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Management of complex renal cysts is guided by the Bosniak classification system, which may be inadequate for risk stratification of patients for intervention. Fractional tumor vascularity (FV) calculated from volumetric contrast-enhanced ultrasound (CEUS) images may provide additional useful information.To evaluate CEUS and FV calculation for risk stratification of patients with complex renal cysts.This was a pilot prospective study with institutional review board approval involving patients undergoing surgery for Bosniak IIF-IV complex renal cysts. CEUS was performed preoperatively on the day of surgery with two-dimensional (2D) and three-dimensional (3D) imaging and sulfur hexafluoride lipid-type A microspheres as the ultrasound contrast agent.A custom MATLAB program was used to select regions of interest on CEUS scans. FV was calculated according to FV = 1 - (total nonenhancing area/total lesion area). We assessed the ability of 2D- and 3D-derived percentage FV (2DFV%, and 3DFV%) and Bosniak classification schemes (pre-2019 [P2019B] and post-2019 [B2019]) to predict malignancy, aggressive histology, and upstaging on surgical pathology. Performance was assessed as area under the receiver operating characteristic curve (AUC).Twenty eligible patients were included in final analysis, of whom 85% (n = 17) had Bosniak IV cysts and 85% (n = 17) had malignant disease on final pathology. Four (24%) of the malignant lesions were International Society of Urological Pathology grade 3-4. The AUC for predicting malignancy was 0.980, 0.824, 0.863, and 0.824 with P2019B, B2019, 2DFV%, and 3DFV%, respectively. When the Bosniak classification was combined with FV%, three models had an AUC of 1, while the combined 2DFV% + B2019 model had AUC of 0.980.FV is a novel metric for evaluating complex cystic renal masses and enhances the ability of the Bosniak classification system to predict malignancy. This metric may serve as an adjunct in risk stratification for surgical intervention. Further prospective evaluation is warranted.Cysts in the kidney are currently classified using a scheme called the Bosniak system. We assessed measurement of the percentage of vascular tissue (called fractional vascularity) in cysts on a special type of ultrasound scan. This promising test adds information when combined with the Bosniak system and can help in guiding appropriate treatment.

Background: The term “financial toxicity” or “hardship” is a patient-reported outcome that results from the material costs of cancer care, the psychological impacts of these costs, and the coping strategies that patients use to deal with the strain that includes delaying or forgoing care. However, little is known about the impact of financial toxicity on cancer screening. We examined the effects of financial toxicity on the use of screening tests for prostate and colon cancer. We hypothesized that greater financial hardship would show an association with decreased prevalence of cancer screening. Methods: This cross-sectional survey–based US study included men and women aged ≥50 years from the National Health Interview Survey database from January through December 2018. A financial hardship score (FHS) between 0 and 10 was formulated by summarizing the responses from 10 financial toxicity dichotomic questions (yes or no), with a higher score associated with greater financial hardship. Primary outcomes were self-reported occurrence of prostate-specific antigen (PSA) blood testing and colonoscopy for prostate and colon cancer screening, respectively. Results: Overall, 13,439 individual responses were collected. A total of 9,277 (69.03%) people had undergone colonoscopies, and 3,455 (70.94%) men had a PSA test. White, married, working men were more likely to undergo PSA testing and colonoscopy. Individuals who had not had a PSA test or colonoscopy had higher mean FHSs than those who underwent these tests (0.70 and 0.79 vs 0.47 and 0.61, respectively; P≤.001 for both). Multivariable logistic regression models demonstrated that a higher FHS was associated with a decreased odds ratio for having a PSA test (0.916; 95% CI, 0.867–0.967; P=.002) and colonoscopy (0.969; 95% CI, 0.941–0.998; P=.039). Conclusions: Greater financial hardship is suggested to be associated with a decreased probability of having prostate and colon cancer screening. Healthcare professionals should be aware that financial toxicity can impact not only cancer treatment but also cancer screening.

Ultrasound's versatility and ease of use has expanded its application in many clinical settings. Technological advancements with contrast-enhanced ultrasound (CEUS) have allowed high quality imaging similar to CT or MRI with lower risk of contrast toxicity and radiation exposure. In this review article we examine the development of CEUS and its vast applications in the field of urology.A PubMed literature search was performed using keywords: contrast enhanced ultrasound, prostate cancer, renal cancer, and multiparametric ultrasound.The development of CEUS has improved transrectal ultrasound imaging with increased detection of prostate cancer (PCa). Further enhancements of CEUS such as subharmonic imaging (SHI), flash replenishment imaging (FRI) and contrast ultrasound dispersion imaging (CUDI) allow improved PCa diagnosis. CEUS has also emerged as an important tool in characterizing suspicious renal mass without compromising renal function with contrast imaging.CEUS has modernized imaging and diagnosis of prostate and renal cancer. Future advancements and utilization of CEUS will allow its expansion into other urological subspecialties.

