Historically AC was discontinued prior to endoscopic surgery however based

Historically, AC was discontinued prior to endoscopic surgery; however, based on small retrospective series reporting no increase in complications, current AUA/ICUD guidelines state that AC/AP use in the perioperative aa dutp is safe. Specifically, in a retrospective matched pair analysis of 692 patients, Turna et al identified 37 patients (5.2%) on chronic AC or AP (warfarin, clopidogrel, and aspirin) and found no difference in intraoperative or postoperative complications, concluding that URS in patients on AC is safe. Notably, the INR of patients on warfarin ranged from 1.1 to 3.3 (mean 1.8), indicating that some were subtherapeutic. Similarly, Watterson et al reviewed 25 patients with bleeding diathesis, including 17 on warfarin (mean INR 2.3), and reported 1 (3%) significant bleeding complication—a retroperitoneal hemorrhage requiring blood transfusion attributed to electrohydraulic lithotripter use. They conclude that outpatient use of the Holmium:Yag laser is safe and cost-effective for patients on AC, negating the need for bridging or in-hospital AC management. In contrast, Daels et al analyzed URS outcomes among nearly 12,000 patients worldwide and found that postoperative bleeding was significantly higher in patients on AC compared to those who were not (1.1% vs 0.4 %; P < .01). We also found that those who bridged with enoxaparin had a higher rate of significant bleeding compared to the control group (9% vs 3%), despite holding their dose the morning of surgery. This finding has been previously demonstrated in other disciplines. In fact, the utility of perioperative bridging itself is controversial. In a recent randomized trial of patients on warfarin for AF, Douketis et al found a higher risk of bleeding with enoxaparin bridging with no corresponding increase in risk of thromboembolism if all AC was held in the perioperative period. Similar findings have been reported for periprocedural NOAC bridging. Although the benefit of bridging is questioned, the risks associated with discontinuation must also be weighed carefully. For example, the ROCKET-AF trial found that the risk of stroke or systemic embolism during and 30 days following temporary interruption (3-30 days) of rivaroxaban or warfarin was 0.30% and 0.41% per 30 days, respectively, among patients with nonvalvular AF. In addition, while the RE-LY trial reported a 5.1% and 4.6% major bleed rate among those on dabigatran and warfarin, oviducts also found a 30-day thrombotic event rate of 1.5% and 1.2%. Weighing the risks and benefits is both specialty and procedure specific. For example, the British Society of Gastroenterology and the European Society of Gastrointestinal Endoscopy recommend continuing warfarin but holding NOAC the morning of surgery for low-risk endoscopic procedures while stopping warfarin 5 days and NOAC 3 days prior to high-risk procedures. Conversely, in orthopedic surgery, periprocedural anticoagulation is given to all patients undergoing knee or hip arthroplasty due to the high risk of VTE.
From a urologic standpoint, in light of current AUA/ICUD guidelines that state that there is no increased risk of bleeding among patients on AC undergoing URS, our findings highlight the need for further examination of this issue. Ultimately, for urologic patients undergoing URS at high risk of VTE (prosthetic metal mitral valve, prosthetic valve and AF, AF with mitral stenosis, VTE within 3 months, thrombophilia syndromes), particularly those on a NOAC, the risks and benefits of discontinuing anticoagulation should be assessed individually and these patients may benefit from specialist evaluation to optimize their periprocedural bleeding risk.
To our knowledge, we provide one of the largest studies to date evaluating bleeding-related complications in urologic patients on AC, demonstrating that continuation of AC and bridging are both associated with a significantly higher risk of periprocedural bleeding. Although our overall sample size is larger than previous studies, our group that continued AC was underpowered to detect a significant difference in event rate between the NOAC and warfarin. We also may have been underpowered to detect significant adverse effects from the discontinuation of AC. Although rare, the implications of these events may be potentially devastating. In addition, the absolute event rate is still low and therefore given the retrospective nature of our study, the findings may be due to unmeasured confounding. Finally, we must acknowledge the error of multiple testing. Although our Type I error rate is 5%, due to the multiple univariate tests performed in Table 2, we are more likely to find false-positive results. Larger studies may be able to address this limitation using multivariate analysis.

