Search

Background The use of surgical clips for athermal dissection of the lateral prostatic pedicles and ligation during pelvic lymph node dissection (PLND) while performing robotic-assisted radical prostatectomy (RARP) has been the gold standard. Clips are used to prevent thermal injury of the unmyelinated nerve fibers and lymphceles, respectively. Objective To compare oncological and functional outcomes of a new technique of clipless, lateral pedicle control and PLND with RARP with bipolar energy (RARP-bi) versus the standard RARP technique with clips (RARP-c). Design, setting, and participants A retrospective study was conducted among 338 men who underwent RARP between July 2018 and March 2020. Surgical procedure RARP-c versus RARP-bi. Measurements We prospectively collected data and retrospectively compared demographic, clinicopathological, and functional outcome data. Urinary as well as sexual function was assessed using the Expanded Prostate Cancer Index for Clinical Practice, and complications were assessed using Clavien-Dindo grading. Multivariable regression modeling was used to examine whether the technical approach of RARP-bi versus RARP-c was associated with positive surgical margins (PSMs) or sexual and urinary function scores. Results and limitations A total of 144 (43%) and 194 (57%) men underwent RARP-bi and RARP-c, respectively. Overall, there were no differences in functional and oncological outcomes between the two approaches. On multivariable regression analysis, the RARP-bi technique was not associated with significant differences in PSMs (odds ratio [OR] = 1.04, 95% confidence interval [CI] 0.6–1.8; p = 0.9), sexual function (OR = 0.4, 95% CI 0.1–1.5; p = 0.8), or urinary function (OR = 0.5, 95% CI 0.2–1.4; p = 0.2). The overall 30-d complication rates (12% vs 16%, p = 0.5) and bladder neck contracture rates (2.1% vs 3.6%, p = 0.5) were similar between the two groups. There was no difference in lymphocele complications (1.4% vs 0.52%, p = 0.58). All complications were of Clavien-Dindo grade I–II. Conclusions Despite the concerns for an increased risk of nerve injury secondary to the use of bipolar energy for prostatic pedicle dissection, we demonstrate that this technique is oncologically and functionally similar to the standard approach with surgical clips. There was no difference in complications or lymphocele formation for techniques with versus without clips. Patient summary We describe a modified technique for prostatic pedicle dissection during robotic-assisted radical prostatectomy, which utilizes bipolar energy and is associated with shorter operative time, without compromising functional or oncological outcomes.

Erectile dysfunction (ED) remains a significant problem in up to 63% of men after robot-assisted radical prostatectomy (RARP). After the discovery of the neurovascular bundle (NVB), additional anatomic description and variation in nerve-sparing (NS) techniques have been described to improve post-RARP ED. However, it remains questionable whether ED rates have improved over time, and this is concerning as competing treatments are introduced that have better ED outcomes. In this review, we describe RARP NS technical modifications that improve erectile function recovery. We focused on reports that included detailed anatomical descriptions as well as video illustrations to disseminate technique. We found that the alternative RARP NS surgical techniques provide better outcomes compared with standard NS RARP. The use of validated quality of life questionnaires is necessary for the appropriate comparison of outcomes. However, the retrospective character and inherent weaknesses of the included studies do not allow one to conclude which is the best NS approach. Overall, there is significant variation in RARP NS techniques and outcomes, and the ideal technical maneuvers to optimize outcomes remains subject to debate. However, there is a consensus on the importance of anatomically dissecting the NVB, minimizing traction and thermal injury as well as preserving the periprostatic fascia. Well-designed randomized controlled trials with videos describing details of different surgical techniques for generalizability are needed to consistently and objectively evaluate sexual function outcomes after RARP to optimize postoperative potency.

PURPOSE OF REVIEW Prostate biopsy is a very commonly performed office procedure leading to the diagnosis of the most prevalent solid-organ malignancy in American men. Although the transrectal technique for prostate biopsy remains the gold standard, there is increasing interest in the transperineal approach as it offers a clean, percutaneous approach that significantly decreases the risk for infection. In this review, we discuss emerging developments in transperineal prostate biopsy that may optimize the way biopsies are performed in clinical practice. RECENT FINDINGS Similarly, to transrectal biopsy, the transperineal approach also allows for the performance of systematic and MRI-targeted biopsy cores. As transperineal biopsy obviates the translocation of rectal bacteria to the prostate or bloodstream, in contrast to transrectal biopsy, it is feasible to forgo peri-procedural antibiotics in accordance with professional guidelines. This may attenuate antimicrobial resistance that may be associated with augmented prophylaxis. In addition, although transperineal biopsy may be traditionally performed under general anesthesia using a template grid, it may also be performed freehand under local anesthesia or sedation. Avoiding prophylactic antibiotics and general anesthesia as well as reducing infections/hospitalizations for transperineal biopsy scaled nationally will likely result in significant healthcare savings. SUMMARY Transperineal biopsy with combined systematic and MRI-targeted cores, offers several advantages over conventional transrectal biopsy. Transperineal biopsy under local anesthesia and without periprocedural antibiotic is emerging as a promising method for prostate cancer diagnosis and surveillance.

Purpose: Salvage radical prostatectomy is rare due to the risk of postoperative complications. We compare salvage Retzius-sparing robotic assisted radical prostatectomy (SRS-RARP) with salvage standard robotic assisted radical prostatectomy (SS-RARP). Materials and Methods: A total of 72 patients across 9 centers were identified (40 SRS-RARP vs 32 SS-RARP). Demographics, perioperative data, and pathological and functional outcomes were compared using Student's t-test and ANOVA. Cox proportional hazard models and Kaplan-Meier curves were constructed to assess risk of incontinence and time to continence. Linear regression models were constructed to investigate postoperative pad use and console time. Results: Median followup was 23 vs 36 months for SRS-RARP vs SS-RARP. Console time and estimated blood loss favored SRS-RARP. There were no differences in complication rates or oncologic outcomes. SRS-RARP had improved continence (78.4% vs 43.8%, p 0-1 pad (HR 0.28, 95% CI 0.10-0.79, p=0.016), although not when defined as >0 pad (HR 0.56, 95% CI 0.31-1.01, p=0.053). On adjusted analysis SRS-RARP was associated with decreased pads per day. Lymph node dissection and primary treatment with stereotactic body radiation therapy were associated with longer console time. Conclusions: SRS-RARP is a feasible salvage option with significantly improved urinary function outcomes. This may warrant increased utilization of SRS-RARP to manage men who fail nonsurgical primary treatment for prostate cancer.