Purpose: To explore the current role of lymph node dissection (LND) in the management of nonmetastatic localized renal cell carcinoma (RCC). Background: There is currently no proven benefit of LND in the setting of RCC, and its role remains controversial because of conflicting evidence. Patients who may benefit from LND are those at greatest risk of nodal disease, but the tools used to predict nodal involvement are limited due to unpredictable retroperitoneal lymphatics. The indications, templates, and extent of LND are also not standardized, adding to the ambiguity of current guidelines surrounding its use. Evidence Acquisition: A PubMed search of the literature from January 2017 to December 2022 was conducted using the search terms “renal cell carcinoma” or “renal cancer” in combination with “lymph node dissection” or “lymphadenectomy”. Case studies and editorials were excluded, whereas studies investigating the therapeutic effect of LND were classified as either demonstrating a benefit or no benefit. References of the studies and review articles were also searched for notable studies and findings that were outside the five-year literature search. The studies in this review were restricted to the English language. Results: Only a number of studies in recent years have found an association between the extent of LND and increased survival. Most studies do not indicate an associated benefit, and some even suggest a negative effect on survival. Most of these studies are retrospective. Conclusion: The therapeutic value of LND in RCC is still unclear, and although prospective data are needed, its declining rates and emerging new therapies make this unlikely. A better understanding of renal lymphatics and improved detection of nodal disease may help determine the role of LND in nonmetastatic localized RCC.

To determine how medical students' Twitter engagement impacted the urology residency match and overall student perception of Twitter.We utilized a mixed methods approach with (1) Twitter metrics data, (2) online student surveys, and (3) qualitative semi-structured interviews. Interviews were evaluated with iterative thematic content analysis, while quantitative data were analyzed with descriptive statistics, and univariate analyses.We identified 245 Twitter accounts of Urology residency applicants from the 2021 cycle. Matched students were more likely to have a Twitter account (59% matched vs 28% unmatched, P = .002) and account creation increased following the COVID-19 pandemic announcement. Matched students' profiles were associated with more followers, bios mentioning Urology, home Urology residency programs, and no international flags and/or references. The online survey had a 16% response rate. A majority reported utilizing Twitter for residency information (95%), wanting to continue Twitter throughout residency (67%), and feeling uncomfortable tweeting about racial, political, or diversity issues (64%). Nine interviews revealed 4 themes: Twitter's opportunities for networking, Twitter's role in the application process, the burden of social media use, and professionalism.Students applying to Urology residency increasingly utilized Twitter during the COVID-19 pandemic and having a Twitter account was associated with matching. While Twitter may not be necessary to succeed in the match and can pose an additional time burden, applicants view it as an opportunity for learning, networking, and personal branding.

Purpose: prostate cancer (PCa) screening, which relies on prostate-specific antigen (PSA) testing, is a contentious topic that received negative attention due to the low sensitivity and specificity of PSA to detect clinically significant PCa. In this context, due to the higher sensitivity and specificity of magnetic resonance imaging (MRI), several trials investigate the feasibility of ""MRI-only"" screening approaches, and question if PSA testing may be replaced within prostate cancer screening programs. Methods: this narrative review discusses the current literature and the outlook on the potential of MRI-based PCa screening. Results: several prospective randomized population-based trials are ongoing. Preliminary study results appear to favor the ""MRI-only"" approach. However, MRI-based PCa screening programs face a variety of obstacles that have yet to be fully addressed. These include the increased cost of MRI, lack of broad availability, differences in MRI acquisition and interpretation protocols, and lack of long-term impact on cancer-specific mortality. Partly, these issues are being addressed by shorter and simpler MRI approaches (5-20 min bi-parametric MRI), novel quality indicators (PI-QUAL) and the implementation of radiomics (deep learning, machine learning). Conclusion: although promising preliminary results were reported, MRI-based PCa screening still lack long-term data on crucial endpoints such as the impact of MRI screening on mortality. Furthermore, the issues of availability, cost-effectiveness, and differences in MRI acquisition and interpretation still need to be addressed., Projekt DEAL

Context With the addition of active surveillance and thermal ablation (TA) to the urologist’s established repertoire of partial (PN) and radical nephrectomy (RN) as first-line management options for localized renal cell carcinoma (RCC), appropriate treatment decision-making has become increasingly nuanced. Objective To critically review the treatment options for localized, nonrecurrent RCC; to highlight the patient, renal function, tumor, and provider factors that influence treatment decisions; and to provide a framework to conceptualize that decision-making process. Evidence acquisition A collaborative critical review of the medical literature was conducted. Evidence synthesis We identify three key decision points when managing localized RCC: (1) decision for surveillance versus treatment, (2) decision regarding treatment modality (TA, PN, or RN), and (3) decision on surgical approach (open vs minimally invasive). In evaluating factors that influence these treatment decisions, we elaborate on patient, renal function, tumor, and provider factors that either directly or indirectly impact each decision point. As current nomograms, based on preselected patient datasets, perform poorly in prospective settings, these tools should be used with caution. Patient decision aids are an underutilized tool in decision-making. Conclusions Localized RCC requires highly nuanced treatment decision-making, balancing patient- and tumor-specific clinical variables against indirect structural influences to provide optimal patient care. Patient summary With expanding treatment options for localized kidney cancer, treatment decision is highly nuanced and requires shared decision-making. Patient decision aids may be helpful in the treatment discussion.

