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Introduction: Prostate cancer is the second most common malignancy in men worldwide. Genomic VPAC receptors are expressed on malignant prostate cancer cells and can be targeted and imaged optically by a peptide labeled fluorophore. The objective of our study was to assess the feasibility of detecting cancer of the prostate using a voided urine sample., Materials and Methods: Patients ≥ 40 years old, with lower urinary tract symptoms and serum PSA > 4 ng/mL formed the study group. The first 50 mL of voided urine sample was collected and processed. The cells that were shed in the voided urine were fixed and stained with a peptide TP4303 and incubated. The slide was then stained with DAPI which binds with the DNA in the nucleus. All patients underwent a standard 12-core TRUS-guided prostate biopsy., Results: A total of 318 patients were included in the study, of these 158 were histologically confirmed cancers. Voided urine samples were positive for VPAC receptors in 154 (97.46%) of these. The remaining 160 patients had no cancer on the HPR examination and none of these patients were positive for VPAC receptors., Conclusions: This study validates our belief that patients with prostate cancer shed malignant cells in the urine that can be identified by targeting the VPAC receptors. If these results are further validated by multicentric studies, then this could form the basis for indications for a preliminary prostate biopsy in patients with elevated serum PSA but normal digital examination or in patients needing a repeat biopsy.

Introduction: To report the impact of our 25-year multidisciplinary care delivery model experience on patients with muscle invasive bladder cancer treated at our National Cancer Institute (NCI)-designated Sidney Kimmel Cancer Center at Jefferson University. To our knowledge, our multidisciplinary genitourinary cancer clinic (MDC) is the longest continuously operating center of its kind at an NCI Cancer Center in the United States., Materials and Methods: We selected a recent group of patients with cT2-4 N0-1 M0 bladder cancer seen in the Sidney Kimmel Cancer Center Genitourinary Oncology MDC from January 2016 to September 2019. These patients were identified retrospectively. SEER-18 (Surveillance, Epidemiology, and End Results) database, November 2019 submission was queried to obtain patients with similarly staged disease diagnosed between 2015 and 2017. Completion rates of radical cystectomy, use of neoadjuvant therapies, and survival outcomes were compared between the two cohorts., Results: Ninety-one patients from the MDC form this time period were identified; 65.9% underwent radical cystectomy and 71.8% received neoadjuvant therapy in the form of chemotherapy, immune checkpoint inhibition or a combination of the two - higher than reported national trends for neoadjuvant therapies. Progression of disease was seen in 24.2% of patients. A total of 8675 patients met inclusion criteria in the SEER database. Rates of radical cystectomy were significantly higher in MCD patients when compared to SEER derived data (65.9% vs. 37.7%, p =< 0.001). MCD patients had significantly better cancer-specific survival (mean 20.4 vs. 18.3 months p = 0.028, median survival not reached)., Conclusion: Our long term experience caring for patients with genitourinary malignancies such as bladder cancer in a uniform multidisciplinary team results in a high utilization of neoadjuvant therapies. When compared to a contemporary SEER-derived cohort, multidisciplinary patients were more likely to undergo radical cystectomy and had longer cancer-specific survival.

We report the case of a 61-year-old male with metastatic prostate cancer who presented with urinary retention secondary to subdermal penile and corpora cavernosa metastases with neuroendocrine transformation of his metastatic hormone sensitive prostate cancer. We highlight the presentation, diagnosis, and management of this rare condition.

Introduction: Hemorrhagic cystitis (HC) is a morbid condition for patients and can be challenging for urologists to manage. There are many potential contributing etiologies and the severity of bleeding can be variable. It is important to consider each clinical scenario when formulating management strategies in order to provide the highest quality of care to patients. We provide a review of the literature including diagnosis and treatment options., Materials and Methods: We performed a literature search on PubMed using the following keywords: hemorrhagic cystitis, cystitis, gross hematuria, intractable hematuria. We considered all available published articles with no specific inclusion or exclusion criteria for the purposes of this review., Results: We reviewed a total of 41 articles and identified a broad differential diagnosis for intractable hemorrhagic cystitis including infection, chemical exposure, malignancy, nephropathy, trauma, radiation therapy, and idiopathic etiology. Depending on the severity of bleeding, many treatments have been described. These range from conservative strategies (bladder fulguration and continuous irrigation) to more extreme and morbid therapies (intravesical instillations, embolization, and urinary diversion)., Conclusion: Hemorrhagic cystitis is a relatively common and can be a difficult condition to manage for urologists. It is important to understand the etiology and available treatments options in order to best treat our patients. We provide a comprehensive and thorough review of the literature and propose a stepwise treatment approach.