Objective To determine whether the academic achievement of Department Chairperson (DC) and Research Director (RD), when present, is associated with increased scholarly productivity and National Institutes of Health (NIH) funding of faculty members in academic urology departments. Materials and Methods We identified the DC, RD and faculty members of 145 academic urology departments. The scholarly productivity and NIH funding for each individual faculty member was assessed from 2018 to 2019 using an h-index extrapolated from the Scopus database and the NIH RePORTER tool, respectively. The Spearman correlation coefficient was employed to define the correlation of these parameters. Hypothesis testing was conducted using the Mann-Whitney U test. Results After excluding 13 departments due to missing faculty listing, our final sample included 132 departments and 2227 faculty members. In 2018, the NIH provided $55,243,658 in urology research grants to 24.2% of departments and 4.0% of faculty members. Of departments with NIH funding, 68.8% employed a RD. DC and RD h-index were positively correlated with departmental h-index. DC h-index positively correlated with department NIH funding. Moreover, NIH funding was significantly higher for departments with a RD vs those without a RD ($1,268,028 vs $62,941, P Conclusion Academic success of a DC and RD was associated with urology departmental scholarly productivity and NIH funding. The presence of a RD, funded or unfunded, was associated with increased departmental NIH funding.

Prostate heterogeneity on multi-parametric MRI (mpMRI) may confound image interpretation by obscuring lesions; systematic biopsy may have a role in this context. To determine if prostate heterogeneity (1) correlates with clinical risk factors for prostate cancer and (2) associates with higher-grade tumor in systematic biopsy (SB), compared with MRI-directed target biopsy (MDTB), i.e., SB > MDTB, thus providing a rationale for combined biopsy. IRB-approved retrospective study included men who underwent mpMRI, SB, and MDTB between 2015 and 2017. Regions of interest were applied to the entire transition zone (TZ) and peripheral zone (PZ) on T2-weighted imaging (T2WI), apparent diffusion coefficient maps (ADC), and early dynamic contrast-enhanced (DCE) images on the midgland slice. Mean signal intensities and standard deviation (SD) of each zone were calculated. SD served as a measure of heterogeneity. Spearman’s rank correlation analysis of clinical and imaging variables was performed. Univariate logistic regression was used to determine if any imaging variable associated with SB > MDTB. 93 patients were included. Significant correlations included age and TZ ADC heterogeneity (rho = 0.34, p = 0.013), PSA density, and mean TZ ADC (rho = − 0.29, p = 0.049). PZ T2WI heterogeneity correlated with PZ ADC heterogeneity (rho = 0.48, p MDTB prior to multiple comparison correction (p = 0.032). p value after correction was 0.24. TZ ADC heterogeneity correlated with age and may reflect prostatic hyperplasia and/or prostate cancer. PZ heterogeneity, possibly a measure of prostatitis, correlated with TZ hyperplasia and/or inflammation. TZ ADC heterogeneity was associated with SB > MDTB with p value of

Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) has been shown to improve continence. However, questions remain regarding feasibility and generalizability of technique and outcomes.To compare the outcomes of 140 consecutive standard robot-assisted radical prostatectomy (S-RARP) versus RS-RARP.A total of 70 S-RARPs were performed followed by 70 RS-RARPs. Demographic, pathologic, and functional outcomes were compared preoperatively and through 12 mo. Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP) was used to compare functional outcomes. Logistic and linear regression analyses were utilized to analyze variables associated with EPIC-CP urinary incontinence and overall quality of life (QOL) scores, and oncologic outcomes. Cox regression analysis was used to analyze incontinence at 12 mo.RS-RARP versus S-RARP.Patient and tumor characteristics (age, body mass index, prostate-specific antigen, Charlson Comorbidity Index, Gleason group, clinical stage, and Prostate Imaging Reporting and Data System score), perioperative outcomes (console time, estimated blood loss, postoperative complications, and length of stay), oncologic outcomes (positive surgical margin [PSM], and biochemical recurrence), overall and 12-mo continence rates (zero pads and zero to one safety pad), time to continence, potency (erection sufficient for sexual activity), EPIC-CP urinary incontinence, sexual function, and overall QOL scores.Median follow-up for S-RARP versus RS-RARP was 46.3 versus 12.3 mo. RS-RARP versus S-RARP had improved overall continence rates at total follow-up (95.7% vs 85.7%, p = 0.042) and 12-mo follow-up (97.6% vs 81.4%, p = 0.002), and faster return to continence (zero to one safety pad, 44 vs 131 d, p 0.001). RS-RARP EPIC-CP urinary incontinence and overall QOL scores remained significantly better at 12 mo. There were no differences in overall PSM rates, although RS-RARP had lower rates of nonfocal PSMs. There were no differences in sexual function. In multivariate analysis, RS-RARP was significantly associated with improved 12-mo EPIC-CP urinary incontinence and improved QOL scores, but was not associated with PSM or biochemical recurrence. Limitations include retrospective study design and unequal follow-up; however, significantly better RS-RARP continence at 12 mo is striking despite fewer patients attaining 12-mo follow-up.RS-RARP significantly improves early and long-term continence without compromising oncologic outcomes and leads to overall improved QOL.Retzius-sparing robot-assisted radical prostatectomy is an emerging technique for robotic radical prostatectomy that improves urinary function and quality of life without compromising cancer control.