Wallis et al (JAMA 2017) demonstrated use of antithrombotic medications (ATMs) is associated with increased prevalence of hematuria-related complications and subsequent bladder cancer diagnosis within 6 months. Stage of diagnosis was lacking in this highly publicized study. This study examined the association of ATM use on bladder cancer stage at the time of diagnosis.We completed a retrospective chart review of patients with a bladder cancer diagnosis at our institution. Patient demographics and bladder cancer work up information were assessed. Patients were stratified based on use of ATMs at time diagnosis. Descriptive statistics were completed to identify association between ATM use and stage of bladder cancer diagnosis, as stratified by non-muscle invasive bladder cancer (NMIBC) versus muscle invasive bladder cancer (MIBC).A total of 1052 patient charts were reviewed. Eight hundred and forty-four were included and 208 excluded due to unavailability of diagnosis history. At diagnosis, 357 (42.3%) patients were taking ATMs. Patients on ATMs presented with NMIBC at similar rates as patients not taking ATMs (81.2% vs. 77.8%, p = 0.23). Subgroup analysis by ATM class similarly demonstrated no statistically significant differences in staging.While Wallis et al established that patients on blood thinners who present with hematuria are more likely to be diagnosed with genitourinary pathology, this factor does not appear to enable an earlier diagnosis of bladder cancer. Future study may assess hematuria at presentation (gross, microscopic), type of blood thinners, and low versus high risk NMIBC presentation.

There remains debate surrounding partial (PN) versus radical nephrectomy (RN) for T1b-T2 renal cell carcinoma (RCC). PN offers nephron-sparing benefits but involves increased perioperative complications. RN putatively maximizes oncologic benefit with complex tumors. We analyzed newly available nephrectomy-specific NSQIP data to elucidate predictors of perioperative outcomes in localized T1b-T2 RCC. We identified 2094 patients undergoing nephrectomy between 2019–2020. Captured variables include surgical procedure and approach, staging, comorbidities, prophylaxis, peri-operative complications, reoperations, and readmissions. 816 patients received PN while 1278 received RN. Reoperation rates were comparable; however, PN patients more commonly experienced 30-day readmissions (7.0% vs. 4.7%, p = 0.026), bleeds (9.19% vs. 5.56%, p = 0.001), renal failure requiring dialysis (1.23% vs. 0.31%, p = 0.013) and urine leak or fistulae (1.10% vs. 0.31%, p = 0.025). Infectious, pulmonary, cardiac, and venothromboembolic event rates were comparable. Robotic surgery reduced occurrence of various complications, readmissions, and reoperations. PN remained predictive of all four complications upon multivariable adjustment. Several comorbidities were predictive of complications including bleeds and readmissions. This population-based cohort explicates perioperative outcomes following nephrectomy for pT1b-T2 RCC. Significant associations between PN, patient-specific factors, and complications were identified. Risk stratification may inform management to improve post-operative quality of life (QOL) and RCC outcomes.

Objective To assesses if active surveillance (AS) is an appropriate treatment modality for patients with intermediate risk (IR) prostate cancer (PCa) utilizing population-level data to compare the survival outcomes of men with low risk (LR) and IR PCa initially treated with AS, watchful waiting (WW) or active treatment (AT). Methods In total, 166,244 patients were initially identified in the surveillance, epidemiology, and end results database using biopsy Gleason grade group (GG) alone—GG1 and GG2. In total, 94,891 patients with GG1 and GG2 disease were further stratified by National Comprehensive Cancer Network risk categories—LR, favorable IR (fIR), and unfavorable IR (uIR). Predictors of cancer-specific (CSS) and overall survival (OS) were analyzed, stratified by risk classification and initial treatment—AT (first-line curative surgery or radiotherapy), AS or WW, utilizing the new “Watchful waiting recode (2010+)” variable. Results We found GG2 patients on AS had worse CSS and OS than GG2 patients who received AT and GG1 patients treated with AS or AT; these trends persist within the National Comprehensive Cancer Network fIR and uIR cohorts. WW patients (GG1, GG2, LR, fIR, and uIR) had the worst survival outcomes of any cohort (log-rank tests P Conclusions We demonstrate a significantly worse 5-year CSS and OS for men with GG2, fIR, and uIR PCa treated with AS compared to AT. Our analysis suggests that AS should not be the preferred treatment modality for IR PCa.