PDE i enhances the effect of

PDE5i enhances the effect of nitric oxide, which is a potent vasodilator. Dilatation of the terminal Histone Compound Library decreases the peripheral vascular resistance, resulting in lowered blood pressure. Moreover, studies have shown that a combination of PDE5i with antihypertensive therapy results in a significantly greater fall of blood pressure.
In the light of all the above information, let us evaluate PDE5i as a cause of the development of NAION. The following factors play important roles:

Sexual dysfunction is a highly prevalent condition in male patients, particularly in patients with lower urinary tract symptoms (LUTS). Recent epidemiologic studies have shown that erectile and ejaculatory dysfunctions (EjDs) are present in more than half of the men aged 55 or older. EjDs consist of premature ejaculation, delayed ejaculation, retrograde ejaculation, anejaculation, decreased force of ejaculation, and pain upon ejaculation. Results of the Multinational Survey of the Aging Male-7 survey show that 46% of men reported reduced amount of ejaculation or no ejaculation, and 59% of them considered it a problem. Moreover, the experience of pain or discomfort on ejaculation was less prevalent, being reported by only ≈10% of men, although nearly 90% of them considered it a problem. Notwithstanding these results, clinicians poorly investigate EjD, and when considering sexual dysfunction, most of the literature concentrates on erectile dysfunction (ED).
Most of the validated questionnaires available for daily clinical practice (ie, International Index of Erectile Function [IIEF], Danish Prostatic Symptom Score, and International Continence Society-sex) concentrate mostly on ED and do not assess ejaculatory function properly. The Male Sexual Health Questionnaire (MSHQ), developed by Rosen et al, evaluates key domains of sexual function and satisfaction of the aging male. Moreover, the recently published short version focuses mainly on EjD and has excellent psychometric properties and represents a useful instrument for assessing EjD in clinical and research settings. The short version measures 3 functional EjD symptoms, including the ability to ejaculate, the ejaculation force, and the ejaculation volume, in addition to subjective bother associated with symptoms of EjD.
Currently, increasing age, LUTS severity, previous benign prostatic enlargement (BPE)-related surgery, some BPE medical treatments (tamsulosin, combination of a 5 alpha reductase inhibitors with an alpha-1-blocker), and cardiovascular comorbidities (hypertension, diabetes, high cholesterol, ischemic heart disease) are considered predictors of EjD. In particular, men with severe LUTS are 2-3 times more likely to have EjD than men with mild LUTS. Metabolic syndrome (MetS), a cluster of metabolic abnormalities whose prevalence has dramatically increased in the last years, has been recently associated with several urologic diseases, including LUTS and ED. However, until now, EjD has only been linked to the single components of MetS, although the possible role of the combination of the different risk factors included in MetS is not known. The aim of our study was to evaluate the role of MetS as a predictor of EjD in a cohort of patients with LUTS.
Materials and Methods
From January 2012 to March 2016, each new patient aged >50 years with LUTS due to BPE presenting at our outpatient clinic was prospectively enrolled. We did not include in the study patients with neurologic disorders, renal insufficiency, bladder stones, prostate cancer, urethral stricture, previous pelvic surgery, and previous BPE surgery. Furthermore, patients currently on alpha-blockers or 5-alpha reductase inhibitors or with a prostate volume <30 mL were excluded from the study. The local independent ethics committee approved the study protocol, and a dedicated informed consent was obtained from all patients before enrolling. LUTS were assessed using the International Prostate Symptom Score (IPSS) Italian version. ED was evaluated using the International Index of Erectile Function short form (IIEF-SF) Italian version, whereas ejaculation function was measured using the Male Sexual Health Questionnaire ejaculatory dysfunction short form (MSHQ-EjD-SF) Italian version. Patients underwent a detailed physical examination, including height, weight, and waist circumference measurement. Body mass index was calculated as weight in kilograms divided by height in meters squared (kg/m2). Obesity was defined as body mass index >30 kg/m2. Waist circumference and resting blood pressure was recorded. Finally, after fasting (8 hours), blood samples were drawn from all patients, and serum samples were analyzed in our laboratory for blood glucose, high-density lipoprotein cholesterol level, triglyceride level using an automated analyzer ARCHITECT c16000 System (Abbott Diagnostics, Copenhagen, Denmark), and total prostate-specific antigen levels using an automated analyzer ARCHITECT i2000 System (Abbot Diagnostics). The data were used to define a binary variable for the presence or absence of the MetS according to the criteria proposed by the third report of the National Cholesterol Education Program expert panel on detection, evaluation, and treatment of high blood cholesterol in adults: Adult Treatment Panel III. Patients with at least 3 of the following factors were classified as having MetS: waist circumference >102 cm, triglyceride level >150 mg/dL, high-density lipoprotein level <40 mg/dL, fasting glucose level >110 mg/dL, and blood pressure >130/85 mm Hg. All patients underwent a transrectal ultrasonography examination to determine the prostate volume using a Falcon ultrasound equipment (B-K Medical, Milan, Italy) equipped with a 5- to 10-MHz biconvex probe (8808 probe; B-K Medical).

