Roderick Clark

Background: Upper tract urothelial carcinoma (UTUC) is a rare malignancy with prognosis predicated on clinical and pathological factors. Radical nephroureterectomy is the standard treatment for higher risk localized UTUC, although competing mortality may influence optimal treatment selection in older patients. Methods: A retrospective population-based cohort study was conducted using the Surveillance, Epidemiology, and End Results program. Individuals diagnosed with UTUC of the renal pelvis or ureter between 2000 and 2017 were included. Patients with unknown tumor grade or size were excluded. Results: A total of 10,894 patients were included. During a median follow-up of 26 months, 57% died from any cause and 27% died from UTUC. For each 5-year increase in age of diagnosis, the cancer-specific mortality risk rises more in low-grade patients (21% increased riskjtp: 0.008) than high-grade patients (9% increased risk p: 0.023). Other-cause mortality risk rose markedly with increasing age (SHR 3.54 for ages 85+, p < 0.001). Conclusions: Age at diagnosis is significantly associated with cancer-specific mortality in UTUC. Incorporating age and competing risk into risk stratification may help inform shared decision-making regarding treatment approaches in older patients.

Introduction and Objectives: Hydrocelectomy is the gold standard treatment for hydrocele. European data showed complication rates between 16% and 25%, however the rate within the United States has not been assessed. We examined the postoperative complication, emergency department visit, readmission and re-operation rates after hydrocelectomy in the United States. Methods: We performed a retrospective cohort study of 27,418 individuals who underwent hydrocelectomy in the United States between 2004 and 2024 identified through the TriNetX US Network using ICD-10 and CPT codes. Patients were excluded for age < 18 years, testicular neoplasm, and orchiectomy. The primary outcome was rate of any surgical complication, emergency department (ED) visit, readmission, or reoperation within 90 days of hydrocelectomy. Statistical analysis was performed with R software and using t-tests. Results: The mean age of our cohort was 51 years. The complication group had higher proportions of older (p < 0.001), African American (p < 0.001), and patients with hypertension, diabetes, and coagulation defects (p < 0.001). The risk of complications was 13% within 90 days of surgery. The ED visit rate was 6.7%, surgical complication rate of 5.6%, readmission rate of 2.6%, and reoperation rate of 2.6%. Of surgical complications, 25% were bleeding, 13% were infection, and 63% were inflammatory or unspecified complications. The median ED visit was day 14 (IQR 6– 41) and the median reoperation was at day 21 (IQR 9– 38). Patients had a 9.2% rate of overall complications in the first month after surgery, after which the risk decreased. Conclusion: The rate of complications after hydrocelectomy in the United States is 13%, with 9% occurring in the first 30 days. There was a 2.8% risk of surgical intervention within 90 days. We recommend close follow-up in the first month to evaluate for developing complications, especially for patients with hypertension, diabetes, or coagulation defects.

Prostate cancer (CaP) remains the most diagnosed malignancy in men, and the incidence of high-grade disease at diagnosis is increasing

This is a summary of existing systematic reviews comparing robotic assisted radical cystectomy (RARC) with open radical cystectomy (ORC). Our aim was to co

Importance: Epidemiological evidence supports a role for statins in improving survival in advanced prostate cancer, particularly among men receiving androgen-ablative therapies.Objective: To study the association between statin use and survival among men with prostate cancer receiving androgen deprivation therapy (ADT) or androgen receptor axis–targeted therapies (ARATs).Data Sources: This systemic review and meta-analysis used sources from MEDLINE, EMBASE, Epub Ahead of Print, Cochrane Clinical Trials, Cochrane Systematic Reviews, and Web of Science from inception to September 6, 2022.Study Selection: Observational studies reporting associations of concurrent statin use and survival outcomes (in hazard ratios [HRs]).Data Extraction and Synthesis: Two authors independently abstracted all data. Summary estimates pooled multivariable HRs with 95% CIs using the generic inverse variance method with random-effects modeling. A priori specified subgroup and sensitivity analyses were undertaken, and heterogeneity, study quality, and publication bias were evaluated. Confidence in the evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach.Main Outcomes and Measures: Overall mortality and prostate cancer–specific mortality (PCSM).Results: Twenty-five cohorts of 119 878 men (65 488 statin users [55%]) with more than 74 416 deaths were included. Concurrent statin use was associated with a 27% reduction in the risk of overall mortality (HR, 0.73 [95% CI, 0.66-0.82]; I² = 83%) and a 35% reduction in the risk of PCSM (HR, 0.65 [95% CI, 0.58-0.73]; I² = 74%), with substantial heterogeneity in both estimates. Subgroup analyses identified a PCSM advantage associated with statins for men receiving ARATs compared with ADT alone (HR, 0.40 [95% CI, 0.30-0.55] vs 0.68 [95% CI, 0.60-0.76]; P = .002 for difference). Confidence in the evidence was rated low for both outcomes.Conclusions and Relevance: The findings of this meta-analysis show that concurrent statin use was associated with reduced overall mortality and PCSM among men receiving androgen-ablative therapies for advanced prostate cancer. These findings are limited by the observational nature of the data and residual unexplained interstudy heterogeneity. Randomized clinical trials are warranted to validate these results.

It is not clear to what extent the age of diagnosis and the attained age impact on cancer mortality rates in men with newly diagnosed prostate cancer. We estimated annual prostate cancer mortality rates and 20-year survival rates according to the age of diagnosis, race, grade and time since diagnosis using data from the Surveillance, Epidemiology and End-Results (SEER) program. We identified 116,796 prostate cancer patients diagnosed between 1992 and 1997 and followed them for 20 years. There were 21,896 deaths from prostate cancer. We calculated actuarial survival rates and annual prostate cancer mortality rates by age of diagnosis and by tumor grade. The risk of a man dying of prostate cancer was 17% for men diagnosed before age 70 and was 21% for those diagnosed after age 70. The mean annual prostate cancer mortality rate calculated over the 20-year period post-diagnosis was 1.5%. The annual rate increased from 0.9% for those diagnosed below age 60 to 2.1% for those diagnosed above age 70. For men with Gleason score ≥ 7 prostate cancer, the annual prostate cancer mortality rate peaked 2–3 years after diagnosis and then declined. For men diagnosed with Gleason score ≤ 6 prostate cancer, the annual prostate cancer mortality rate continued to rise 20 years after diagnosis and peaked after age 85. This suggests that high-grade prostate cancers are aggressive from the outset, but that low-grade prostate cancers may enter a state of dormancy and reactivate as the patient ages.

Most criteria for genetic testing for prostate cancer susceptibility require a prior diagnosis of prostate cancer, in particular cases with metastatic disease are selected. Advances in the field are expected to improve outcomes through tailored treatments for men with advanced prostate cancer with germline pathogenic variants, although these are not currently offered in the curative setting. A better understanding of the value of genetic testing for prostate cancer susceptibility in screening, for early detection and prevention is necessary. We review and summarize the literature describing germline pathogenic variants in genes associated with increased prostate cancer risk and aggressivity. Important questions include: what is our ability to screen for and prevent prostate cancer in a man with a germline pathogenic variant and how does knowledge of a germline pathogenic variant influence treatment of men with nonmetastatic disease, with hormone-resistant disease and with metastatic disease? The frequency of germline pathogenic variants in prostate cancer is well described, according to personal and family history of cancer and by stage and grade of disease. The role of these genes in aggressive prostate cancer is also discussed. It is timely to consider whether or not genetic testing should be offered to all men with prostate cancer. The goals of testing are to facilitate screening for early cancers in unaffected high-risk men and to prevent advanced disease in men with cancer.