Urologic and gynecologic surgeons are the top utilizers of robotic surgery; however, nonobstetrical robotic-assisted laparoscopic surgery (RALS) in pregnant patients is infrequent. A systematic literature review was performed to ascertain the frequency, indication and complications of RALS in pregnancy. Results showed 38 pregnancies from eleven publications between 2008 and 2020. Five cases were for urologic indication and 33 for gynecologic indication. Minimal surgical alterations were required. Although no adverse maternal-fetal outcomes were reported, there are not enough cases published to determine safety. This review demonstrates the feasibility of RALS for the pregnant population in the hands of competent robotic surgeons.

Resumen Introduccion En los ultimos anos, la vigilancia activa (VA) ha ganado popularidad como una opcion segura y razonable para los pacientes con cancer de prostata de bajo riesgo clinicamente localizado. Objetivo Resumir la informacion mas reciente sobre el uso de resonancia magnetica multiparametrica (RMmp) en el contexto de la vigilancia activa (VA) para el tratamiento del cancer de prostata (CaP). Adquisicion de la evidencia Se realizo una busqueda en la literatura en ingles mediante PubMed hasta febrero de 2020. Se seleccionaron los articulos originales, metaanalisis, y revisiones sistematicas mas relevantes. Sintesis de la evidencia La gran importancia de la RMmp de la prostata en el contexto del diagnostico del CaP es su capacidad de detectar lesiones cancerosas de alto grado que pueden haber sido omitidas en biopsias sistematicas. Diversos estudios han demostrado que la RMmp tiene un rendimiento superior con respecto a los modelos basados en la clinica para identificar aquellos candidatos que se beneficiaran mas de la VA. Aunque hay poca informacion sobre la RMmp de prostata durante el seguimiento de hombres en VA, existe la posibilidad de que esta pueda mejorar significativamente los programas de VA, gracias a una seleccion mas rigurosa de candidatos optimos, una identificacion mas precisa de la progresion de la enfermedad, y una reduccion en el numero de biopsias. El objetivo de la reevaluacion de los pacientes sometidos a VA es encontrar el momento en el que cambiar la estrategia hacia el tratamiento activo sea lo mas efectivo. Conclusion El valor de la RMmp ha sido reconocido debido a su alto valor predictivo negativo (VPN) en la deteccion de lesiones de mayor grado en pacientes con CaP de bajo riesgo. Un mejor sistema de deteccion en las pruebas de imagen y un diagnostico mas exacto con RMmp podria reducir las clasificaciones erroneas en el diagnostico inicial y durante el seguimiento, reduciendo asi el numero de biopsias.

737 Background: The standard of care for larger localized RCC lesions is radical (RN) or partial (PN) nephrectomy. RN is increasingly utilized to maximize oncologic benefit in complex tumors. Although PN is a more technically complex procedure, its nephron-sparing nature confers lasting renal and cardiovascular benefits. We utilized the National Surgical Quality Improvement Program (NSQIP) database to elucidate predictors of perioperative morbidity in T1b-T2 RCC patients. Methods: Using the NSQIP Nephrectomy-Targeted PUF, 2,094 patients undergoing nephrectomy between 2019-2020 for localized T1b-T2 RCC were identified. Variables of interest included surgical procedure and approach, tumor stage, demographics, pre-operative laboratory values, comorbidities, infection and venothromboembolism (VTE) prophylaxis techniques, peri-operative complications, operative time, length of hospital stay, 30-day reoperations, and 30-day readmissions. Chi square test was used to analyze univariate associations between certain comorbidities and complications. Multivariate regression analysis was utilized to compare complication rates between PN and RN after adjusting for baseline characteristics and surgical approach. p

576 Background: Radical cystectomy (RC) is standard of care for muscle-invasive bladder cancer, but it comes with significant perioperative risk with half of patients experiencing major postoperative complications. Robot-assisted radical cystectomies (RARC) have aimed to decrease patient morbidity and have become increasingly adopted in North America. Currently, both open radical cystectomies (ORC) and RARC are frequently performed. To contribute to the existing literature using newly available data from the American College of Surgeons National Surgical Quality Improvement Project (NSQIP), representing one of the most recent, largest multi-institutional studies, while uniquely accounting for a variety of factors including type of urinary diversion, cancer staging, and neoadjuvant chemotherapy. Methods: RC procedures performed between 2019-2020 were identified in NSQIP and the corresponding Cystectomy Targeted database. Cases in the ORC group were planned open procedures, and cases in the RARC group were robotic with intra- or extracorporeal diversions, including unplanned conversion to open cases for intention-to-treat. Chi-square and t-tests were performed to compare baseline demographics and operative parameters. Multivariate analysis was performed for outcomes including major complications, minor complications, and 30-day mortality, while adjusting for operative approach, medical comorbidities, functional status, age, race, sex, BMI, ASA-classification, preoperative labs, type of urinary diversion, pathological staging, prior pelvic surgery or radiation, need for preoperative transfusion, preoperative sepsis, emergent or elective surgery, and recent chemotherapy. Results: 4,022 RC cases were identified. Of these, 3,146 (78.2%) received planned ORC while 876 (21.8%) received RARC. Baseline demographics of the patients who received ORC versus RARC were largely similar, with no significant difference in age or medical comorbidities. RARC was associated with longer operative times and shorter hospital length of stay compared to ORC. On multivariate analysis, ORC was associated with a higher rate of 30-day mortality [OR 3.1; 95% CI 1.3-7.2; p=0.009], reintubation, cardiac arrest, superficial wound infection, bleeding requiring transfusion [OR 4.7; 95%CI 3.6 - 6.1; p

