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The utility of radical prostatectomy (RP) for locally-advanced prostate cancer remains unknown. Retrospective data has shown equivalent oncologic outcomes compared to radiation therapy (RT). RP may provide local tumor control and prevent secondary interventions from local invasion, and may decrease costs.Using SEER-Medicare data from 1995-2011 we identified men with locally-advanced prostate cancer undergoing RP or RT. Rates of post-treatment diagnoses and interventions were identified using ICD-9 and CPT codes. Skeletal related events (SRE), androgen deprivation therapy (ADT) utilization, all-cause mortality, prostate cancer-specific mortality, and costs were compared.A total of 8367 men with locally-advanced prostate cancer were identified (6200 RP, 2167 RT). RT was associated with increased urinary obstruction, hematuria, infection, and cystoscopic intervention while RP was associated with increased urethral stricture intervention and erectile dysfunction. Compared to RT, RP was associated with decreased all-cause mortality (3.1 versus 5.2 deaths/100-person-years, p0.001), prostate cancer-specific mortality (0.8 versus 2.0 deaths/100-person-years, p0.001), SREs (2.0 versus 3.4 events/100 person-years, p0.001), and ADT utilization overall (7.4 versus 33.8 doses/100-person-years, p0.001) and3 years after treatment (3.6 versus 4.6 doses/100-person-years, p0.001). Overall and cancer specific costs were significantly lower for RP versus RT.RT for locally-advanced prostate cancer has a higher incidence of mortality, secondary diagnoses and interventions, SRE, and ADT utilization compared to RP. This may lead to increased costs and have implications for quality of life. Our findings support the utility of RP in appropriately selected men with locally-advanced prostate cancer given the possible decreased morbidity and survival benefit.

Gleason score from biopsy specimens is important for prostate cancer (PCa) risk stratification and influences treatment decisions. Gleason score upgrading (GSU) between biopsy and surgical pathology specimens has been reported as high as 50 % and presents a challenge in counseling low-risk patients. While recent studies have investigated predictors of GSU, populations in these studies have been largely Caucasian. We report our analysis of predictors of GSU in a large urban African-American population. A total of 959 patients with D’Amico low-risk prostate cancer underwent radical prostatectomy at Georgetown University or Washington Hospital Center between January 2005 and July 2012. Race, age, PSA, body mass index (BMI), cancer of the prostate risk assessment (CAPRA) score, and transrectal ultrasound (TRUS) biopsy characteristics (percent of biopsy cores showing adenocarcinoma, highest percent of biopsy core involved with cancer, and measured TRUS prostate volume) were analyzed with both univariate and multivariate analyses to identify significant predictors of GSU while controlling for clinical parameters. Of the 959 cases, 288 (30.0 %) were upgraded on final pathologic specimen with approximately 38 % (133/355) of African-American patients experiencing GSU. BMI (P = 0.02), percent positive biopsy cores (P

Objective: To elucidate the oncologic behavior of Micropapillary Urothelial Bladder Carcinoma (MPBC), a rare aggressive variant histology. Methods: All MPBC patients in SEER 17 database were compared with those with traditional urothelial carcinoma (UC). Kaplan-Meier curves were used to determine OS and CSS. A Cox proportional hazards model (CPH) was constructed to test the effect of covariates on outcomes. Results: From 2001-2008, 120 MPBC patients were identified, 0.1% of all bladder cancer. MPBC presented with more high grade (86.1% vs. 38.7%, p

INTRODUCTION AND OBJECTIVES: Prior studies have suggested that poverty is associated with advanced stage or aggressive prostate cancer at presentation. However, due to strong associations between poverty and race, the independent contribution of poverty, irrespective of race, remains unclear. To eliminate potential confounding, we sought to test for an association between poverty and adverse pathology in a population comprised exclusively of African-American (AA) men treated with radical prostatectomy (RP). METHODS: African American men who underwent radical prostatectomy between September 2010 and September 2015 at Temple University Hospital and the University of Pennsylvania were identified through our institutional databases. Median household income for each patient’s residential zip code was determined using United States Census Bureau data. The median income for the study population was calculated, and patients were stratified as either lowor high-income relative to the median. Pathological outcomes, CAPRA-S score, and rates of adverse pathology (defined as pathological stage pT3, pathological Gleason score 4+3, or lymph node involvement) were compared between income groups. Linear and logistic regression were used to test for associations of income with CAPRA-S score and adverse pathology, respectively. RESULTS: 385 African American men met inclusion criteria. Median household income was $40,031 (range $14,297-$162,617), The table compares disease-specific and pathological outcomes between low and high income men. Low income men had significantly higher PSA values (p