Background While Prostate Imaging Reporting and Data System (PI-RADS) 4 and 5 lesions typically warrant prostate biopsy and PI-RADS 1 and 2 lesions may be safely observed, PI-RADS 3 lesions are equivocal. Purpose To construct and cross-validate a machine learning model based on radiomics features from T2 -weighted imaging (T2 WI) of PI-RADS 3 lesions to identify clinically significant prostate cancer (csPCa), that is, pathological Grade Group ≥ 2. Study type Single-center retrospective study. Population A total of 240 patients were included (training cohort, n = 188, age range 43-82 years; test cohort, n = 52, age range 41-79 years). Eligibility criteria were 1) magnetic resonance imaging (MRI)-targeted biopsy between 2015 and 2020; 2) PI-RADS 3 index lesion identified on multiparametric MRI; (3) biopsy performed within 1 year of MRI. The percentages of csPCa lesions were 10.6% and 15.4% in the training and test cohorts, respectively. Field strength/sequence A 3 T; T2 WI turbo-spin echo, diffusion-weighted spin-echo echo planar imaging, dynamic contrast-enhanced MRI with time-resolved T1-weighted imaging. Assessment Multislice volumes-of-interest (VOIs) were drawn in the PI-RADS 3 index lesions on T2 WI. A total of 107 radiomics features (first-order histogram and second-order texture) were extracted from the segmented lesions. Statistical tests A random forest classifier using the radiomics features as input was trained and validated for prediction of csPCa. The performance of the machine learning classifier, prostate specific antigen (PSA) density, and prostate volume for csPCa prediction was evaluated using receiver operating characteristic (ROC) analysis. Results The trained random forest classifier constructed from the T2 WI radiomics features good and statistically significant area-under-the-curves (AUCs) of 0.76 (P = 0.022) for prediction of csPCa in the test set. Prostate volume and PSA density showed moderate and nonsignificant performance (AUC 0.62, P = 0.275 and 0.61, P = 0.348, respectively) for csPCa prediction in the test set. Conclusion The machine learning classifier based on T2 WI radiomic features demonstrated good performance for prediction of csPCa in PI-RADS 3 lesions. Evidence level 4 TECHNICAL EFFICACY: 2.

Optimal treatment of intermediate risk prostate cancer remains unclear. National Comprehensive Cancer Network® guidelines recommend active surveillance, prostatectomy or radiotherapy. Recent trials demonstrated no difference in prostate cancer specific mortality for men undergoing active surveillance for low risk prostate cancer compared to prostatectomy or radiotherapy. The use of active surveillance for intermediate risk prostate cancer is less clear. In this study we characterize U.S. national trends for demographic, clinical and socioeconomic factors associated with active surveillance for men with intermediate risk prostate cancer.This retrospective cohort study examined 176,122 men diagnosed with intermediate risk prostate cancer from 2010 to 2016 in the National Cancer Database. Temporal trends in demographic, clinical and socioeconomic factors among men with intermediate risk prostate cancer and association with the use of active surveillance were characterized. The analysis was performed in April 2020.In total, 176,122 men were identified with intermediate risk prostate cancer from 2010 to 2016. Of these men 57.3% underwent prostatectomy, 36.4% underwent radiotherapy and 3.2% underwent active surveillance. Active surveillance nearly tripled from 1.6% in 2010 to 4.6% in 2016 (p0.001). On multivariate analysis use of active surveillance was associated with older age, diagnosis in recent years, lower Gleason score and tumor stage, type of insurance, treatment at an academic center and proximity to facility, and attaining higher education (p0.05). Race and comorbidities were not associated with active surveillance.Our findings highlight increasing active surveillance use for men with intermediate risk prostate cancer demonstrating clinical and socioeconomic disparities. Prospective data and improved risk stratification are needed to guide optimal treatment for men with intermediate risk prostate cancer.

Background Retzius-sparing robotic-assisted radical prostatectomy (RS-RARP) has improved urinary function compared with standard robotic-assisted radical prostatectomy (S-RARP). As RS-RARP spares the dorsal vascular complex, pelvic fascia, and anterior abdominal fascia, it may also lower the incidence of “neglected” postprostatectomy sequelae such as penile shortening, Peyronie’s disease, and inguinal hernias. Objective To determine whether there are patient-perceived differences in penile shortening, Peyronie’s disease, and inguinal hernia rates among men undergoing RS-RARP versus S-RARP. Design, setting, and participants Researchers uninvolved in clinical care and blinded to surgical approach surveyed 60 RS-RARP versus 57 S-RARP men with validated patient-reported items to assess penile shortening, Peyronie’s disease, and inguinal hernia sequelae following surgery. Intervention RS-RARP versus S-RARP. Outcome measurements and statistical analysis Univariate differences between the two cohorts were analyzed using Student t test. Logistic regression was used to analyze variables associated with postoperative penile shortening. Cox proportional hazards models were used to assess the risk of developing Peyronie’s disease and inguinal hernia postoperatively. Results and limitations RS-RARP was associated with less patient-reported penile shortening (41.7% vs 64.9%, p = 0.012), Peyronie’s disease (0% vs 8.7%, p = 0.020), and inguinal hernia (0.0% vs 13.0%, p = 0.004). In adjusted analyses, RS-RARP (odds ratio [OR] 0.24, 95% confidence interval [CI] 0.09–0.63, p = 0.004) was associated with lower odds of penile shortening, while a higher body mass index was associated with increased odds of penile shortening (OR 1.13, 95% CI 1.01–1.26, p = 0.037). RS-RARP was not associated with a decreased risk of Peyronie’s disease on Cox proportion hazard model; however, these models are limited due to a limited number of events in our cohort. Limitations include retrospective design, patient-reported outcomes, and small cohorts. Conclusions RS-RARP is associated with less patient-reported penile shortening and may decrease the risk of Peyronie’s disease and postoperative inguinal hernia development. These new findings add to research, showing improved urinary continence and quality of life following RS-RARP; however, a prospective study is needed to validate these findings. Patient summary Retzius-sparing robotic-assisted radical prostatectomy (RS-RARP) is an evolving surgical technique for prostate cancer treatment, which has shown improved postoperative urinary control compared with the standard technique, likely due to preservation of natural pelvic anatomy. Our findings suggest that the preservation of normal pelvic anatomy during RS-RARP may also reduce the risk of postprostatectomy penile shortening, Peyronie’s disease, and inguinal hernia., Take Home Message Retzius-sparing robotic-assisted radical prostatectomy (RS-RARP) is an evolving surgical technique for prostate cancer treatment that has shown improved postoperative urinary control compared with the standard technique, likely due to the preservation of natural pelvic anatomy. Our findings suggest that the preservation of normal pelvic anatomy during RS-RARP may also reduce the risk of postprostatectomy penile shortening, Peyronie’s disease, and inguinal hernia.