270 Background: Historically, surgical management with radical prostatectomy (RP) has been a definitive treatment option only for localized prostate cancer (PCa). However, recent studies suggest an overall survival benefit to treating the primary tumor with radiation therapy in metastatic PCa (mPCa). Therefore, RP may have a role in treating mPCa, but the perioperative safety of that remains unclear. Here, we aim to compare the perioperative outcomes of RP for locally advanced, node positive, and metastatic PCa using the National Surgical Quality Improvement Project (NSQIP) database. Methods: RPs performed between 2019-2020 were identified in NSQIP and the corresponding Prostatectomy-Targeted Participant Use File. Cases were grouped into six distinct categories: T1N0M0-T2N0M0; T3N0M0; T4N0M0; T1-3N1M0; T4N1M0; and T1-4N0-1M1. Baseline age, race, and medical comorbidities were compared between the groups. Patients were then further grouped into T1-2N0M0 versus T3-4N0M0 cases to compare the effect of locally advanced disease, TanyN1M0 versus TanyN0M0 to compare the effect of node-positivity, and TanyN0M1 versus TanyN0M0 to compare the effect of metastases. 30-day outcomes, operative time, hospital length-of-stay, 30-day mortality, readmissions, reoperations, major complications, minor complications, and surgery-specific complications were compared between groups. Results: Pathologic staging was available for 5,248 RPs. Baseline demographics were largely similar, with the exceptions of increased Black race, diabetes, and smoking in the node-positive-group and increased age in the T4 group. There was a slightly higher rate of minor complications in the locally advanced (T3-4N0M0) versus localized (T1-2N0M0) group, but no significant difference in major complications, 30-day mortality, readmissions, or rectal injuries. In comparison to node-negative patients (T1-4N0M0), node-positivity (T1-4N1M0) was associated with longer operative time, LOS, and incidence of 30-day renal failure, but was otherwise not associated with a higher rate of any complication. Compared to non-metastatic cases (T1-4N0M0), metastatic cases (T1-4N0M1) were associated with a higher rate of bleeding, prolonged-NG-tube use, ureteral obstruction, and LOS. Conclusions: RP for patients with locally advanced, node positive, and metastatic prostate cancer appears to be safe; it is not associated with significantly higher rates of 30-day mortality or major complications compared to RP for localized prostate cancer. Given the potential survival benefit in treating the primary tumor in advanced disease, there may be a role for RP in treating patients with advanced PCa.

Patient participation in clinical trials is influenced by demographic and other individual level characteristics. However, there is less research on the role of geography and neighborhood-level factors on clinical trial participation. This study identifies the demographic, clinical, geographic, and neighborhood predictors of consenting to a clinical trial among cancer patients at a large, urban, NCI-designated cancer center in the Mid-Atlantic region.We used demographic and clinical data from patients diagnosed with cancer between 2015 and 2017. We geocoded patient addresses and calculated driving distance to the cancer center. Additionally, we linked patient data to neighborhood-level educational attainment, social capital and cancer prevalence. Finally, we used generalized linear mixed-effects conditional logistic regression to identify individual and neighborhood-level predictors of consenting to a clinical trial.Patients with higher odds of consenting to trials were: Non-Hispanic White, aged 50-69, diagnosed with breast, GI, head/neck, hematologic, or certain solid tumor cancers, those with cancers at regional stage, never/former tobacco users, and those with the highest neighborhood social capital index. Patients who lived further from the cancer center had higher odds of consenting to a trial. With every 1-km increase in residential distance, there was a 4% increase in the odds that patients would consent to a trial. Neither of the additional neighborhood-level variables predicted consenting to a clinical trial.This study identifies important demographic, patient-level, and geographic factors associated with consenting to cancer clinical trials, and lays the groundwork for future research exploring the role of neighborhood-level factors in clinical trial participation.