Introduction Numerous clinical series have reported an association between 5-alpha-reductase inhibitors (5ARIs) and sexual dysfunction, but there are limited preclinical data available. Aim To further investigate the mechanisms of erectile dysfunction (ED) related to 5ARI therapy using a rat model. Main Outcome Measures Outcome measures include serum dihydrotestosterone (DHT), relaxant and contractile properties of cavernosal muscle, and nitric oxide synthase expression. Methods Twenty adult male Sprague-Dawley rats were randomized into control (N = 10) and dutasteride (0.5 mg/rat/day, in drinking water, N = 10) groups. Serum samples were obtained at baseline, from which DHT was measured after 30 days of treatment via radioimmunoassay (Beckman Coulter, Fullerton, CA, USA). Before the terminal blood draw, erectile response was measured using cavernosal nerve stimulation. The relaxant and contractile properties of cavernosal muscle strips were evaluated in tissue baths, and immunohistochemical (IHC) staining for nitric oxide synthase (NOS) and collagen deposition was performed. Results Mean serum DHT was suppressed by 86.5% (range 64.2–94.8%) after 30 days of 5ARI treatment and was statistically significant (P = 0.0024). In vivo erectile response in the dutasteride treated group decreased significantly compared with control (P Conclusions The 5ARIs, as demonstrated in these rat cavernosal smooth muscle studies, have a detrimental effect on erectile function. Enhanced iNOS expression may protect penile smooth muscle from fibrosis. The effect of 5ARIs on human sexual function warrants further investigation.

Study Type – Aetiology (case control) Level of Evidence 3b OBJECTIVE To evaluate the effect of N(G)-nitro-l-arginine methyl ester (L-NAME)-induced hypertension (HT) on erectile function in the rat and determine if the phosphodiesterase (PDE)-5 inhibitor, sildenafil, can reverse the effects of nitric oxide (NO) deficiency, as HT is a risk factor for erectile dysfunction (ED) and the NO synthase (NOS) inhibitor L-NAME induces NO-deficient HT. MATERIALS AND METHODS Thirty-six adult Sprague-Dawley male rats were divided into three groups, i.e. a control, L-NAME-HT (40 mg/rat/day in the drinking water for 4 weeks), and sildenafil-treated L-NAME-HT (1.5 mg/rat/day sildenafil, by oral gavage concomitantly with L-NAME). The erectile response expressed as a ratio of intracavernosal pressure (ICP)/mean arterial pressure (MAP), evaluated after electrical stimulation of the right cavernous nerve. The isometric tension of corpus cavernosum smooth muscle (CCSM) was measured in organ-bath experiments. NOS expression was determined immunohistochemically for neuronal (n)NOS and by Western blot analysis for endothelial (e) and inducible (i) NOS protein. cGMP levels were evaluated by enzyme-linked immunosorbent assay. RESULTS The erectile response was diminished in the HT group. Nitrergic and endothelium-dependent relaxation was reduced, while the relaxation response to sodium nitroprusside and contractile response to phenylephrine were not altered in CCSM from L-NAME-treated rats. HT rats showed decreased expression of nNOS, whereas eNOS and iNOS protein expression was increased. Sildenafil partly restored endothelial and molecular changes in CCSM from HT rats, but did not reverse the decreased erectile response, even as cGMP levels returned to normal levels. CONCLUSIONS Sildenafil treatment did not correct the ED in L-NAME-treated HT rats. Under sustained high blood pressure, up-regulation of PDE5 expression failed to reverse the depletion of neuronal NO and/or impaired nNOS activity. However, endothelium-dependent relaxation was restored. Drug targeting of neuronal dysfunction might delay the onset of ED in HT.

INTRODUCTION AND OBJECTIVES: Enucleation of the prostate has been found to be an effective treatment for bladder outlet obstruction. Traditional techniques, such as the HOLEP, require specialized equipment and training that are not widespread amongst Urologists. Bipolar enucleation has recently been reported as a new method of prostate surgery but the nuances of the surgery are not yet well known. METHODS: We present our technique using common endoscopic equipment in video format with early post-operative outcome data. RESULTS: N1⁄413 patients. Mean prostate size, operative time, and EBL were 61.2 grams, 111 minutes, and 62.5mL, respectively. Mean hospital stay was 1.08 days. Pre-operative and six week postoperative parameters shown in Table 1 below. CONCLUSIONS: Transurethral Bipolar Enucleation (TuBE) is likely an effective procedure that can be accomplished with basic endoscopic equipment.