The etiology of decreased renal function in patients

The etiology of decreased renal function in patients with locally advanced disease is difficult to determine. Multiple studies have shown the correlation between preservation of functional nephrons and postoperative renal function. In our study, we found that patients with stage III had worse renal function than patients with stage II disease (despite similarly sized tumors). The loss of functional parenchyma with increased tumor size and complexity, along with the disruption of blood flow to the affected kidney, is a likely etiology specifically in patients with tumor thrombus (stage III). There is significant evidence in the literature suggesting that reduced blood flow leading to intrarenal ischemia may contribute to fibrosis in renal parenchyma. Despite the known development of collateral blood flow in patients with renal vein obstruction, the long-term effects of ischemia to the remaining nephrons are difficult to quantify, and these patients may be more likely to recover renal function after nephrectomy. In the setting of locally advanced RCC, it is imperative for urologists to be mindful of preoperative renal function and potential postoperative outcomes in counseling of patients. As the involved kidney may have reduced function, a renal scan to assess relative renal function is likely indicated in these patients to help make clinical decisions.

Conclusion

Acknowledgment

Radical cystectomy (RC) with urinary diversion is the standard of care for patients with muscle-invasive KN-93 hydrochloride cancer. Despite improvements in surgical techniques and perioperative care, RC remains associated with significant patient morbidity. Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care pathways designed to achieve early recovery, and have been associated with lower rates of complication and shorter hospital lengths of stay (LOSs) in cystectomy patients.

Early investigations of B-mode or two-dimensional transrectal ultrasound (TRUS) in the evaluation of prostate cancer (PCa) demonstrated that intraprostatic hypoechoic ultrasound lesions (HULs) may correlate with cancer-containing foci. Although exclusively targeting HUL is attractive in terms of efficiency, this strategy results in lower cancer detection rates than systematic 12-core biopsy of the gland. However, as HUL biopsy may demonstrate clinically significant PCa otherwise missed by a 12-core approach, current guidelines advocate a combination of systematic and lesion-directed needle biopsies.
Targeted biopsy is being reevaluated due to the development of platforms that enable the sampling of regions of interest on multiparametric magnetic resonance imaging (MP-MRI) of the prostate in an office setting via software fusion with real-time TRUS, resulting in improved detection of high-risk PCa as compared with systematic 12-core biopsy. However, the significance of HUL which may be encountered during MRI-TRUS fusion biopsy is unclear.For instance, the incremental benefit of routine biopsy of HUL in addition to MP-MRI lesions is unknown in patients selected for biopsy based on imaging findings that may confer higher risk at baseline. The aim of Ochre suppressor study was to determine whether supplemental biopsy of HUL improves cancer detection in men with MRI abnormalities undergoing MRI-TRUS fusion biopsy.
Methods

Results
Altogether, 1260 patients underwent MP-MRI and initial MRI-TRUS fusion biopsy from August 2007 to February 2015. Of this population, 106 out of 1260 men (8%) underwent biopsy of 119 HULs. Table 1 lists the demographic and biopsy data of these men. The median time from MP-MRI to biopsy was 30 days (interquartile range: 6-66). The overall cancer detection rate by either systematic 12-core, MRI lesion, or HUL biopsy was 58% (62 out of 106). PCa was present in 28 out of 119 (24%) HULs. Patients with a positive HUL biopsy had comparable median age, serum PSA level, HUL diameter and location, number of biopsy cores overall and MRI-TRUS-targeted cores specifically, and racial distribution to those with negative HUL biopsy, but had smaller prostates (46 mL vs 56 mL, P = .007) and correspondingly greater PSA density (0.18 ng/mL2 vs 0.11 ng/mL2, P = .002). Positive HUL biopsy was more common when there was a highly suspicious MRI lesion (12 out of 28 vs 7 out of 78, P = .0002). The proportions of patients with palpable nodules by DRE and with prior history of a TRUS biopsy positive for PCa were greater where HUL biopsy demonstrated PCa (11 out of 28 vs 8 out of 78, P = .001; and 11 out of 28 vs 14 out of 78, P = .003).

eGFR grade and stage are significant

eGFR, grade and stage are significant predictive variables of NMIBC recurrence, progression and survival. Integrating eGFR into NMIBC risk calculation helped to discriminate individuals with high and low risk of cancer recurrence, progression and survival. Confirmatory studies and external validation are needed to corroborate these findings.

The incidence of upper tract urothelial carcinoma (UTUC) and chronic kidney disease (CKD) are high in southern Taiwan. The renal sparing surgery (RSS) is an optional choice of treatment of UTUC. This study was designed to assess the predictive factors on multifocal UTUC.
This study was retrospectively designed to determine the predictive factors on concurrent renal pelvis urothelial carcinoma (RPUC). From 2004 to 2012, 263 patients with preoperative solitary ureter tumor underwent radical nephroureterectomy (RNU) at our tertiary medical center. Perioperative data were recorded by chart review. Multivariate binary logistic regression was used to analyze the impact of risk factors for concurrent RPUC by SPSS ver. 17.
There are thirty-eight patients (14%) had postoperative finding of concurrent RPUC. There is no significant difference of grade of preoperative hydronephrosis between both groups ( = 0.533), and there are significant difference of proportion of preoperative CKD stage ( = 0.005) and past history of nobiletin cancer ( = 0.003) between both groups. Multivariate analysis disclosed both bladder cancer history (odds ratio: 2.948;  = 0.005) and preoperative CKD stage >3 (odds ratio: 2.207;  = 0.033) are independent risk factors for multifocal UTUC.
In addition to the EAU guideline of conservative treatment for UTUC, we supposed that past history of bladder cancer and preoperative CKD stage greater than stage 3 are both important and independent risk factors to synchronously multifocal UTUC. More consequent studies about the oncologic outcome of RSS are necessary.