OBJECTIVE To evaluate existing practice patterns and potential barriers to implementing opioid stewardship protocols after robot-assisted prostatectomies among providers in the Pennsylvania Urology Regional Collaborative. METHODS The Pennsylvania Urology Regional Collaborative (PURC) is a voluntary quality improvement initiative of 11 academic and community urology practices in Pennsylvania and New Jersey representing 97 urologists. PURC distributed a web-based survey of 24 questions, with 74 respondents, including 56 attendings, 11 residents, and 7 advanced practice providers. RESULTS More pills were prescribed if there was a default number of pills from the electronic health record (median 30) then if the number of pills was manually placed (P = .01). Only 8% discussed how to dispose of opioids with their patients, and less than a third of respondents discussed postoperative pain expectations or risks of opioid use. Patient level risk factors were often not reviewed, as 42% did not ask about previous opioid exposure. CONCLUSION This study revealed extensive knowledge disparities among providers about opioid stewardship and significant gaps in the evidence-to-practice continuum of care. In the next year, PURC will be implementing targeted interventions to augment provider education, establish clear pathways for opioid disposal, improve utilization of known resources and implement opioid reduction protocols in all participating sites.

3D printing is a growing tool in surgical education to visualize and teach complex procedures. Previous studies demonstrating the usefulness of 3D models as teaching tools for partial nephrectomy used highly detailed models costing between $250 and 1000. We aimed to create thorough, inexpensive 3D models to accelerate learning for trainees and increase health literacy in patients. Patient-specific, cost-effective ($30-50) 3D models of the affected urologic structures were created using pre-operative imaging of 40 patients undergoing partial nephrectomy at Thomas Jefferson University Hospital (TJUH) between July 2020 and May 2021. Patients undergoing surgery filled out a survey before and after seeing the model to assess patient understanding of their kidney, pathophysiology, surgical procedure, and risks of surgery. Three urological residents, one fellow, and six attendings filled out separate surveys to assess their surgical plan and confidence before and after seeing the model. In a third survey, they ranked how much the model helped their comprehension and confidence during surgery. Patient understanding of all four subjects significantly improved after seeing the 3D model (P 0.001). The urology residents (P 0.001) and fellow (P 0.001) reported significantly increased self-confidence after interacting with the model. Attending surgeon confidence increased significantly after seeing the 3D model (P 0.01) as well. Cost-effective 3D models are effective learning tools and assist with the evaluation of patients presenting with renal masses, and increase patient, resident, and fellow understanding in partial nephrectomies. Further research should continue to explore the utility of inexpensive models in other urologic procedures.

To examine cancer prevalence in men with and without military service history, using national-level self-reported outcomes. A cross-sectional survey-based US study, including men aged 18 and above from the Health Information National Trends Survey database between 2011 and 2014. The primary endpoint was self-reported cancer prevalence. Multivariable logistic regression analyses assessed the association of various covariates with the prevalence of cancer. A total of 4,527 men were analyzed, with 1,352 (29.9%) reporting a history of military service. Compared to men with no military service history, men with a military service history were older (median of 65 [IQR 56, 74] vs. 53 [IQR 41, 62] years, p

OBJECTIVES To assess whether free PSA ratio (FPSAR) at biochemical recurrence (BCR) can predict metastasis, castrate-resistant prostate cancer (CRPC), and cancer-specific survival (CSS), following therapy for localised disease. PATIENTS AND METHODS A single-centre retrospective cohort study (NCT03927287) including a discovery cohort composed of patients with an FPSAR after radical prostatectomy (RP) or radiotherapy (RT) between 2000 and 2017. For validation, an independent Biobank cohort of patients with BCR after RP was tested. Using a defined FPSAR cut-off, the metastasis-free-survival (MFS), CRPC-free survival, and CSS were compared. Multivariable Cox models determined the association between post-treatment FPSAR, metastases, and CRPC. RESULTS Overall, 822 patients (305 RP- and 363 RT-treated patients and 154 Biobank patients) were analysed. In the RP cohort, a total of 272/305 (89.1%) and 33/305 (10.9%) had a FPSAR test incidentally and reflexively, respectively. In the RT cohort, 155/363 (42.7%) and 208/263 (57.3%) had a FPSAR test incidentally and reflexively, respectively. However, in the prospective Biobank RP cohort, FPSAR testing was done on all samples of patients diagnosed with BCR. A FPSAR cut-off of 0.10 was determined using receiver operating characteristic analyses in both the RP and RT cohorts. A FPSAR of