Concurrent with the decrease in the number of men diagnosed with prostate cancer (PCa), the proportion of men with low-risk PCa managed conservatively (active surveillance or watchful waiting) has increased in the United States. We aimed to determine whether this increase is a result of more men being managed conservatively or rather a higher proportion of the diminishing number of low-risk PCa managed this way. The SEER “Prostate Watchful Waiting Database” identified men managed initially with conservative management between 2010 and 2016. Men > 40 years old who were diagnosed with low-risk (Gleason score 3 + 3, T1–T2a, PSA level

Reconsidering PSA Screening Shoag and colleagues review the long-term results of PSA screening from randomized trials and raise questions about whether the risk–benefit ratio is as strongly in favo...

Background Adoption of prostate magnetic resonance imaging (MRI) before biopsy is based on evidence demonstrating superior detection of clinically significant prostate cancer on biopsy. Whether this is due to the detection of otherwise occult higher grade cancers or preferential sampling of higher grade areas within an otherwise low-grade cancer is unknown. Methods To distinguish these two possibilities, this study examined the effect of prebiopsy MRI on the rate of pathologic upgrading and downgrading at prostatectomy in Surveillance, Epidemiology, and End Results-Medicare linked data from 2010 to 2015. Logistic regression was performed to assess the effect of MRI use on the Gleason grade change between biopsy and prostatectomy. Results Among biopsy-naive men, those who underwent prebiopsy MRI had higher odds of downgrading at prostatectomy (odds ratio [OR], 1.32; 95% confidence interval [CI], 1.05-1.66). In contrast, the odds of upgrading were significantly lower for men who underwent prebiopsy MRI (OR, 0.78; 95% CI, 0.61-0.99). Limitations included a low overall rate of MRI-utilization prior to biopsy and an inability to distinguish between template, software-assisted and cognitive fusion biopsy. Conclusions Prebiopsy MRI is associated with both oversampling of higher grade areas, which results in downgrading at prostatectomy, and the detection of otherwise occult higher grade lesions, which results in less upgrading at prostatectomy.

OBJECTIVES: To characterize trends in the incidence and severity of post-biopsy infection using nationally representative data, given that population-based data have revealed an increasing incidence of post-prostate biopsy infections through 2007. Little is known about contemporary trends in prostate biopsy related infections and associated risk-factors, particularly considering the increased focus on preventative strategies. METHODS: We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data from 2001 to 2015 and recorded 30-day infection rate and emergency department, hospital and, ICU admissions. We performed an adjusted analysis to account for the effect of age, demographic data, surgeon volume, rectal swab use, and biopsy year. RESULTS: We found that the overall rate of post-biopsy infections increased from 2001 (5.9%) to 2007 (7.2%) but remained stable through 2015. Despite this, post-biopsy emergency room visits rose from 0.2% to 0.5% (95% CI 0.2%−0.4%, p

To characterize the role of clinical and sociodemographic factors in the use of conservative management for localized prostate cancer in the US between 2010 and 2015, and to understand how those factors evolved in light of the recent national increase in conservative management rates.Data from the Surveillance, Epidemiology, and End Results Program "Prostate with Watchful Waiting Database," where conservative treatment was delineated by a distinct classifier, was used to evaluate factors associated with electing for conservative management at initial diagnosis (2010-2015). Men aged ≥40 years with cT1-T2a and T2NOS with Gleason score 3 + 3 and 3 + 4 were included (n = 118,415). Multivariable logistic regression was used to determine the association between clinical and sociodemographic factors and electing conservative management.Between 2010 and 15, a total of 22,099 (18.6%) men were managed conservatively. Mean age of men managed conservatively decreased from 66.6 to 64.6 years, and median prostate-specific antigen (PSA) increased from 5.7 to 6.0 ng/mL, P.0001. Men with lower income experienced a greater increase in conservative management rates compared to those with high income (152% vs 72% for third and fifth [richest] income quintiles, respectively). On multivariable analysis, Gleason score 3 + 3, older age, lower PSA, more recent year, treatment in the West, and higher levels of county income were significantly associated with conservative management.Characteristics of men undergoing conservative management are rapidly changing. Younger men, men with higher PSAs, and men of all incomes are increasingly being managed conservatively. Narrowing of income-based disparities with concurrent broadening of patients considered eligible for surveillance is encouraging.

Purpose:Asian American men have distinctly different prostate cancer epidemiology than other men. To our knowledge the role of multiparametric magnetic resonance imaging and targeted biopsy for ele...

Prostate-specific antigen (PSA) density is an established prognostic marker for prostate cancer. We investigated whether the inclusion of PSA density or prostate volume in the Memorial Sloan Kettering Cancer Center nomograms improves the prediction of biochemical recurrence (BCR) after radical prostatectomy (RP). Among the 11 725 men included, 2140 developed BCR. Neither PSA density nor prostate volume was associated with BCR when added to either the pre-RP or post-RP model (all p values ≥0.10) and changes in the C index were very small (largest change, 0.002). The results were robust to exclusion of outlying prostate volumes and restriction to patients treated after 2005. There is no justification for adding prostate volume or PSA density to BCR nomograms. Patient summary Addition of prostate volume or prostate-specific antigen density to Memorial Sloan Kettering Cancer Center prediction schemes did not improve the prediction of recurrence of prostate cancer after removal of the prostate.

