BACKGROUND Many patients with low-risk prostate cancer (PC) who are diagnosed with Gleason score 6 at biopsy are ultimately found to harbor higher grade PC (Gleason ≥7) at radical prostatectomy. This finding increases risk of recurrence and cancer-specific mortality. Validated clinical tools that are available preoperatively are needed to improve the ability to recognize likelihood of upgrading in patients with low-risk PC. METHODS More than 30 clinicopathologic parameters were assessed in consecutive patients with Gleason 6 PC upon biopsy who underwent radical prostatectomy. A nomogram for predicting upgrading (Gleason ≥7) on final pathology was generated using multivariable logistic regression in a development cohort of 431 patients. External validation was performed in 2 separate cohorts consisting of 1151 patients and 392 patients. Nomogram performance was assessed using receiver operating characteristic curves, calibration, and decision analysis. RESULTS On multivariable analysis, variables predicting upgrading were prostate-specific antigen density using ultrasound (odds ratio [OR] =229, P =.003), obesity (OR =1.90, P =.05), number of positive cores (OR =1.23, P =.01), and maximum core involvement (OR =0.02, P =.01). On internal validation, the bootstrap-corrected predictive accuracy was 0.753. External validation revealed a predictive accuracy of 0.677 and 0.672. The nomogram demonstrated excellent calibration in all 3 cohorts and decision curves demonstrated high net benefit across a wide range of threshold probabilities. The nomogram demonstrated areas under the curve of 0.597 to 0.672 for predicting upgrading in subsets of men with very low-risk PC who meet active surveillance criteria (all P <.001), allowing further risk stratification of these individuals. CONCLUSIONS A nomogram was developed and externally validated that uses preoperative clinical parameters and biopsy findings to predict the risk of pathological upgrading in Gleason 6 patients. This can be used to further inform patients with lower risk PC who are considering treatment or active surveillance.

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Background: Statins are thought to possess antineoplastic properties related to their effect on cell proliferation and steroidogenesis. Progression to castrate resistant prostate cancer (CaP) includes de-regulation of androgen synthesis suggesting a role for statins in this setting. Our goal was to assess the role of statin use on oncologic outcomes in patients with advanced CaP being treated with androgen deprivation therapy (ADT). Methods:The national VA database was used to identify all men diagnosed with CaP who were treated with ADT for at least 6 months between 2000 and 2008 with follow-up through May 2016.Our cohort was stratified based on statin use of at least 6 months duration during the same time. Multivariable Cox proportional hazards analyses with inverse propensity score weighted (IPSW) adjustment were calculated to assess for primary outcomes of CaP-specific survival (CSS), overall survival (OS) and skeletal related events (SREs).Results: A total of 87,346 patients on ADT were included in the study cohort, 53,360 patients used statins and 33,986 did not. Statin users were younger in age (median 73 vs. 76, P < 0.001), more likely to have a higher Charlson comorbidity index (CCI) >3 (3.1% vs. 2.5%, P < 0.001) and more likely to have a high grade (Gleason score 8-10) cancer (12.3% vs. 10.9%, P < 0.001). Statin users had longer OS (median 6.5 vs. 4.0 years P < 0.001) and decreased death from CaP (5-year CSS 94.0% vs. 87.3%, P < 0.001). Statin use was also associated with longer time to a SRE (median 5.9 vs. 3.7 years, P < 0.001). On multivariable Cox proportional hazards analysis with inverse propensity score weighted, statin use was an independent predictor of improved OS (hazard ratio [HR] 0.66, confidence interval [CI] 0.63-0.68; P < 0.001), CSS (HR 0.56, 95% CI 0.53-0.60; P < 0.001), and SREs (HR 0.64, 95%CI 0.59-0.71; P < 0.001) when controlling for age, race, Charlson comorbidity index, prostate-specific antigen, and Gleason score.

Pharmacological inhibition of the renin-angiotensin system is associated with improved outcomes in patients with bladder cancer. Renin-angiotensin system inhibitor administration in nonmuscle invasive bladder cancer cases should be studied in a prospective randomized trial.