The role of percent free prostate specific antigen (%fPSA) in patients who have undergone radical prostatectomy and subsequently experienced disease relapse is unclear. We previously conducted 2 retrospective studies and found %fPSA 15 or greater in the setting of biochemical recurrence confers more aggressive disease. To validate that finding we used biobank specimens collected prospectively when patients were first diagnosed with biochemical recurrence.Biobank specimens of patients with undetectable prostate specific antigen after radical prostatectomy and subsequent biochemical recurrence (prostate specific antigen 0.1 ng/ml or greater) were analyzed for %fPSA. Patients were stratified according to the %fPSA cutoff of 15. Univariable and multivariable logistic regression analysis was performed to predict covariates associated with a higher %fPSA. Cox proportional hazard models were performed to evaluate the prognostic effect of %fPSA on androgen deprivation therapy-free survival, metastasis-free survival, castration resistant-free survival and cancer specific survival.A total of 154 men were included in the study, of whom 126 (82%) had %fPSA less than 15 and 28 (18%) had %fPSA 15 or greater. Median followup for %fPSA less than 15 and %fPSA 15 or greater was 75 and 69 months, respectively. Patients with %fPSA 15 or greater had increased hazard of receiving androgen deprivation therapy (43% vs 25%, adjusted HR 2.40, 95% CI 1.12-5.11), metastatic disease (21% vs 7.9%, adjusted HR 4.10, 95% CI 1.11-15.2) and castration resistant prostate cancer (14% vs 4.0%, unadjusted HR 4.14, 95% CI 1.11-15.5) vs %fPSA less than 15, respectively.Patients with %fPSA 15 or greater were started on androgen deprivation therapy earlier, and they had progression to castration resistant prostate cancer and metastatic stage earlier. %fPSA 15 or greater in the setting of biochemical recurrence after radical prostatectomy is an indicator of a more aggressive disease. Unlike in the diagnostic setting, a higher %fPSA portends a worse clinical outcome.

Proton pump inhibitors (PPIs) are commonly prescribed medications that have been shown to have contradicting effects on cancer. We aimed to investigate the effect of pantoprazole and other PPIs on prostate cancer (PCa) specific mortality (PCSM), use of androgen deprivation therapy (ADT), and PCa diagnosis using a large Canadian population-based cohort. We identified 21,512 men aged ≥ 66, with a history of a single negative prostate biopsy and no previous use of any of the analyzed medications between 1994 and 2016. Multivariable Cox regression models with time-dependent covariates were used to assess the associations of PPIs with PCa outcomes. All models included other medications with a putative chemopreventative effect on PCa-outcomes, and were adjusted for age, rurality, comorbidity, and study inclusion year. Over a mean follow-up of 8.06 years (SD 5.44 years), 10,999 patients (51.1%) used a PPI, 5187 patients (24.1%) had PCa, 2043 patients (9.5%) were treated with ADT, and 805 patients (3.7%) died from PCa. For every 6 months of cumulative use, pantoprazole was associated with a 3.0% (95% CI 0.3–6.0%) increased rate of ADT use, while any use of other PPIs was associated with a 39.0% (95% CI 18.0–64.0%) increased risk of PCSM. No association was found with PCa diagnosis. Upon validation of the potentially negative association of PPIs with PCa, PPI use may need to be reassessed in PCa patients.

Multiparametric magnetic resonance imaging with informed targeted biopsies has changed the paradigm of prostate cancer diagnosis. Randomized studies have demonstrated a diagnostic benefit of clinical significance for targeted biopsy compared to standard systematic biopsies. We evaluated whether multiparametric magnetic resonance imaging informed targeted biopsy has superior diagnosis rates of any, clinically significant, high grade and clinically insignificant prostate cancer compared to systematic biopsy in biopsy naïve men.Data were searched in Medline®, Embase®, Web of Science and Evidence-Based Medicine Reviews-Cochrane Database of Systematic Reviews from database inception until 2019. Studies were selected by 2 authors independently, with disagreements resolved by consensus with a third author. Overall 1,951 unique references were identified and 100 manuscripts underwent full-text review. Data were pooled using random effects models. The meta-analysis is reported according to the PRISMA statement and the study protocol is registered with PROSPERO (CRD42019128468).Overall 29 studies (13,845 patients) were analyzed. Compared to systematic biopsy, use of multiparametric magnetic resonance imaging informed targeted biopsy was associated with a 15% higher rate of any prostate cancer diagnosis (95% CI 10-20, p0.00001). This relationship was not affected by the study methodology (p=0.11). Diagnoses of clinically significant and high grade prostate cancer were more common in the multiparametric magnetic resonance imaging informed targeted biopsy group (risk difference 11%, 95% CI 0-20, p=0.05 and 2%, 95% CI 1-4, p=0.005, respectively) while there was no difference in diagnosis of clinically insignificant prostate cancer (risk difference 0, 95% CI -3 to 3, p=0.96). Notably, the exclusion of systematic biopsy in the multiparametric magnetic resonance imaging informed targeted biopsy arm significantly modified the association between a multiparametric magnetic resonance imaging strategy and lower rates of clinically insignificant prostate cancer diagnosis (p=0.01) without affecting the diagnosis rates of clinically significant or high grade prostate cancer.Compared to systematic biopsy a multiparametric magnetic resonance imaging informed targeted biopsy strategy results in a significantly higher diagnosis rate of any, clinically significant and high grade prostate cancer. Excluding systematic biopsy from multiparametric magnetic resonance imaging informed targeted biopsy was associated with decreased rates of clinically insignificant prostate cancer diagnosis without affecting diagnosis of clinically significant or high grade prostate cancer.