INTRODUCTION The objective of our review is to summarize the 2019 Philadelphia Prostate Cancer Genetic Consensus recommendations and discuss their implications to the US Military Health System., Materials and Methods: Literature review., Results: Our fighting force and retired service members will significantly benefit from the Philadelphia Prostate Cancer Genetic Consensus recommendations. Moreover, the experience of the equal access US Military Health System may help advancing genetic testing for cancer at national levels., Conclusions: Priorities recommended by the 2019 Consensus for more research on genetic predisposition to prostate cancer in racially diverse populations is a promising step. The US Military Health System has the ability of providing equal access to implement advanced germline testing for its racially diverse population.

INTRODUCTION Accurate staging of urothelial bladder cancer (UBC) with imaging, which guides effective bladder cancer treatment, remains challenging. This investigation is to validate a hypothesis that targeting Vasoactive intestinal and pituitary adenylate cyclase activating peptide (VPAC) receptors using ⁶⁴Cu-TP3805 can PET image UBC efficiently., Materials and Methods: Nineteen patients (44-84 years of age) scheduled for radical cystectomy, underwent VPAC positron emission tomography (PET) imaging prior to surgery. Sixteen had completed neoadjuvant chemotherapy prior to imaging. All 19 received ⁶⁴Cu-TP3805 (148 % ± 10% MBq) intravenously, and were imaged 60 to 90 minutes later. Standard uptake value (SUV)max for malignant lesions and SUVmean for normal tissues were determined and mean +/-SEM recorded. Following radical cystoprostatectomy, pelvic lymphadenectomy and urinary diversion imaging, results were compared with final surgical pathology., Results: ⁶⁴Cu-TP3805 had no adverse events, negligible urinary excretion and rapid blood clearance. UBC PET images for residual disease were true positive in 11 patients and true negative in four. Of remaining 4, one had false positive and 3 had false negative scans, equating to 79% sensitivity (95%, CI 49%-95%), 80% specificity (95%, CI 28%-100%), 92% positive predictive value (95%, CI 62%-100%) and 57% negative predictive value (95%, CI 18%-90%)., Conclusions: These first in man results, in a group, heavily pretreated with neoadjuvant chemotherapy, indicate that VPAC PET imaging can identify UBC effeiciently and suggest, that VPAC PET can diagnose UBC in a treatment naïve cohort for accurate staging, guide biopsy and treatment in patients with suspected metastasis and determine response to therapy. Further investigation of this molecular imaging approach is warranted.

INTRODUCTION To interpret data and update the traditional categorization of prostate cancer in order to help treating clinicians make more informed decisions. These updates include guidance regarding how to best use next generation imaging (NGI) with the caveat that the new imaging technologies are still a work in progress., Materials and Methods: Literature review., Results: Critical goals in prostate cancer management include preventing or delaying emergence of distant metastases and progression to castration-resistant disease. Pathways for progression to metastatic castration-resistant prostate cancer (mCRPC) involve transitional states: nonmetastatic castration-resistant prostate cancer (nmCRPC), metastatic hormone-sensitive prostate cancer (mHSPC), and oligometastatic disease. Determination of clinical state depends in part on available imaging modalities. Currently, fluciclovine and gallium-68 (⁶⁸Ga) prostate-specific membrane antigen (PSMA) positron emission tomography (PET)/computed tomography (CT) are the NGI approaches with the most favorable combination of availability, specificity, and sensitivity. PET imaging can be used to help guide treatment selection in most patients. NGI can help determine patients who are candidates for new treatments, most notably (next-generation androgen antagonists, eg, apalutamide, enzalutamide, darolutamide), that can delay progression to advanced disease., Conclusions: It is important to achieve a consensus on new and more easily understood terminology to clearly and effectively describe prostate cancer and its progression to health care professionals and patients. It is also important that description of disease states make clear the need to initiate appropriate treatment. This may be particularly important for disease in transition to mCRPC.