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Introduction: Neutrophil/lymphocyte ratio (NLR) is an indicator of systemic inflammation and has been proven to be associated with an increased risk of extravesical disease, decreased cancer specific survival and overall survival in bladder cancer patients. A large proportion of healthy African Americans have a WBC count that is persistently lower than the normal range defined for individuals of European ancestry, this condition has been called “benign ethnic neutropenia”. The purpose of our study was to determine if NLR was different in patients of African ancestry (AA) vs European ancestry (EA) across different tumor grades and stages at the time of transurethral resection of bladder tumor(s) (TURBT).Materials and Methods: The records of consecutive patients who underwent TURBT were reviewed from the University of Wisconsin and the Atlanta Veterans’ Administration Medical Center (2000–2012). NLR was compared across tumor stage, tumor grade and ethnicity.Results: 297 consecutive patients met study criteria. 89% and 86%, were males and of European ancestry (EA) respectively. NLRs were different across T-stages (Ta-2.5, T1-3.9, T2-3.8; p = 0.001). but not across tumor grades in Ta (LG-2.5 vs HG-3.9, p = 0.57). EA had higher NLRs than AA (3.4 vs 1.9; p < 0.001).Conclusions: Higher NLRs appear to be associated with more advanced tumor stage at the time of TURBT. Patients of African ancestry have lower NLRs across all tumor stages compared to patients of European ancestry. Ethnicity should be taken into account when interpreting the NLR in patients with bladder cancer.

Context:Venous thromboembolism (VTE) is a common cause of postoperative morbidity and mortality in cystectomy patients.Aims:The aim of this study is to identify variables associated with risk of developing deep venous thrombosis (DVT) or pulmonary embolism (PE) within 90 days after radical cystectomy (RC).Setting and Design:Retrospective chart review of patients undergoing RC from 2004 to 2011 at the University of Wisconsin.Subjects and Methods:Clinical variables collected for all RC patients. All patients received mechanical prophylaxis, and routine heparin prophylaxis began in 2010.Statistical Analysis Used:Univariate and multivariate analyses were used to evaluate VTE association with known risk factors.Results:A total of 241 patients were identified with median age of 67.1 (interquartile range: 57.8-74.3) years. Body mass index (BMI) was ≥30 in 36.8% of patients. Median blood loss was 950 (600-1500) mL and 157/241 (65.2%) patients received a blood transfusion.Conclusions:Patients with BMI ≥30 or nonurothelial cancer are at highest risk for postoperative VTE and should be considered for extended heparin prophylaxis.

Background and Purpose: While laparoscopic adrenalectomy (LA) is considered the standard of care for removal of small adrenal masses, there are minimal data describing the feasibility and outcomes of LA after previous ipsilateral nephrectomy (PIN). The purpose of the study was to describe the perioperative outcomes in a series of patients who were undergoing LA after PIN. Patients and Methods: Using an institutional database, we identified patients who underwent LA since 2002 by a single surgeon. Clinical and pathologic data were collected and analyzed. To evaluate outcomes, patients undergoing LA after PIN were compared with patients undergoing LA without PIN. Results: Of 54 consecutive patients undergoing LA, 8 had PIN for renal-cell carcinoma (RCC). Estimated blood loss was not significantly greater in patients with PIN: 50 mL vs 100 mL, P = 0.109. Operative time was longer in patients with PIN: 120 minutes vs 156 minutes, P = 0.015. There was no difference in length of hospital stay between groups: Median 2 days for both groups, P = 0.635. One patient in the PIN group had a conversion to open adrenalectomy and needed blood transfusion. Perioperative complications were seen in 5/46 (10.6%) patients without and in 1/8 (12.5%) patients with PIN. Surgical margins were negative in all patients. Conclusions: To the authors' knowledge, this study represents the largest experience with adrenalectomy in the reoperative setting. LA after PIN is associated with a longer operative time. While the potential for conversion is possible, it is technically feasible in selected patients and thus far appears to be associated with similar perioperative outcomes compared with patients without PIN.