PPV 88.8%; NPV 89.5%; and accuracy 94.5% in detecting regional LN spread. In patients who had neo-adjuvant chemotherapy, PET/CT accurately predicted downstaging of cancer with 80% sensitivity and 80% specificity. All lesions that were suspicious for metastasis on PET/CT were found to be positive on biopsy. Recommendations of urologists changed in 17% of cases when information from PET scans were provided. 8 studies were eligible for inclusion in the meta-analysis. Pooled sensitivity and specificity for detecting local lymph node metastasis were 53% and 96% respectively. Positive likelihood ratio was 11.53. CONCLUSIONS: PET/CT has high sensitivity and specificity in detecting locoregional LN. These results indicate that PET CT has better performance characteristics than CT alone. A positive LN on PET/CT is very likely to be metastatic on pathology as based on high positive LH ratio. PET CT performed with forced diuresis can predict response to neo-adjuvant chemotherapy with relatively high accuracy.

Background: Laparoscopic and robotic simple prostatectomy (SP) have been introduced with the aim of reducing the morbidity of the standard open technique. Objective: To report a large multi-institutional series of minimally invasive SP (MISP). Design, setting, and participants: Consecutive cases of MISP done for the treatment of bladder outlet obstruction (BOO) due to benign prostatic enlargement (BPE) between 2000 and 2014 at 23 participating institutions in the Americas and Europe were included in this retrospective analysis. Intervention: Laparoscopic or robotic SP. Outcome measurements and statistical analysis: Demographic data and main perioperative outcomes were gathered and analyzed. A multivariable analysis was conducted to identify factors associated with a favorable trifecta outcome, arbitrarily defined as a combination of the following postoperative events: International Prostate Symptom Score 15 ml/s, and no perioperative complications. Results and limitations: Overall, 1330 consecutive cases were analyzed, including 487 robotic (36.6%) and 843 laparoscopic (63.4%) SP cases. Median overall prostate volume was 100 ml (range: 89-128). Median estimated blood loss was 200 ml (range: 150-300). An intraoperative transfusion was required in 3.5% of cases, an intraoperative complication was recorded in 2.2% of cases, and the conversion rate was 3%. Median length of stay was 4 d (range: 3-5). On pathology, prostate cancer was found in 4% of cases. Overall postoperative complication rate was 10.6%, mostly of low grade. At a median follow-up of 12 mo, a significant improvement was observed for subjective and objective indicators of BOO. Trifecta outcome was not significantly influenced by the type of procedure (robotic vs laparoscopic; p = 0.136; odds ratio [OR]: 1.6; 95% confidence interval [CI], 0.8-2.9), whereas operative time (p = 0.01; OR: 0.9; 95% CI, 0.9-1.0) and estimated blood loss ( p = 0.03; OR: 0.9; 95% CI, 0.9-1.0) were the only two significant factors. Retrospective study design, lack of a control arm, and limited follow-up represent major limitations of the present analysis. Conclusions: This study provides the largest outcome analysis reported for MISP for BOO/BPE. These findings confirm that SP can be safely and effectively performed in a minimally invasive fashion in a variety of healthcare settings in which specific surgical expertise and technology is available. MISP can be considered a viable surgical treatment in cases of large prostatic adenomas. The use of robotic technology for this indication can be considered in centers that have a robotic program in place for other urologic indications. Patient summary: Analysis of a large data set from multiple institutions shows that surgical removal of symptomatic large prostatic adenomas can be carried out with good outcomes by using robot-assisted laparoscopy.

Purpose: Robot-assisted laparoscopic simple prostatectomy (RALSP) is a feasible option in men with markedly enlarged prostates (over 100 g) and urinary obstruction.1 Since January 2011, we have modified our surgical method in hope of further enhancing the perioperative outcomes related to RALSP. Herein, we report our initial experience utilizing a circumferential urinary reconstruction technique. Methods: A total of nine patients underwent RALSP with a surgical modification for symptomatic benign prostatic hypertrophy (BPH) in 2011. All, but one patient, were in complete urinary retention preoperatively. All RALSP were performed via the suprapubic approach. Upon removal of the obstructing prostate adenomas, a circumferential anastomosis was completed by advancing and approximating the bladder neck to the prostate urethral stump with 8 to 10 interrupted 2-0 vicryl suture, similar to that of the urethral vesical anastomosis during robotic radical prostatectomy. Six patients who underwent a standard...