Infection of artificial urinary sphincters or inflatable penile prostheses is one of the most devastating complications after prosthetic surgery and can have a significant impact on a quality of life. Patients undergoing revision surgery with or without device replacement may have increased risk for infection when compared to initial primary surgery. As such, surgeons may utilize traditional culture results to direct antimicrobial therapy for these patients. Unfortunately, culture results can be inconclusive in up to one-third of the time even in the setting of active device infection. Next-generation sequencing (NGS) of DNA is an emerging technology capable of sequencing entire bacterial genomes and has the potential to identify microbial composition in explanted devices. Herein, we describe our institutional experience on NGS utilization in patients with genitourinary prostheses. We also highlight our methods and techniques to inform readers on the potential practices that can enhance the utility and diagnostic yield of this new and upcoming technology.

Introduction: Prostate cancer is a common malignancy with highly variable clinical presentation and outcomes. Diagnosis and management remain a challenge and at times become highly controversial. Novel biomarker assays have shown promise as an adjunctive tool to aid in patient shared decision-making, risk stratification, and disease management. This presentation at the 2020 Jefferson Urology Symposium provided a review of current commonly used biomarkers for prostate cancer., Materials and Methods: We reviewed the current literature on the use of biomarkers in the diagnosis and treatment decisions in localized prostate cancer., Results: Biomarker assays were reviewed and presented according to clinical application of each test. In the consideration of initial prostate biopsy the blood tests for PHI, and 4K Score, and urine tests PCA3, Select MDx and ExoDx are available. In the consideration of treatment versus active surveillance in the biopsy positive setting OncotypeDx, Prolaris and Decipher are available. In patients with an initial negative biopsy, 4K score, PCA3, ExoDx and the tissue biopsy based Confirm MDx assay can help guide the decision to perform repeat biopsy. In the consideration for adjuvant radiation following radical prostatectomy the most extensive literature available supports the use of Prolaris or Decipher tissue assays., Conclusions: With the significant burden of men being diagnosed with prostate cancer, it is desirable to appropriately risk stratify patients to avoid unnecessary biopsies and over-treatment in low risk patients and guide appropriate treatment strategies in high risk patients. Selected biomarkers presented are useful adjunctive precision medicine tools to aid in shared decision making and to direct treatment decisions.

Introduction: To assess whether standard American Urological Association (AUA) and other recommendations for prostate biopsy prophylaxis provide sufficient coverage of common urinary organisms responsible for post biopsy infections by comparing local antibiograms in Philadelphia-area hospitals., Materials and Methods: De-identified culture results derived from antibiograms were collected from six academic and community hospitals in the Philadelphia region. Analysis specifically focused on four major bacterial causes of urinary tract infection following prostate biopsy (Escherichia coli (E. coli), Klebsiella pneumoniae, Proteus mirabilis and Enterococcus faecalis) along with commonly recommended antibiotics including fluoroquinolones (FQ's), trimethoprim/sulfamethoxazole, ceftriaxone, and gentamicin., Results: Bacterial sensitivities to each antibiotic across institutions showed variation in E.coli sensitivities to FQs (p < 0.001), trimethoprim/sulfamethoxazole (p < 0.001), ceftriaxone (p < 0.001) and gentamicin (p < 0.001). Klebsiella pneumoniae and Proteus mirabilis exhibited similar variations. Sensitivity comparisons for Enterococcus faecalis was unable to be performed due to absent or incomplete data across institutions., Conclusion: Institutional antibiograms vary within our regional hospitals. Standardized recommendations for commonly used antibiotic prophylaxis such as fluoroquinolones may be inadequate for peri-procedural prostate biopsy prophylaxis based on local resistance patterns. Valuable information about the potential effectiveness of antibiotic prophylaxis for prostate biopsies can be found in local institutional antibiograms, and should be consulted when considering antibiotic prophylaxis for prostate biopsy procedures.

In 2017 the Sidney Kimmel Cancer Center of Thomas Jefferson University held the first international consensus conference on the role of genetic testing for inherited prostate cancer risk. This article outlines the key elements of our 2017 consensus meeting and discusses the rationale and design of our follow up 2019 Philadelphia Prostate Cancer Consensus titled the 'Implementation of Genetic Testing for Inherited Prostate Cancer.'