Effect of a Trial on Surgery for Cervical Cancer The results of the Laparoscopic Approach to Cervical Cancer Trial, published in 2018, showed that in patients with cervical cancer, minimally invasi...

New technical modifications enable transperineal prostate biopsy to be performed in the ambulatory setting under local anaesthesia. Although a variety of techniques for administration of local anaesthetic during transperineal prostate biopsy have been described, no consensus exists regarding the most effective method to use. Thus, ample opportunity exists for procedural innovation and future study on this topic.

PURPOSE Typically stored as unstructured notes, surgical pathology reports contain data elements valuable to cancer research that require labor-intensive manual extraction. Although studies have described natural language processing (NLP) of surgical pathology reports to automate information extraction, efforts have focused on specific cancer subtypes rather than across multiple oncologic domains. To address this gap, we developed and evaluated an NLP method to extract tumor staging and diagnosis information across multiple cancer subtypes. METHODS The NLP pipeline was implemented on an open-source framework called Leo. We used a total of 555,681 surgical pathology reports of 329,076 patients to develop the pipeline and evaluated our approach on subsets of reports from patients with breast, prostate, colorectal, and randomly selected cancer subtypes. RESULTS Averaged across all four cancer subtypes, the NLP pipeline achieved an accuracy of 1.00 for International Classification of Diseases, Tenth Revision codes, 0.89 for T staging, 0.90 for N staging, and 0.97 for M staging. It achieved an F1 score of 1.00 for International Classification of Diseases, Tenth Revision codes, 0.88 for T staging, 0.90 for N staging, and 0.24 for M staging. CONCLUSION The NLP pipeline was developed to extract tumor staging and diagnosis information across multiple cancer subtypes to support the research enterprise in our institution. Although it was not possible to demonstrate generalizability of our NLP pipeline to other institutions, other institutions may find value in adopting a similar NLP approach—and reusing code available at GitHub—to support the oncology research enterprise with elements extracted from surgical pathology reports.

INTRODUCTION AND OBJECTIVE:While subject to frequent speculation, the actual impact of the COVID-19 pandemic on urologic operative practice is unknown. Understanding the consequences of the pandemi...

PURPOSE: The following is a summary of discussion at a United States FDA (Food and Drug Administration) public workshop reviewing potential trial designs and end points to develop therapies to treat localized prostate cancer. MATERIALS AND METHODS: The workshop focused on the challenge that drug and device development to treat localized prostate cancer has been limited by the large trial sizes and lengthy timelines required to demonstrate an improvement in overall or metastasis-free survival and by the lack of agreed on alternative end points. Additionally, evolving treatment paradigms in the management of localized prostate cancer include the widespread use of active surveillance of patients with low and some intermediate risk prostate cancer, and the availability of advances in imaging and genomics. RESULTS: The workshop addressed issues related to trial design in this setting. Attendees discussed several potential novel end points such as a delay of morbidity due to radiation or prostatectomy and pathological end points such as Gleason Grade Group upgrade. CONCLUSIONS: The workshop provided an open forum for multiple stakeholder engagement to advance the development of effective treatment options for men with localized prostate cancer.

Objective To evaluate differences in the incidence of benign ureteroenteric stricture, we compared stricture rates of robot-assisted radical cystectomy (RARC) and open radical cystectomy (ORC) using Surveillance, Epidemiology, and End Results (SEER)-Medicare data. Methods We identified 332 RARC and 1449 ORC performed between 2009-2014 to determine stricture rates at 6, 12, and 24 months following surgery. We defined ureteroenteric stricture as the need for procedural intervention. Additionally, we compared the incidence of stricture diagnosis. Multivariable proportional hazards regression was performed to determine factors associated with stricture development. Results The incidence of ureteroenteric stricture at 6 and 12 months was higher for RARC vs. ORC at 12.1% vs. 7.0% (p Conclusion RARC is associated with a higher rate of ureteroenteric stricture diagnosis and intervention on a population-based level that is mitigated by higher hospital volume. A significant study limitation is inability to differentiate extracorporeal versus intracorporeal diversion. However, a stricture complication compounds the financial burden of care and efforts must be pursued to improve this surgical outcome.

OBJECTIVES We sought to evaluate sociodemographic disparities in insurance coverage among nonelderly adults with a common cancer after Affordable Care Act (ACA) implementation. PATIENTS AND METHODS In total, 109,182 patients aged 18 to 64 years diagnosed with a common cancer (lung, breast, or prostate cancer) were identified from 2010 to 2014. Multivariable logistic regressions analyzed associations between ACA implementation and uninsured rates on the basis of state approach to Medicaid expansion, stratified by race (black, white), and income (stratified at 138% Federal Poverty Line). RESULTS Uninsured rates declined after ACA implementation, with the greatest rate reductions associated with traditional Medicaid expansion (Pinteraction

Sepsis following transrectal prostate biopsy occurs in 2%-5% of cases and the risk is increasing. We performed a comprehensive literature search for the cost of post-prostate biopsy sepsis to define the potential cost savings of reducing infectious complications. Reporting of cost is varied and presents a challenge to interpretation. Length of hospitalization ranged from 1.1 to 14 days and the percent admitted to an ICU ranged from 1.1% to 25%. The estimated cost of sepsis post-prostate biopsy, adjusted for inflation, ranged from $8,672 to $19,100. Healthcare costs of treating post-biopsy infection are substantial. Our findings should guide payers and policymakers, especially in value-based care models.