Intravesical therapy with Mitomycin-C and Bacillus Calmette-Guérin is a standard treatment for superficial bladder cancer. Owing to the worldwide shortage of Bacillus Calmette-Guérin, the use of Mitomycin-C for intravesical therapy is increasing. Sometimes, calcified lesion of bladder wall at previous resection site were found during scheduled cystoscopy. Are these lesions should be resected?
We retrospectively included 43 non-muscle invasive bladder cancer patients who were treated with transurethral resection of bladder tumor followed by adjuvant intravesical mitomycin C intravesical therapy between 2011 and 2014 at Tri-service General Hospital. These patients were classified into calcification and non-calcification groups. This study analyzes the characteristic of these two groups in order to find the predictive factor of bladder wall calcification and the meaning of bladder wall calcification in clinical practice.
Of the 43 patients, 7 had calcified lesion of bladder wall after intravesical mitomycin-C therapy and the other 36 didn\’t. The urinary pH is lower in calcification group (5.43±0.071) than non-calcification group (5.94±0.150, p = 0.002). The calcification group reveal the tendency of higher tumor recurrent rate than non-calcification group (28.6% V.S. 2.8%, p = 0.014).
The patients with lower urinary pH during intravesical mitomycin-C therapy are prone to have bladder wall calcification and higher tumor recurrent rate. Our results revealed the calcified lesion might be the cover of tumor. Based on these results, we suggest resect the calcified lesion.

To identify Neutrophil/Lymphocyte ratio(NLR) as a prognostic predictor influencing long term survival for patient undergoing radical cystectomy with different urothelial carcinoma stages
We obtained 163 patients who admitted for urothelial carcinoma and underwent radical cystectomy during nobiletin 2005-2008 in Linkou Chang-Gung Memorial Hospital. The preoperative factors including gender, tumor pathology, tumor size, pathological characteristics and pre-OP lab data were analysed. The paired t-test was used to analyze associations between categorical variables. Multivariate analysis was performed. Significance level was set at p<0.05. All stastical analysis was done with SPSS for MAC.

Introduction Kidney cancer is not a single

Introduction
Kidney cancer is not a single disease because it comprises a number of different cancers that occur in the kidney, each with a different histology, which respond differently to therapy and are caused by mutations in different genes. Renal cell carcinoma (RCC) is the most common kidney malignancy and the development of macroscopic metastases of RCC is the major cause of tumor-associated deaths. The morbidity of RCC has consistently increased by approximately 1.5% to 5.9% annually until RCC is now the 10th most common in men and 14th most common in women [1]. Pathologic stage, based on the size of the tumor and the extent of invasion, grade, the histological cell type as well as clinical parameters are widely used in clinical practice for the prognosis of RCC. Despite this, none of these algorithms are 100% accurate. Identification of alterations that contribute to the variation in tumor behavior and clinical outcome within organ-confined or metastatic RCC is needed for improved management of RCC. Recent advances in understanding cancer as a genetic disease have allowed the development of targeted molecular therapies; however, resistance to these drugs remains a significant problem. Perhaps the key to understand the different clinical outcome and resistance to treatment as well as developing more effective treatments is an in depth study of the metastatic tumors. Little is known about the molecular mechanisms enabling metastatic spread of the primary tumor; however, there is some evidence that primary RCC and metastases of RCC exhibit molecular differences. This article provides an overview of the most important publications on genetic and molecular variations between primary tumors and metastases of RCC.

Results and discussion

Conclusion
The present review describes differences between primary renal tumors and their metastases at various levels of cellular functionality associated with tumor biology and clinical outcome. Disease progression in RCC is associated with significant changes in the eicosapentaenoic acid of genes and proteins, which probably makes metastatic cancer cells that are more aggressive. These changes may partially explain the difficulties connected with different clinical outcomes within organ-confined and metastatic RCC but at present, no RCC biomarker is an appropriate candidate for use in clinical practice. However, Wuttig et al. provided evidence that “late metastases” diagnosed≥5 years after nephrectomy and “early metastases” occurred≤9 months after nephrectomy showed differential expression of genes involved in metastasis-associated processes and have greater metastatic potential [12] despite clinical analyses showing a better outcome of patients with a longer period from nephrectomy to recurrence of the disease. This may indicate that differential expression of genes and proteins in a primary tumor and matched metastases is only one of the causes of the various clinical behaviors of these tumors. Greater analysis of the differences between primary tumors and metastases, also on immunological level, is required to gain a full assessment of the pathway changes, as these differences may have implications for future work understanding the cancer biology. Further prospective studies on large cohort patients are needed to identify differences representing promising targets for prognostic purposes, predicting the disease-free survival and metastatic burden of a patient as well as their suitability as potential therapeutic targets.

