.7% patients in CR group vs 1.4% in no-CR group(p=0.4). Additionally, there was no difference in median operative time (168 minutes and 162 minutes, respectively;p=0.2), or ischemia time (18 minutes and 17 minutes, respectively;p=0.7). Conclusions: Omission of CR did not significantly improve operative or ischemia time; however, it also had no adverse effect on perioperative outcomes after RPN in a multi-institutional setting.https://scholarlycommons.henryford.com/merf2019clinres/1003/thumbnail.jp

Long-term risk of recurrence in surgically treated intermediate-high risk renal cell carcinoma: a post-hoc analysis of the Eastern Cooperative Oncology Group - American College of Radiology Imaging Network E2805 Trial cohort

Background: Surgical resection remains the gold standard treatment modality for clinically localized renal cell carcinoma (RCC). However, the optimal follow-up period in these individuals is controversial, and the current recommendations are based on retrospective data, which inevitably contain attrition bias. Our objective was to re-visit the recurrence rate of surgically treated intermediate-high risk RCC patients using randomized clinical trial data. MethodsWe performed a post-hoc analysis of all the patients that were included in the ECOG-ACRIN E2805 Trial. We assessed post-operative recurrence rates using the cumulative incidence method. Conditional estimates of a 36-month recurrence for patients whom did not have recurrence at set intervals following surgery was performed. Assessment of routinely available clinical and pathological features in predicting disease recurrence at time 0-months after surgery was compared it to that of the same features at 60-months after surgery.ResultsThe original cohort consisted of 1943 patients . Median follow-up for the 1508 patients whom were alive at the end of the study was 67.9 months (IQR 56.7 – 82.0). 730 patients developed disease recurrence. The 36-month cumulative incidence of recurrence was found to be 31.1% (IQR 29.3 – 33.6) for the entire cohort at 0-months from surgery. The rate changed to 26.0% (IQR 23.7 – 28.2), 18.8% (IQR 16.5 – 21.1), 16.1% (IQR 13.6 – 18.8), 18.9% (IQR 15.0 – 23.1) and 20.3% (IQR 12.5 – 28.1) for patients whom did not have recurrence at 12-, 24-, 36-, 48- and 60-months from surgery, respectively. At time 0-month from surgery, age (hazard ratio [HR]: 1.01, 95% confidence interval [CI]: 1.00-1.02), pathologic T3/4 stage (HR: 1.557, 95%CI: 1.17 - 2.07), pathologic N1/2 stage (HR: 2.38, 95%CI: 1.85 - 3.07), Fuhrman grade 3 (HR: 1.36, 95%CI: 1.14 - 1.62) and Fuhrman grade 4 (HR: 2.41, 95%CI: 1.96 - 2.96) were independent predictors of recurrence. Conversely, none of the aforementioned covariates were predictors of disease recurrence at 60-months following surgery. Conclusions: Long-term follow-up, beyond 5-years, is supported by the findings within the present study. Also, the usual independent predictors that are frequently used to guide patient follow-up demonstrated validity immediately following surgery however lose their predictive power at 5 years from surgery.https://scholarlycommons.henryford.com/merf2019clinres/1028/thumbnail.jp

Impact of treatment modality on overall survival in localized ductal prostate adenocarcinoma: A National Cancer Database analysis