The SPARED CRN (Study of Prostate Ablation Related Energy Devices Coordinated Registry Network) is a private-public partnership between academic and community urologists, the FDA (U.S. Food and Drug Administration), the Medical Device Epidemiology Network and device manufacturers to examine the safety and effectiveness of technologies for partial gland ablation in men with localized prostate cancer.We report on a recent workshop at the FDA with thought leaders to discuss a critical framework for partial gland ablation, focusing on patient selection, surgical planning, followup, study design and appropriate comparators in terms of adverse events and cancer control outcomes. We summarize salient points from experts in urology, oncology and epidemiology that were presented and discussed in an open forum.Given the challenges in achieving patient and physician equipoise to perform a randomized trial, as well as an inherent paradigm shift when comparing partial gland ablation (inability to assess prostate specific antigen recurrence) to whole gland treatments, the group focused on objective performance criteria and goals as a platform to guide the creation of single arm studies in the SPARED CRN.This summit lays the foundation for prospective, multi-center data collection and evaluation of novel medical devices and drug/device combinations for partial gland ablation.

The accurate determination of the frequency and severity of treatment-related complications is vital to informing patients and clinicians in their decision-making process. In published studies, complications are assed via administrative data, patient-reported outcomes, and physician-graded toxicity, each with their strengths and limitations. Administrative data provide a vast, accessible history of patient data, but are limited in the ability to accurately capture diagnosis and causality, and are subject to differing interpretations of billing codes. Patient-reported outcomes provide direct and nuanced descriptions of both symptoms and bother; but are by definition subjective, affected by nonrespondents, and results (scores) are often difficult to interpret for patients and clinicians alike. Physician-graded toxicity is a relatively more objective measure, but relies on both clinicians fully assessing all relevant symptoms and patients accurately reporting them to the clinician. Understanding these strengths and limitations will help clinicians become more informed readers of the published literature.

A mobile application (app) designed on the basis of a literature review and interviews with urologic oncologists was created to help streamline robot-assisted radical prostatectomy care and in compliance with quality indicators. Use of the app was limited to English-speaking men with iPhones; 20 of 43 men approached (47%) agreed to participate. Lack of an iPhone was the most common reason for non-enrollment (52%). Preoperatively, men received daily push notifications to perform Kegel exercises and 19 men (95%) completed an Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP) questionnaire using the app. After hospital discharge, men completed a postoperative pain questionnaire and received push notifications to ambulate and increase their fluid intake. After catheter removal, daily notifications to perform Kegel exercises and complete weekly EPIC-CP surveys were pushed to monitor recovery of functional outcomes. EPIC-CP and postoperative pain assessment response rates were 75% and 90%, respectively. 85% of the men complied with notifications to ambulate, hydrate, and perform Kegel exercises. The 15 men (75%) who completed the satisfaction survey found the app easy to use and understand, which suggests that mobile apps can be easily implemented perioperatively. Mobile apps have the potential to improve compliance with perioperative instructions and allow more frequent capture of patient-reported outcomes with minimal resource utilization. Patient summary: We examined the use of a mobile application designed to capture patient-reported outcomes and guide postoperative care after major urologic surgery. Mobile apps can be implemented with relative ease and high patient satisfaction.

Purpose:The rise in opioid related deaths and addiction has been linked to physician prescribing. Opioids are commonly prescribed to patients with renal colic due to nephrolithiasis. The aim of thi...

Magnetic resonance imaging/ultrasound-guided fusion biopsy (FBx) is more accurate at detecting clinically significant prostate cancer than conventional transrectal ultrasound-guided systematic biopsy. However, learning curves for attaining accuracy may limit the generalizability of published outcomes.To delineate and quantify the learning curve for FBx by assessing the targeted biopsy accuracy and pathological quality of systematic biopsy over time.We carried out a retrospective analysis of 173 consecutive men who underwent Artemis FBx with computer-template systematic sampling between July 2015 and May 2017.The accuracy of targeted biopsy was determined by calculating the distance between planned and actual core trajectories stored on Artemis. Systematic sampling proficiency was assessed via pathological analysis of fibromuscular tissue in all cores and then comparing pathology elements from individual cores from men in the first and last tertiles. Polynomial linear regression models, change-point analysis, and piecewise linear regression were used to quantify the learning curve.A significant improvement in targeted biopsy accuracy occurred up to 98 cases (p0.01). There was a significant decrease in fibromuscular tissue in the systematic biopsy cores up to 84 cases (p0.01) and an improvement in pathological quality when comparing systematic cores from the first and third tertiles. Use of a different fusion platform may limit the generalizability of our results.There is a significant learning curve for targeted and systemic biopsy using the Artemis platform. Improvements in accuracy of targeted biopsy and better sampling for systematic biopsy can be achieved with greater experience.We define the learning curve for magnetic resonance imaging/ultrasound-guided fusion biopsy (FBx) using targeted biopsy accuracy and systematic core sampling quality as measures. Our findings underscore the importance of overcoming learning curves inherent to FBx to minimize patient discomfort and biopsy risk and improve the quality of care for accurate risk stratification, active surveillance, and treatment selection.

PURPOSE: To evaluate the comparative effectiveness of robot-assisted laparoscopic prostatectomy (RALP) and open radical prostatectomy (ORP) in a multicenter study. MATERIALS AND METHODS: We evaluated men with localized prostate cancer at eleven high-volume academic medical centers in the United States from the PROST-QA (2003–2006) and the PROST-QA/RP2 cohorts (2010–2013) with a pre-specified goal of comparing RALP (N = 549) and ORP (N = 545). We measured longitudinal patient-reported health related quality of life (HRQOL) at pre-treatment, 2, 6, 12, and 24 months, and pathologic and peri-operative outcomes/complications. RESULTS: Demographics, cancer characteristics, and margin status were similar between surgical approaches. ORP subjects were more likely to undergo lymphadenectomy (89% vs 47%; p