Introduction
Kidney cancer, which is predominantly renal cell carcinoma (RCC) in histology, is among the most lethal of urologic malignancies. In 2015, a total of 61,560 new cases were estimated to occur in the United States, with approximately 23% expected to die of the disease [1]. Although, the 5-year survival of localized RCC patient is around 90%, this decreases to 65% in patients with locally advanced, nonmetastatic RCC. Despite ongoing effort in clinical testing of adjuvant treatments for those at high risk for recurrence, surveillance remains the standard of care after the curative-intent surgery [2].

Introduction Kidney cancer is not a single

Introduction
Kidney cancer is not a single disease because it comprises a number of different cancers that occur in the kidney, each with a different histology, which respond differently to therapy and are caused by mutations in different genes. Renal cell carcinoma (RCC) is the most common kidney malignancy and the development of macroscopic metastases of RCC is the major cause of tumor-associated deaths. The morbidity of RCC has consistently increased by approximately 1.5% to 5.9% annually until RCC is now the 10th most common in men and 14th most common in women [1]. Pathologic stage, based on the size of the tumor and the extent of invasion, grade, the histological cell type as well as clinical parameters are widely used in clinical practice for the prognosis of RCC. Despite this, none of these algorithms are 100% accurate. Identification of alterations that contribute to the variation in tumor behavior and clinical outcome within organ-confined or metastatic RCC is needed for improved management of RCC. Recent advances in understanding cancer as a genetic disease have allowed the development of targeted molecular therapies; however, resistance to these drugs remains a significant problem. Perhaps the key to understand the different clinical outcome and resistance to treatment as well as developing more effective treatments is an in depth study of the metastatic tumors. Little is known about the molecular mechanisms enabling metastatic spread of the primary tumor; however, there is some evidence that primary RCC and metastases of RCC exhibit molecular differences. This article provides an overview of the most important publications on genetic and molecular variations between primary tumors and metastases of RCC.

Results and discussion

Conclusion
The present review describes differences between primary renal tumors and their metastases at various levels of cellular functionality associated with tumor biology and clinical outcome. Disease progression in RCC is associated with significant changes in the eicosapentaenoic acid of genes and proteins, which probably makes metastatic cancer cells that are more aggressive. These changes may partially explain the difficulties connected with different clinical outcomes within organ-confined and metastatic RCC but at present, no RCC biomarker is an appropriate candidate for use in clinical practice. However, Wuttig et al. provided evidence that “late metastases” diagnosed≥5 years after nephrectomy and “early metastases” occurred≤9 months after nephrectomy showed differential expression of genes involved in metastasis-associated processes and have greater metastatic potential [12] despite clinical analyses showing a better outcome of patients with a longer period from nephrectomy to recurrence of the disease. This may indicate that differential expression of genes and proteins in a primary tumor and matched metastases is only one of the causes of the various clinical behaviors of these tumors. Greater analysis of the differences between primary tumors and metastases, also on immunological level, is required to gain a full assessment of the pathway changes, as these differences may have implications for future work understanding the cancer biology. Further prospective studies on large cohort patients are needed to identify differences representing promising targets for prognostic purposes, predicting the disease-free survival and metastatic burden of a patient as well as their suitability as potential therapeutic targets.

Introduction
Kidney cancer, which is predominantly renal cell carcinoma (RCC) in histology, is among the most lethal of urologic malignancies. In 2015, a total of 61,560 new cases were estimated to occur in the United States, with approximately 23% expected to die of the disease [1]. Although, the 5-year survival of localized RCC patient is around 90%, this decreases to 65% in patients with locally advanced, nonmetastatic RCC. Despite ongoing effort in clinical testing of adjuvant treatments for those at high risk for recurrence, surveillance remains the standard of care after the curative-intent surgery [2].

