Knoedler, John

Background and objectives Prior work has suggested a higher risk of hypertension in kidney stone formers but lacked disease validation and adjustment for potential confounders. Certain types of stone formers may also be at higher risk of hypertension. Design, setting, participants, & measurements In our study, incident symptomatic stone formers in Olmsted County from 2000 to 2011 were manually validated by chart review and age and sex matched to Olmsted County controls. We followed up patients through November 20, 2015. Hypertension was also validated by manual chart review, and the risk of hypertension in stone formers compared with controls was assessed both univariately and after adjusting for comorbidities. The risk of hypertension among different subtypes of stone formers was also evaluated. Results Among 3023 coded stone formers from 2000 to 2011, a total of 1515 were validated and matched to 1515 controls (mean age was 45 years old, and 56% were men). After excluding those with baseline hypertension (20% of stone formers and 18% of controls), 154 stone formers and 110 controls developed hypertension. Median follow-up time was 7.8 years in stone formers and 9.6 years in controls. Stone formers were found to have a higher risk of hypertension compared with controls (hazard ratio, 1.50; 95% confidence interval, 1.18 to 1.92), even after adjusting for age, sex, body mass index, serum creatinine, CKD, diabetes, gout, coronary artery disease, dyslipidemia, tobacco use, and alcohol abuse (hazard ratio, 1.58; 95% confidence interval, 1.12 to 2.21). Results were similar after excluding patients who were ever on a thiazide diuretic (hazard ratio, 1.65; 95% confidence interval, 1.16 to 2.38). Stone composition, radiographic stone burden, number of subsequent stone events, and stone removal surgeries were not associated with hypertension ( P >0.05 for all). Conclusions The risk of hypertension was higher after the first symptomatic kidney stone event. However, kidney stone severity, type, and treatment did not associate with hypertension.

Objectives To evaluate oncological outcomes after combination intravesical therapy with gemcitabine ( GC ) and mitomycin C ( MMC ) in the setting of recurrent non‐muscle‐invasive bladder cancer ( NMIBC ) after failure of previous intravesical therapy. Patients and Methods We retrospectively identified patients with recurrent NMIBC after previous intravesical therapy, who refused or were not candidates for cystectomy, between 2005 and 2011. GC and MMC were sequentially instilled weekly for 6–8 weeks. Data were collected regarding patient demographics, bladder cancer history, and number and type of intravesical therapies before GC / MMC . Outcomes evaluated included time to recurrence and/or progression after GC / MMC . Recurrence‐free outcomes were estimated using the Kaplan–Meier method, and Cox proportional hazards regression models were used to test the association of clinicopathological features with outcomes. Results In all, 27 patients were identified, 23 with high‐risk disease (high‐grade or carcinoma in situ ) and four with intermediate‐risk disease (multifocal or recurrent low‐grade). All patients received prior intravesical therapy, and 17 patients (63%) received multiple courses. Twenty‐four patients were treated with BCG . The median (range) disease‐free survival of all patients was 15.2 (1.7–39.3) months. Seventeen patients (63%) developed recurrent bladder cancer, a median of 15.2 months after therapy. One patient progressed to muscle‐invasive disease 5 months after treatment, and one developed metastatic disease 22 months after treatment. Three patients went on to cystectomy. Ten patients (37%) had no evidence of disease at last follow‐up, with a median follow‐up of 22.1 months. Conclusion The combination of intravesical GC and MMC could offer durable recurrence‐free survival to some patients with recurrent NMIBC who are not candidates for, or refuse, cystectomy.

Objective To evaluate survival among patients with urothelial carcinoma ( UC ) within the prostate in order to assess the impact of depth of tumour invasion as well as the importance of a concurrent bladder tumour. Patients and Methods We identified 201 patients who underwent radical cystectomy ( RC ) between 1980 and 2006 and were found to have UC involving the prostate. All specimens were re‐reviewed by a genitourinary pathologist. Survival was estimated using the K aplan– M eier method and compared with the log‐rank test. Cox hazard regression models tested the association of clinicopathological variables with outcome. Results In all, 93 patients had pTis disease in the prostate, 43 had pT2 tumours, and 66 patients were pT4a . The median follow‐up was 10.5 years. The 5‐year cancer‐specific survival for patients with pTis , pT2 , and pT4a prostate UC was 73%, 57%, and 21% respectively ( P < 0.001). On multivariable analysis, higher prostate tumour stage (hazard ratio [ HR ] 2.09; P = 0.01), positive lymph node status ( HR 2.09; P = 0.002), and concurrent ≥ pT3 bladder cancer ( HR 4.16; P < 0.001) were significantly associated with an increased risk of death from UC . Conclusions Among patients with prostatic UC involvement, depth of tumour invasion was significantly associated with cancer‐specific mortality, validating the staging reclassification. Concurrent locally advanced bladder cancer also negatively impacted survival, suggesting the potential prognostic value of reporting a secondary tumour stage in such cases.

Objective To describe the extent of use and in‐hospital outcomes of open and laparoscopic pyeloplasty for paediatric pelvi‐ureteric junction ( PUJ ) obstruction in the USA . Patients and Methods Using the 2004–2008 N ationwide I npatient S ample, we identified 4590 paediatric patients (≤18 years old) who underwent open or laparoscopic pyeloplasty for PUJ obstruction at 195 hospitals. Multivariable regression models were used to test the associations between hospital and patient covariates (age, gender, race, primary health insurance), type of admission (emergent vs elective), and hospital characteristics (teaching vs non‐teaching status; rural vs urban location) with complications, length of stay ( LOS ), and total hospitalization costs. Results During the 5‐year study interval, 4426 (96.4%) and 164 (3.6%) paediatric patients diagnosed with PUJ obstruction underwent open and laparoscopic pyeloplasty, respectively. The proportion of patients undergoing laparoscopic pyeloplasty gradually increased from 2.4% in 2004 to 4.4% in 2008, but this increase was not significant ( P = 0.22 for trend). On multivariable analysis, laparoscopic pyeloplasty was observed to have rates of postoperative complications (2.51 vs 5.00; P = 0.67), LOS (2.42 vs 2.75; P = 0.33) and total hospitalization cost ($9755 vs $8537; P = 0.24) similar to those of open pyeloplasty. Conclusions While laparoscopic pyeloplasty was generally an infrequent operation performed for paediatric PUJ obstruction during the period studied, this minimally invasive surgery provided similar outcomes in terms of in‐hospital complications, LOS and total hospitalization costs. The results of this study inform policymakers about the comparative effectiveness of laparoscopic and open pyeloplasty.