Introduction: An important aspect of overlapping surgery is to determine the 'critical portion' of an operation. Currently, there are no guidelines that standardize the critical portions of common urologic procedures. We sought to determine the relationship between the critical portions of common urologic operations as defined by the primary surgeon compared to the trainee at a single academic medical center., Materials and Methods: In an open-ended survey of the Urology Department at Thomas Jefferson University, attending surgeons and urology residents, were asked to list five of their most commonly performed surgeries and subsequently identify what they defined as the critical portion for each. Responses were examined for surgeon-trainee congruence. Response agreement was defined as identifying key words that provided reasonable evidence that the responders were referring to identical portions of the case., Results: Nine residents and eight attending physicians provided 67 and 63 responses, respectively, encompassing 28 different procedures. Six procedures were chosen for further analysis based on high volume of responses. Overall, of the 67 resident-reported critical portions, 32 (47.8%) were in agreement with attending-reported critical portions. Year of training in residency was not a predictor of surgeon-trainee agreement., Conclusion: External pressures from the public and lawmakers alike may demand that providers be present during all 'critical portions' of a procedure. Our study shows that the understanding of critical portions of an operation is often incongruent between surgeons and trainees. Critical portions of all procedures should be established by the surgical team in order to accurately schedule overlapping surgeries.

Introduction: We evaluated the UroVysion (Abbott Molecular, IL, USA) fluorescence in situ hybridization (FISH) assay for the diagnosis of urothelial cancer in patients diagnosed with or suspected to have bladder, upper tract urothelial carcinoma (UTUC), and combined upper and lower tract urothelial carcinoma (BC)., Materials and Methods: A single institution retrospective analysis comparing sensitivity, specificity, positive predictive value, and negative predictive values for FISH and urinary cytology. FISH within 6 months of endoscopic evaluation were obtained from outpatient voided urine samples. Our institutional pathology department confirmed pathologic disease from specimens obtained during endoscopic evaluations for lower tract disease. For upper tract disease, disease was confirmed by retrograde ureteroscopy, biopsies of visual lesions, and site-specific upper tract cytology., Results: A total of 415 patients submitted FISH specimens. Overall, FISH was more sensitive than cytology 54.9% in comparison with cytology 42.2% (p = 0.01), specificity favored cytology 92.9% compared to 73.5% with FISH (p < 0.01). For BC only patients, the same significant finding of increased sensitivity and decreased specificity was identified, but for UTUC alone and combined UTUC and BC, there was no significant difference. Cytology had improved positive predictive value (PPV) over FISH, 76.9% in comparison to 64.6% (p = 0.02). Negative predictive value (NPV) also favored cytology 74.2% versus 64.9% (p = 0.02). When analyzing individual cohorts, cytology had improved PPV for BC alone patients. UTUC showed no difference for PPV and NPV. For both UTUC and BC, NPV was slightly favored for FISH over cytology 93.2% versus 91.2% (p = 0.03)., Conclusions: Voided urine FISH testing does offer a higher detection of urothelial carcinoma for BC compared to voided cytology; however, specificity was worse. FISH does not appear to improve detection of urothelial carcinoma in patients with either UTUC only or both BC and UTUC.

Radium-223 dichloride is a first-in-class bone-directed radiopharmaceutical that has been shown to prolong survival in men with metastatic castrate resistant prostate cancer (mCRPC). Unlike other radiopharmaceuticals, radium-223 uniquely uses alpha-emission to deliver high intensity, short range cytoxic treatments resulting in minimal myelosuppression. Following the results of the ALSYMPCA trial, radium-223 (Xofigo) was FDA approved in the United States in May 2013 and approved by Health Canada in December 2013 for the treatment of mCRPC with symptomatic bone metastases and no visceral disease. This 'How I do it' article describes the background of radium 223 as well as the methods and techniques that our institution uses for safe and effective administration and notes the subtle differences when administering the drug in Canada.

Prostate cancer has a substantial heritable component, which is often under-appreciated in the urologic community. Inherited prostate cancer which may account for up to 10% of cases has been associated with genetic mutations which are also linked with other hereditary cancer syndromes. Therefore, family history indicating inherited prostate cancer predisposition may extend beyond prostate cancer to include other cancers such as breast, ovarian and others. Genetic counseling and genetic testing guidelines for prostate cancer are slowly emerging, which emphasizes the need for urologists and other providers involved in the care of prostate cancer patients to consider referring appropriate prostate cancer patients for genetic counseling. Here we will highlight the key elements involved in prostate cancer risk assessment, current knowledge of genetic contribution to prostate cancer, and factors for urologists and other providers to consider when referring prostate cancer patients for genetic counseling.