br Commentary The authors retrospectively evaluate

Commentary
The authors, retrospectively, evaluate 160 organ confined RCCs<7cm in largest dimension (pT1a and pT1b). Most common types of renal cell tumors were included—60 clear cell RCC, 50 papillary RCC, 25 chromophobe RCC, and 25 oncocytomas. The presence, thickness, and extend of fibromuscular pseudocapsule around the tumor were studied. The authors demonstrated that clear cell RCC most often had a pseudocapsule that was thickest and usually entirely surrounded the tumor. These features were increasingly less frequently seen in papillary and chromophobe RCCs. Oncocytoma most often directly continued with the surrounding renal human leukocyte elastase without any intervening pseudocapsule. Papillary RCC nearly 4 times more often invaded through the pseudocapsule.
The pseudocapsule of RCC is characterized by the presence of true smooth muscle fibers—this distinguishes this cancer from any other epithelial malignancies in the body that are usually surrounded by desmoplastic (connective tissue) reaction. In our prior study we investigated 105 RCCs and also concluded that clear cell RCC had the most frequent and the most prominent fibromuscular pseudocapsule [1]. A recent study by Snarskis et al. [2] also demonstrated that papillary RCC were more often to infiltrate through the pseudocapsule. This finding is consequential as enucleation of papillary RCC may be associated with a higher likelihood of residual carcinoma and local recurrence what we have observed in the data from the University of Miami (manuscript in preparation for publication by the author). The study by Snarskis et al. also demonstrated that ISUP grade 4 RCCs (clear cell and papillary, chromophobe RCC is not assigned a grade and only rarely has sarcomatoid change) were also more likely to demonstrate infiltration through the pseudocapsule. This feature overlaps with rhaboid and sarcomatoid changes that most commonly justifying ISUP grade 4. Clinically, the radiologic evidence of prominent pseudocapsule along with a pattern of enhancement may be used to predict histologic type of renal tumor. Pathologically, low-grade renal cell carcinomas may extensively degenerate and retain their pseudocapsule that can help to arrive at the correct diagnosis [3]. Occasionally, I encounter renal tumor biopsies that are composed of extensive myxoid degeneration with prominent vasculature. Presence of fibromuscular pseudocapsule in such cases allows me to alert a clinician that the biopsy may have been taken from an area of clear cell RCC and additional tissue sampling may be needed. On the other hand, such benign renal tumors as oncocytoma or metanephric adenoma often do not have a pseudocapsule and are in direct contiguity with the surrounding renal parenchyma.

Commentary
The authors analyzed if grading system proposed by Delahunt et al. [1] could better predict outcome in 842 consecutive patients with localized renal cell carcinoma (RCC) compared to nucleolar ISUP grade. The former system combines ISUP grade [2] and the presence of necrosis as follows: grade 1 = ISUP grade 1 and non-necrotic ISUP grade 2; grade 2 = necrotic ISUP grade 2 and non-necrotic ISUP grade 3; grade 3 = necrotic ISUP grade 3 and non-necrotic nonsarcomatoid/rhabdoid ISUP grade 4; grade 4 = necrotic ISUP grade 4 and sarcomoatid/rhabdoid features. The authors excluded from analysis tumors with no recurrence potential, that is, multilocular cystic renal neoplasm of low-malignant potential and clear cell papillary RCC. Interesting observation that in univariate analysis there was no difference in outcome between ISUP grade 1–3 tumors and only grade 4 tumors had a significantly worse prognosis. However, ISUP grade 1–3 tumors with necrosis behaved significantly worse than those without. When necrosis was factored in, ISUP grade 1 and 2 tumors had similar outcome regardless of the presence or absence of necrosis. However, a significant stratification of prognosis was achieved when ISUP grade 3 and 4 tumors were classified according to the presence of necrosis. In ISUP grade 4 RCC further separation could have been reached if the tumors were dichotomized into having<10% and>10% necrosis.