Introduction: A functional tool to optimize patient selection for magnetic resonance imaging (MRI)-guided prostate biopsy (MRGB) is an unmet clinical need. We sought to develop a prostate cancer risk calculator (PCRC-MRI) that combines MRI and clinical characteristics to aid decision-making for MRGB in North American men. Methods: Two prospective registries containing 2354 consecutive men undergoing MRGB (September 2009 to April 2019) were analyzed. Patients were randomized into five groups, with one group randomly assigned to be the validation cohort against the other four groups as the discovery cohort. The primary outcome was detection of clinically significant prostate cancer (csPCa) defined as Gleason grade group greater than or equal to 2. Variables included age, ethnicity, digital rectal exam (DRE), prior biopsy, prostate-specific antigen (PSA), prostate volume, PSA density, and MRI score. Odds ratios were calculated from multivariate logistic regression comparing two models: one with clinical variables only (clinical) against a second combining clinical variables with MRI data (clinical+MRI). Results: csPCa was present in 942 (40%) of the 2354 men available for study. The positive and negative predictive values for csPCa in the clinical+MRI model were 57% and 89%, respectively. The area under the curve of the clinical+MRI model was superior to the clinical model in discovery (0.843 vs. 0.707, p

OBJECTIVE. The potential for significant disparities exists in the setting of increased adoption of prostate MRI. We sought to assess temporal trends in the utilization of MRI before prostate biops...

ObjectiveTo analyze population-level changes in operative practice since the onset of the COVID-19 pandemic to contextualize observations made by individual practices and optimize future responses.Materials and MethodsThis US retrospective analysis used the Premier Perspectives Database. We investigated changes in operative volume through March 2020. Baseline operative volume for urologic surgery was calculated using data from the preceding 12 months and compared on a total and by procedure basis. Multivariable linear regression was used to identify hospital-level predictors of change in response to the pandemic.ResultsAt baseline, we captured 23,788 urologic procedural encounters per month as compared with 19,071 during March 2020– a 19.9% decrease. Urologic oncology-related cases were relatively preserved as compared to others (average change in March 2020: +1.1% versus -32.2%). Northeastern (β = -5.66, 95% confidence interval [CI]: -10.2 to -1.18, p = 0.013) and Midwestern hospitals (β = -4.17, 95% CI: -7.89 to -0.45, p = 0.027; both with South as reference region), and those with an increasing percentage of patients insured by Medicaid (β= -0.17 per percentage point, 95% CI: -0.33 to -0.01, p = 0.04) experienced a significantly larger decrease in volume.ConclusionsThere was a 20% decline in urologic operative volume in March 2020, compared with baseline, that preferentially affected hospitals serving Medicaid patients, and those in Northeast and Midwest. In the face of varying mandates on elective surgery, widespread declines in operative volume may also represent hesitancy on behalf of patients to interface with healthcare during the pandemic.

Risk stratification of men with clinically localized prostate cancer has historically relied on basic clinicopathologic parameters such as prostate specific antigen level, grade group, and clinical stage. However, prostate cancer often behaves in ways that cannot be accurately predicted by these parameters. Thus, recent efforts have focused on developing tissue-based genomic tests that provide greater insights into the risk of a given patient’s disease. Multiple tests are now commercially available and provide additional prognostic information at various stages of the care pathway for prostate cancer. Indeed, early evidence suggests that these assays may have a significant impact on patient and physician decision-making. However, the impact of these tests on oncologic outcomes remains less clear. In this review, we highlight recent advances in the use of tissue-based biomarkers in the treatment of prostate cancer and identify the existing evidence supporting their clinical use.

To assess the prostate cancer diagnostic yield, complications, and costs of transperineal prostate biopsies when performed with local anesthesia versus sedation.Data were prospectively collected for men undergoing transperineal MRI-targeted biopsy at the outpatient clinic and tertiary hospital of a single center between October 2017 to February 2020. These data included demographic, procedural, and pathologic variables and complications. Time-driven activity-based costing was performed to compare procedural costs.126 men were included. Age, BMI and PSA were similar for local (n = 45) vs sedation (n = 81), all P0.05. Detection of clinically significant prostate cancer (CSPC) on combined systematic and targeted biopsy was similar for local vs sedation (24% vs 36%; P = 0.2). Local had lower detection on targeted biopsies alone (8.9% vs 25%; P = 0.03). However, fewer targeted cores were obtained per region of interest with local vs sedation (median 3 vs 4 cores; P0.01). For local vs sedation, the complication rate was 2.6% and 6.1% (P = 0.6). The median visual analog pain score for local vs sedation was 3/10 vs 0/10 (P0.01). The mean procedure time for local vs sedation was 22.5 vs 17.5 minutes (48.3 minutes when including anesthesia time). Time-driven activity-based costs for local vs sedation were $961.64 vs $2208.16 (P0.01).Transperineal biopsy with local anesthesia is safe with comparable outcomes to sedation. While the number of cores taken differed, there was no statistical difference in the detection of clinically significant cancer.

Urinary incontinence remains a significant postprostatectomy sequala. While it has been found that many patient and technical factors contribute to postprostatectomy incontinence, the impact of anatomical differences by races has not been studied. Shorter preoperative membranous urethral length (MUL) on prostate magnetic resonance imaging has been associated with a higher risk of postprostatectomy incontinence. We compared MUL between Asian and non-Asian men and their postprostatectomy urinary function using the Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP). We found that MUL was significantly shorter for Asian (7.9 mm, 95% confidence interval [CI] 7.5–8.3) than for non-Asian men (10.9 mm, 95% CI 10.2–11.7), with a mean difference of 3.0 mm (95% CI 2.15–3.87; p

The impact of the coronavirus disease 2019 (COVID-19) pandemic on urology worldwide has been the subject of frequent speculation, but population-level estimates on changes in urology care are sparsely reported. Here, we use newly released data from a large USA-based cohort to provide further insight into the impact of the pandemic on our field. For a final cohort of 900,900 patient encounters in 418 hospitals, we describe an approximately 20% decrease in urology-specific emergency room (ER) visits (19.4%, 95% confidence interval [CI] 17.4–21.5%), admissions to a urology service (19.3%, 95% CI 13.7–24.9%), and ambulatory urology surgeries (22.9%, 95% CI 13.2–32.6%) during March 2020 relative to baseline. On linear regression, region was the sole predictor of decrease in volume, reflecting the heterogeneous spread of the SARS-CoV-2 virus within the USA. Selected higher-acuity ER presentations, such as obstructing kidney stones and “acute scrotum”, appeared to be preserved relative to lower-acuity presentations, such as nonobstructing stones, hematuria, and urinary retention. These data create context for changes observed by individual urology practices and shed light on triage patterns during natural disasters. Patient summary The coronavirus disease 2019 (COVID-19) pandemic decreased the amount of urology care provided in the USA by approximately 20% during March 2020. Patients with complaints potentially requiring imaging tests or surgery seemed to come to the emergency room at nearly normal levels.