With the increasing incidence of small renal masses, there is greater use of ablation, nephron sparing surgery and surveillance compared to radical nephrectomy. However, patterns of care in the use of posttreatment imaging remain uncharacterized. The purpose of this study is to determine the rate of posttreatment imaging after various treatments for small renal mass.Using SEER (Surveillance, Epidemiology and End Results)-Medicare data during 2005 to 2009, we identified 1,682 subjects diagnosed with small renal mass and treated with open partial nephrectomy (330), minimally invasive partial nephrectomy (160), open radical nephrectomy (404), minimally invasive radical nephrectomy (535), thermal ablation (212) and surveillance (42). Use of imaging was compared within 24 months of treatment and multivariate regression models were constructed to identify factors associated with increased imaging use.On adjusted analyses thermal ablation was associated with almost eightfold greater odds of surveillance imaging compared with open radical nephrectomy (OR 7.7, 95% CI 1.01-59.4). Specifically, thermal ablation was associated with increased computerized tomography (OR 5.28) and magnetic resonance imaging (OR 2.19) use and decreased ultrasound use (OR 0.59). Minimally invasive partial nephrectomy (OR 3.28) and open partial nephrectomy (OR 3.19) were also associated with increased computerized tomography use to a lesser extent.Subjects undergoing nephron sparing surgery undergo more posttreatment imaging compared to open radical nephrectomy. Although possibly associated with lower morbidity, thermal ablation is associated with significantly greater use of imaging compared to other small renal mass treatments. This may increase costs and radiation exposure, although further study is needed for confirmation.

INTRODUCTION AND OBJECTIVES: Gleason score from biopsy specimens is important for prostate cancer risk stratification and influences treatment decisions. Gleason score upgrading (GSU) between biopsy and surgical pathology specimens has been reported as high as 50% and presents a challenge in counseling low-risk patients. While recent studies have investigated predictors of GSU, populations in these studies have been largely Caucasian. We report our analysis of predictors of GSU in a large urban African-American population across two institutions. METHODS: A total of 959 patients with DAEAmico low risk prostate cancer underwent radical prostatectomy at our institution between January 2005 and July 2012. Race, age, PSA, body mass index, CAPRA score and TRUS biopsy characteristics (number of reported biopsy cores showing adenocarcinoma, highest percent of biopsy core positive for adenocarcinoma, and measured TRUS prostate volume) were analyzed with both univariate and multivariate analysis to identify significant predictors of GSU while controlling for clinical parameters. RESULTS: Of the 959 cases, 288 (30.0%) were upgraded on final pathologic specimen, while the remaining 671 had the same Gleason sum as the preoperative biopsy. (Table 1) Our patient population consisted of 40.0% African-Americans and 42.0 of the AfricanAmerican population showed GSU. Mean Gleason score for those who were upgraded was 7.24. Upon univariate and multivariate analysis, BMI, total positive biopsy cores, percent of core involved with cancer, CAPRA score, and smaller prostate volume were statistically significant in the upgraded cohort. Patients who upgraded tended to be of higher BMI and of African-American descent in our analysis. Transrectal biopsies of these patients showed smaller prostate volumes but higher cores positive with high % disease per core. CONCLUSIONS: More than a quarter of low-risk prostate cancer patients were upgraded on final pathology in our series. Higher BMI and CAPRA score, smaller prostate volume and total number of cores and percent of cores involved were independent predictors of GSU. Individuals, especially African-Americans, with those clinical parameters may harbor occult high-grade disease and should be carefully counseled on treatment decisions.

Radical cystectomy is associated with significant morbidity, with rates of gastrointestinal complications as high as 30%. Alvimopan is a mu opioid receptor antagonist that has been shown in randomized control trials to accelerate gastrointestinal recovery in patients undergoing bowel resection with primary anastamosis. We report our experience with gastrointestinal recovery for patients undergoing cystectomy with urinary diversion treated with alvimopan.Between January 2008 and August 2011, 50 consecutive patients underwent radical cystectomy with urinary diversion at our institution. The first 27 patients in our study did not receive alvimopan preoperatively. The latter 23 patients received perioperative alvimopan and were without postoperative nasogastric decompression. Return of bowel function, initiation of diet, and gastrointestinal complications were evaluated.Times to first flatus (3.1 versus 5.6 days, p0.001, 95% CI 1.66-3.26) and bowel movement (3.8 versus 6.0 days, p0.001, 95% CI 1.35-2.99) were significantly shorter in those patients who received alvimopan. Additionally, the initiation of clear liquid diet (4.1 versus 6.3 days, p0.001, 95% CI 1.20-3.12), regular diet (5.7 versus 7.3 days, p = 0.023, 95% CI 0.57-2.63) and hospital discharge (7.4 versus 9.5 days, p = 0.04, 95% CI 0.03-4.21) were accelerated in the alvimopan cohort. There were no incidences of prolonged ileus in patients who received perioperative alvimopan (0% versus 25.9%, p = 0.012).In our experience, the use of alvimopan perioperatively significantly accelerates the rate of gastrointestinal recovery and hospital discharge, eliminates the need for nasogastric tube decompression, and reduces the incidence of postoperative ileus in patients following radical cystectomy and urinary diversion.