INTRODUCTION AND OBJECTIVE: Ductal adenocarcinoma is considered a rare histological variant of prostate adenocarcinoma (PCa). Given the rarity of this subtype, optimal treatment strategies for men with nonmetastatic ductal PCa is largely unknown. We aimed to describe the impact of surgery, radiotherapy, and systemic therapy on overall survival (OS) in men with nonmetastatic ductal PCa. METHODS: We retrospectively selected 2209 cases of ductal PCa, diagnosed between 2004 and 2015, within the National Cancer Database (NCDB). Exclusion of metastatic patients yielded a total sample of 1993 individuals. Cox regression analysis tested the impact of treatment (surgery, radiotherapy, systemic therapy and no treatment) on OS. Covariates included age, race, Charlson comorbidity score (CCI), clinical T stage, biopsy Gleason score, serum prostate specific antigen (PSA), and income. Adjusted Kaplan-Meier estimates were used to visualize the impact of treatment modality on OS. RESULTS: In men with nonmetastatic ductal PCa, median (IQR) age and PSA were 67 (61-74) years and 6.3 (4.3-10.8) ng/mL, respectively. Further, 9.8% (n=195) of patients presented with cT3 disease or higher, 3.4% (n=68) presented a CCI score ≥ 4, and 40.6% (808) presented with a Gleason biopsy score ≥ 4. Further, 1212 (60.8%) patients were treated surgically, 406 (20.4%) with radiotherapy, 102 (5.1%) with systemic therapies, and 273 (13.7%) received no treatment. Multivariable analysis showed that in comparison to men treated surgically, OS was significantly lower for patients receiving radiotherapy (HR 2.6; 95% CI 1.7-4.0) and systemic therapies (HR 9.1; 95% CI 5.0-16.5). Adjusted Kaplan-Meier curves are shown in the associated figure. CONCLUSIONS: Our findings show that in the rare ductal PCa variant, starting treatment with surgery offers more favorable long-term OS outcomes than radiotherapy and systemic therapies. While residual selection bias might persist after adjustment, the rarity of this disease precludes the possibility of a future trial, and the presented data represents the best available level of evidence on this topic

Admission Rates, Healthcare Utilization, and Economic Burden of Radiation Cystitis (RC) in the United States

INTRODUCTION AND OBJECTIVES: Radiation cystitis (RC) is a major cause of morbidity after radiotherapy for pelvic cancers. In the absence of a definite cure, patients may require repeated admissions, undergoing multiple - often morbid - urological procedures. Our aim was to study the inpatient economic burden and healthcare utilization associated with RC in the United States (US). METHODS: We focused on 13,272 records of adult (age \u3e= 18) patients with a diagnosis of RC within the National Inpatient Sample (NIS) from 2008- 2014. Patients with a concurrent diagnosis of other bladder conditions (n=914) were excluded. Due to a change in NIS sampling methodology in 2012, trend of RC-associated admissions was analyzed for 2012-2014. ICD-9 diagnosis and procedure codes were used to study inpatient procedures performed during admission. Complex survey procedures were used to study the descriptive characteristics of RC patients and the procedures received during admission. Inflation- adjusted cost for each admission and cumulative annual cost of RC-associated admissions were calculated for the study period. RESULTS: The 12,358 assessable patients represented 61,346 admissions for RC nationally per NIS survey weights. The number of admissions increased gradually from 1681 (weighted 8405) in 2012 to 1803 (weighted 9015) in 2014. Overall 84% of all RC-associated admissions were non-elective. 74% of the patients were males. A vast majority (82%) of the patients had Medicare/Medicaid insurance. The admissions were equally distributed between teaching (49%) and non-teaching (51%) hospitals, however, 90% of the admissions were in hospitals located in urban areas. Any RC-directed procedure code was recorded in 62% admissions. Of these, 3,331 (43%) admissions recorded more than one procedure code. Blood transfusion was the most frequently recorded code (33%), followed by transurethral procedures (28%) and cystoscopy (12.6%). Radical cystectomy was done in 1.3% of the admissions. The median length of stay was 4.4 days (IQR 2.2-8.4).The inflation-adjusted cost per admission was 9207 US dollars (IQR 5275 -17,573) overall, being higher in teaching hospitals (median 9802 vs 8463 US dollars in non-teaching hospitals. The cumulative cost of inpatient treatment of radiation cystitis was 63.5 million US dollars per year, amounting to a total of 952.2 million over the study period. CONCLUSIONS: The incidence of RC-associated admissions is rising in the US. This disease is a major burden to US healthcare. The awareness of the inpatient economic burden and healthcare utilization associated with RC may have funding implications.https://scholarlycommons.henryford.com/merf2019qi/1020/thumbnail.jp