Context In recent years, new technologies have been developed to treat benign prostatic enlargement (BPE). Three of these devices may be utilized in office and are promising additions. Objective To systematically review all clinical trials investigating prostatic urethral lift (PUL), water vapor thermal therapy (WVTT), and temporary implantable nitinol device (TIND), with emphasis on clinical efficacy and complications. Evidence acquisition We performed a systematic review of PubMed/Medline database in November 2020 according to Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. Evidence synthesis Of 168 articles identified, 18 met the inclusion criteria. Evidence consisted of few randomized controlled trials, and multiple single-arm prospective and retrospective studies. Among the three modalities, PUL demonstrates rare occurrence of serious complications but higher retreatment rates at short- and long-term follow-up. WVTT offers lower retreatment rates with a similar safety profile. TIND studies report varying rates of retreatment and complications. All technologies offer low rates of erectile and ejaculatory dysfunction, although the risk appears to be highest for WVTT ( Conclusions Among the emerging technologies introduced to treat BPE, the in-office PUL, WVTT, and TIND systems are valuable additions to the current surgical options. These systems offer unique advantages that should be considered in the shared decision-making process. Patient summary In this report, we identified all clinical trials reporting on the efficacy and safety of the in-office prostatic urethral lift (PUL), water vapor thermal therapy (WVTT), and temporary implantable nitinol device (TIND) systems for the treatment of benign prostatic enlargement. We found that PUL and WVTT demonstrate acceptable outcomes in terms of functional improvement, retreatment, and complications. More data with longer follow-up are required to further evaluate TIND, but early results are promising.

Background Trials of cancer screening present results in terms of deaths prevented, but metastasis is also a key endpoint that screening seeks to prevent. We developed a framework for projecting overall (de novo and progressive) metastases prevented in a screening trial using prostate cancer screening as a case study. Methods Mechanistic simulation model in which screening shifts a fraction of cases that would be metastatic at diagnosis to being non-metastatic. This shift increases the incidence of non-overdiagnosed, organ-confined cases. We use estimates of the risk of metastatic progression for these cases to project how many progress to metastasis after diagnosis and tally the projected de novo and progressive metastatic cases with and without screening. We use data on stage shift from the European Randomized Study of Screening for Prostate Cancer (ERSPC) and data on the risk of metastatic progression from the Scandinavian Prostate Cancer Group-4 trial. We estimate the relative risk and absolute risk reductions in metastatic disease at diagnosis and compare these with reductions in overall metastases. Results Assuming no effect of screening beyond initial stage shift at diagnosis, the model projects a 43% reduction in metastasis at diagnosis but a 22% reduction in the cumulative probability of metastasis over 12 years in favor of screening. These results are consistent with the empirical findings from the ERSPC. Conclusion Any reduction in metastatic disease at diagnosis under screening is likely to be an overly optimistic predictor of the impact of screening on overall metastasis and disease-specific mortality.

Introduction: Evaluation of surgical competency has important implications for training new surgeons, accreditation, and improving patient outcomes. A method to specifically evaluate dissection performance does not yet exist. This project aimed to design a tool to assess surgical dissection quality. Methods: Delphi method was used to validate structure and content of the dissection evaluation. A multi-institutional and multi-disciplinary panel of 14 expert surgeons systematically evaluated each element of the dissection tool. Ten blinded reviewers evaluated 46 de-identified videos of pelvic lymph node and seminal vesicle dissections during the robot-assisted radical prostatectomy. Inter-rater variability was calculated using prevalence-adjusted and bias-adjusted kappa. The area under the curve from receiver operating characteristic curve was used to assess discrimination power for overall Dissection Assessment for Robotic Technique (DART) scores as well as domains in discriminating trainees (100). Results: Four rounds of Delphi method achieved language and content validity in 27/28 elements. Use of 3 or 5-point scale remained contested; thus, both scales were evaluated during validation. The 3-point scale showed improved kappa for each domain. Experts demonstrated significantly greater total scores on both scales (3-point, p

Item does not contain fulltext Interpretation guidelines for prostate multiparametric magnetic resonance imaging findings in the post-ablation setting are not available yet; this poses a significant challenge for accurate risk stratification in this clinical setting. Here we propose the development and implementation of a post-ablation Prostate Imaging-Reporting and Data System that would improve patient surveillance and management after prostate ablation for localized prostate cancer.

With the advent of electronic medical records and digitalization of health care over the past 2 decades, artificial intelligence (AI) has emerged as an enabling tool to manage complex datasets and deliver streamlined data-driven patient care. AI algorithms have the ability to extract meaningful signal from complex datasets through an iterative process akin to human learning. Through advancements over the past decade in deep learning, AI-driven innovations have accelerated applications in health care. Herein, the authors explore the development of these emerging AI technologies, focusing on the application of AI to endourology and robotic surgery.

Robot-assisted radical prostatectomy (RARP) is the most common surgical treatment of localized prostate cancer. The ideal procedure would achieve maximum oncological efficacy while minimizing associated side effects, such as erectile dysfunction and urinary incontinence. Surgeon experience and surgical technique affect RARP outcomes. Here, the authors review RARP technical modifications aimed at optimizing cancer control and postoperative urinary and sexual function.

This retrospective study uses data from the National Cancer Database of new cancer diagnoses across the US to examine trends in proportional diagnosis rates and management of patients with high-risk prostate cancer.