Erectile dysfunction (ED) treatment can be divided into three main categories. These are oral agents, intracavernosal and intraurethral therapies, and local devices, such as vacuum and penile prosthesis. The first-line treatment for ED is oral phosphodiesterase type 5 inhibitors (PDE5Is); second-line treatment options include any combination of intracavernosal agents, such as papaverine, phentolamine, PGE1, or transurethral alprostadil. For this reason, penile prosthesis continues to be an important form of treatment for ED. Penile prosthesis implantation is a highly effective treatment option which yields high success rates, increased patient satisfaction, and low complication rates for men who fail first- and second-line treatment. Penile prostheses are indicated in a variety of conditions which cause ED, such as diabetes mellitus (DM), Peyronie’s disease, corporal fibrosis following priapism, ED following radical prostatectomy for prostate cancer and spinal cord injury.

Introduction Benign prostatic hyperplasia (BPH) is a common problem affecting middle‐aged and elderly men. First‐line medical therapy includes α 1blockers and 5α‐reductase inhibitors (5ARIs), such as finasteride and dutasteride. 5ARI use has been associated with adverse sexual outcomes, including erectile dysfunction (ED), ejaculatory dysfunction (EjD), and decreased libido. Aim To clarify the association between sexual adverse effects (AEs) and 5ARIs through review of literature concerning 5ARIs and to review the proposed mechanisms of these effects. Methods A comprehensive literature review, using MEDLINE and PUBMED search engines, was conducted for all publications concerning 5ARIs and sexual AEs. Main Outcome Measure Sexual adverse effects, such as ED, EjD, and decreased libido, were the measured outcomes of this literature review. Results Sexual AEs are reported in clinical trials at rates of 2.1% to 38%. The most common sexual AE is ED, followed by EjD and decreased libido. These effects occur early in therapy and attenuate over time. A proposed mechanism for sexual dysfunction involves decreased nitric oxide synthase activity due to decreased dihydrotestosterone. Conclusion The connection between 5ARIs and sexual dysfunction is apparent upon review of the literature. Though theories have been proposed, little is known about the exact mechanisms behind 5ARI‐related sexual dysfunction. Since the connection between 5ARIs and sexual AEs is established in the literature, future research should be directed toward deciphering the pathophysiologic mechanisms. When more basic science knowledge is attained in this area, the focus can shift toward prevention and treatment. Erdemir F, Harbin A, and Hellstrom WJG. 5‐alpha reductase inhibitors and erectile dysfunction: The connection. J Sex Med **;**:**–**.

The cervix is the cylindrical portion of the uterus which enters the vagina and lies at right angles to it. It is well documented in the literature that pregnancy following assisted reproductive technologies (ART) has a higher risk of adverse outcomes. A meta-analysis comparing in-vitro fertilization (IVF) with spontaneous conceptions showed that IVF singleton pregnancies had significantly higher odds of perinatal mortality. Cervical funneling is described as dilatation of the internal os so that the cervical canal changes in shape, with bulging of the bag of membranes through the dilated cervix into the cervical canal. Vasa previa is diagnosed by transvaginal or transabdominal ultrasound, and with Doppler flow studies. Cervical pregnancy is a rare ectopic pregnancy defined as implantation of the gestational sac in the endocervix. Due to its difficult diagnosis, cervical pregnancy should be differentiated from the cervical stage of spontaneous abortion, nabothian cyst, and cervical choriocarcinoma.

315 Background: Micropapillary Urothelial Bladder Carcinoma (MPBC) is a rare aggressive variant histology of bladder cancer. Management of non-muscle invasive (NMI) MPBC is controversial, as bladder sparing strategies routinely used when managing TCC have resulted in worse outcomes. In order to better understand its behavior, we reviewed all MPBC pts in the SEER database and compared them with TCC pts. Methods: Data was collected from SEER 17. Age, sex, race, grade, stage, treatment, and cause of death were collected. Kaplan-Meier (KM) and Cox proportional hazards (CPH) models were performed. Results: From 2001-2008, 120 pts with MPBC were identified, 0.1% of all bladder cancer. Mean age was 70.3 yrs, 76.7% were male, and 90.8% were Caucasian. No difference in age, sex, or race was detected between MPBC and TCC pts. MPBC presented with more high grade (HG) disease (86.1% vs. 38.7%, p