Because the patients had significant differences in preoperative clinical

Because the patients had significant differences in preoperative clinical characteristics, we performed propensity score matching according to the propensity to receive PN. The propensity scores were calculated by using nonparsimonious and multivariate logistic regression based on preoperative characteristics such as patients’ age, body mass index (BMI), sex, surgery type (open vs. laparoscopic and robotic surgery), American Society of Anesthesiologists score, history of R-115777 and hypertension, and tumor size. As postoperative outcomes cannot influence the preoperative decision, the postoperative pathological outcomes were excluded from the propensity score matching. Except for 1 subject without an appropriate pair, 317 patients with PN were successfully matched to 841 patients with RN in a 1:3 ratio using the nearest neighbor matching method with 0.02 caliber. Our propensity score models were well calibrated and discriminating, showing all minimal mean standardized differences less than 0.05 (Table 1).
To compare the clinical and pathological characteristics between the RN and PN groups, independent t-tests and chi-square tests were performed. Kaplan-Meier analyses were performed to compare the survival outcomes among the subgroups. Multivariate Cox proportional regression models were used to identify the independent predictors for progression-free, cancer-specific, and overall survival (OS). All of the statistical analyses were performed by using the SPSS software package (Version 19.0, Chicago, IL) and all P values were 2-sided. P<0.05 was considered statistically significant.
Discussion
In this study, we compared the postoperative survival outcomes and early complications of patients with RCC of clinical T1b or higher treated with RN or PN. When we performed univariate Kaplan-Meier analysis in our nonmatched entire cohort, the PN group showed superior PFS, CSS, and OS, but the multivariate Cox analysis did not show any relationship between the surgery type and survival endpoints. These superior outcomes after PN in the entire cohort are the result of the favorable preoperative clinical characteristics of the PN group. The patients in the PN group were significantly younger (P<0.001), had higher BMI (P = 0.006), had fewer cases of hypertension (P = 0.032), and most importantly, had smaller tumor volumes (P<0.001). As these variables are known to be significant prognostic factors from previous studies [8–11], the results from the analysis of our full cohort misled us toward favoring PN. However, after we matched our cohorts according to the preoperative variables by propensity score, the matched cohort R-115777 did not show any significant differences in survival outcomes between RN and PN in PFS, CSS, or OS. The multivariate analysis also did not show any significant relationship between surgery type and survival outcomes.
Several studies have shown that PN can be extended to patients with T1b renal tumors [12–15]. Leibovich et al. [12] previously reported that the 5-year CSS rates were 86% and 98% after RN and PN, respectively. Their study also showed superior survival outcomes in the PN group initially, but this difference was no longer significant after adjusting for several preoperative covariables. Patard et al. [13] analyzed a multicenter database of 1,048 patients treated with PN. Among them, 247 patients had tumors larger than 4cm. When sensory input compared the patients with clinical T1a RCC and T1b or higher, there were no significant differences in recurrence or CSS in their study. Badalato et al. performed a retrospective analysis of data from 11,256 cases of T1b RCC treated with RN or PN in the United States recorded in the Surveillance, Epidemiology, and End Results (SEER) registry [14]. They also performed propensity score matching using age, sex, tumor size, geographic location, and treatment year and reported that there were no significant differences in OS (P = 0.161) in their study. Although they analyzed a huge number of patients from the SEER database, they could not evaluate any detailed information regarding pathological outcomes or specific survival endpoints such as CSS or PFS. Recent meta-analysis by Maria et al. analyzed 21 studies with 11,204 patients and concluded that the PN can provide acceptable surgical morbidity and equivalent cancer control even in larger tumors [16]. As there has been no randomized trial comparing the true outcomes after RN and PN for T1b RCC, we think our study provides valuable data for supporting comparable oncological outcomes after PN and RN. We also performed a subgroup analysis for patients with clinical T2 RCC. Although the number of patients was small, our study showed that PN can be used in some selected patients with large RCCs (≥7cm).

Approximately of patients traveled outside of their HRR of residence

Approximately 36% of patients traveled outside of their HRR of residence for RC (Table 3). Significantly more patients left their HRR of residence for the procedure over time (P<0.001). Most patients (87%) had RC at a hospital within 1 of the 72 included HRRs. Of the 1,351 patients who had cystectomy outside of these HRRs, most (79%) had surgery in 1 of 6 cities not located in SEER that p-Cresyl sulfate were home to high-volume tertiary referral p-Cresyl sulfate centers: Manhattan, Philadelphia, Ann Arbor, Nashville, Rochester (Minnesota), and Houston.

Discussion
The changes we observed in the distribution of RCs among hospitals are consistent with a recent report based on hospital discharge data from 3 states, which found a shift in RCs from low- to high-volume hospitals between 1996 and 2009 [12]. By 2009, most procedures were performed at high- and very high–volume hospitals, and several hospitals stopped performing RC altogether. Another study used inpatient discharge data from 1988 through 2000 and found that most cystectomies were performed at urban hospitals, and the percentage of procedures performed at high-volume hospitals and teaching hospitals increased significantly over time [11]. In the absence of a mandate to regionalize RCs to high-volume hospitals in the United States, the cause of increased regionalization is likely a function of patient demand, physician referral patterns, and the availability of surgeons and hospitals that offer the procedure.
Increased regionalization of complex cancer surgery has been described for several procedures. Using discharge data from 3 states between 1996 and 2006, one study found a redistribution of esophagectomy, pancreatectomy, and colectomy from low- to high-volume hospitals [4]. Another study using Nationwide Inpatient Sample discharge data examined trends in pancreatectomy, esophagectomy, gastrectomy and major lung resection from 1997 to 2006 [5]. Many hospitals stopped performing these complex operations, and there was a significant shift from low- to high-volume hospitals. A study that used Medicare data to examine trends in market concentration and mortality for several complex operations, including RC, found an increase in the proportion of patients treated at high-volume hospitals and a reduction in postoperative mortality between 1999 and 2008 [3]. Although the absolute mortality reduction for cystectomy was modest (4.3%–3.7%), the relative reduction in mortality was 14%, much of which was attributed to increases in hospital volume.
Others have found similar associations between the concentration of specialty care and patient access. A cross-sectional study examining geographic access to medical oncologists found increasing travel times to more specialized oncology treatment centers [20]. Although this study did not examine variations in utilization, processes of care or cancer outcomes as a function of travel burden, it did find an inverse relationship between specialization of care and access. Following a Medicare requirement that bariatric surgery patients seek treatment at high-volume Centers of Excellence, patients presenting for bariatric surgery experienced significantly longer travel distances [21]. Finally, travel distance for esophagectomy, pancreatectomy and colectomy all increased over time in proportion to the degree each became centralized [4].
We also observed an increase in the proportion of patients who traveled outside their tertiary health care regions for RC over time, further evidence of regionalization. A recent study used discharge data from Washington State between 2003 and 2007 to examine travel requirements for patients having RC, radical prostatectomy, radical nephrectomy, partial nephrectomy and transurethral resection of the prostate [22]. Significantly more patients had to travel outside of their HRR of residence for RC than for any other procedure. Although HRR boundaries were not created based on RC specifically, they are intended to define geographic areas in which patients receive tertiary care for complex surgical procedures. Therefore, these findings may have implications for access to tertiary surgical care.

Though Ellison suggests that target is the most

Though Ellison (2005) suggests that target is the most important factor in a risk assessment, he argues that many arborists who perform tree risk assessments focus on the tree defects and neglect to consider target occupancy ⿿ potentially resulting in an overestimation of risk posed by trees in more remote locations. This assumption is supported by work from Koeser et al. (2015), who found that defect severity made up as much as 55% of an arborist⿿s risk rating decision. Two attributes related to target (i.e., proximity and type) accounted for less than 24% of the same group⿿s risk rating decision and were only a significant consideration among advanced arborists (Koeser et al., 2015). They go on to say that this is potentially due to researchers in arboriculture focusing more on tree biomechanics rather than target occupancy.

Conclusion
Bellett-Travers (2010) attests that the subjective nature of visual tree inspections can be reduced if assessment methods include an analysis of similar populations that can later be used as a comparison when inspecting individual trees. It is thought that this would remove some of the personal judgement on the part of the assessor. Thus, future research on target occupancy has the potential to change the views of the industry to a more quantitative approach based on target occupancy, getting away from the current trend to Fmoc-Ser(tBu)-OH decisions on the severity of defects, which can be both highly subjective and guided by perceptions of risk posed by a particular tree, rather than the reality of a given risk. Much like Ellison (2005), this study has shown that quantifying target occupancy through the use of traffic counters can be a useful tool for arborists and tree care professionals that preform tree risk assessments. Ratings derived from traffic counts were more strongly correlated with the Fmoc-Ser(tBu)-OH actual measured occupancy than those derived from visual indicators. The relationship could be further strengthened with a clearer definition of what constitutes rare, occasional, frequent, and constant occupancy.

Acknowledgements

Introduction
Urban forestry has been defined as “the art, science and technology of managing trees and forest resources in and around urban community ecosystems for the physiological, sociological, economic, and aesthetic benefits trees provide society” (Konijnendijk et al., 2006). This field is important because it entails a multidisciplinary approach to the management and planning for all woody angiosperms that are found near- or within an urbanized area (Konijnendijk et al., 2005). Moreover, benefits derived from urban trees include: health, psychological, aesthetic, recreational, climatic and economic aspects (Tyrväinen et al., 2005). Also, urban trees contribute to improve the conditions of the environment by improving air quality and taking up pollutants (Tyrväinen et al., 2005). Various regions worldwide have contributed numerous studies to the field of urban forestry (Konijnendijk et al., 2005; Thaiutsa et al., 2008; Padoch et al., 2008; Escobedo et al., 2015). Particularly, North America and Europe are among the best documented (Konijnendijk et al., 2005). In contrast to these regions, the field has been less studied in tropical regions. Urban forestry studies in the tropics have been conducted in various countries and regions, such as Thailand (Thaiutsa et al., 2008), Colombia (Escobedo et al., 2015), and the Amazon-Basin (Padoch et al., 2008). The most abundant tropical species that have been studied as part of the urban environment include Pterocarpus indicus Wild., Tabebuia rosea (Bertol.) DC., and Cassia fistula L. among 127 other tree species from Bangkok, Thailand (Thaiutsa et al., 2008). Escobedo et al. (2015) reported more than 100 species from urban areas in Bogotá, Colombia on a study about socio-ecological dynamics and inequality linked to the urban forest. Most studies conducted in tropical regions emphasize mostly on forestry species with less emphasis on fruit tree species growing within the urban forest. Fruit trees are an important component of the urban forest because they provide a number of ecological functions and services e.g. pollination, feeding grounds for birds and mammals, etc.