Objectives To examine the predictors of prostate-specific antigen discussion with a physician and prostate-specific antigen testing in men aged ≥55 years. Methods Utilizing the USA Health Information National Trends Survey, 4th Ed., a cross-sectional study from 2011 to 2014 was carried out to analyze the factors predicting prostate-specific antigen testing and discussion in men ≥55 years. Associations between each covariate and prostate-specific antigen discussion/testing were determined. Multivariable logistic regression models were used to determine clinically relevant predictors of prostate-specific antigen discussion/testing. Due to multiple comparisons, the Bonferroni correction was used. Results A total of 2731 men included in the Health Information National Trends Survey were analyzed. Several socioeconomic parameters were found to increase the likelihood of men aged ≥55 years to undergo prostate-specific antigen testing: living with a spouse, a higher level of education (college graduate or above), a higher income (>$50 000 annually) and previous history of any cancer. In contrast, current smokers were less likely to undergo prostate-specific antigen testing. Having a prostate-specific antigen discussion with a physician was more likely for men surveyed in 2014, for men who were living with a spouse, who had a higher annual income (>$50 000 annually) and those with a history of any cancer. Conclusions Significant inequalities in prostate-specific antigen testing and discussion exist among men in the USA, mainly driven by socioeconomic factors. Ideally, prostate-specific antigen testing and discussion should be based on relevant clinical factors with a shared decision-making approach for every man. Therefore, a better understanding of the socioeconomic factors influencing prostate-specific antigen testing/discussions can inform strategies to reduce existing gaps in care.

Treatment progression for men on active surveillance (AS) for prostate cancer (PCa) is driven primarily by grade and volume progression on isolated prostate biopsies (PBx). As PCa is a multifocal disease, regional disease progression over time should be accounted for.To validate the utility of the cumulative cancer location (CCLO) metric, which assesses regional core involvement, as described by Erickson et al (Cumulative cancer locations is a novel metric for predicting active surveillance outcomes: a multicenter study. Eur Urol Oncol 2018;1:268-75), in predicting AS outcomes in a North American cohort.A single-institutional retrospective chart review of all AS patients evaluated between 2015 and 2017.CCLO defined as the total number of cancer-positive sextant locations among all PBx to that point in time (range 1-6). Baseline demographics and clinical characteristics of the entire cohort were stratified by CCLOΔ, defined as the difference between the first and the last CCLO. CCLOΔ then correlated with progression to treatment and treatment outcomes.A total of 261 men met the inclusion criteria. Though the mean number of biopsies was slightly higher in the CCLOΔ 3-5 cohort than in the CCLOΔ 0-2 cohort (p = 0.006), mean AS follow-up time (3.3 yr) was not significantly different (p = 0.327). As CCLOΔ increased, the proportion of men remaining on AS decreased, while the proportion of men receiving treatment increased (p 0.001). In men undergoing radical prostatectomy, a higher CCLOΔ was not associated with higher rates of Gleason 7-10 (p = 0.38) or pT3 (p = 0.52) disease. However, as CCLOΔ increased, upgrading from final PBx to RP pathology increased, while downgrading decreased (p = 0.12). In Kaplan-Meier analyses, lower CCLOΔ and lower initial cancer location scores were associated with the highest 5-yr treatment-free survival rates (p 0.001).Higher regional cancer core involvement is associated with higher rates of progression to treatment in AS patients. The CCLO metric is a potentially useful modality in stratifying AS patients among the North American cohort for treatment, while not compromising disease outcomes.In the North American population, cumulative cancer-positive locations among biopsies can be used to predict active surveillance outcomes in men with prostate cancer.

Purpose To identify incidence and predictors of stress urinary incontinence (SUI) following Holmium laser enucleation of the prostate (HoLEP). Materials and Methods We performed a retrospective review of 589 HoLEP patients from 2012-2018. Patients were assessed at pre-operative and post-operative visits. Univariate and multivariate regression analyses were performed to identify predictors of SUI. Results 52/589 patients (8.8%) developed transient SUI, while 9/589 (1.5%) developed long-term SUI. tSUI resolved for 46 patients (88.5%) within the first six weeks and in 6 patients (11.5%) between 6 weeks to 3 months. Long-term SUI patients required intervention, achieving continence at 16.4 months on average, 44 men (70.9%) with incontinence were catheter dependent preoperatively. Mean prostatic volume was 148.7mL in tSUI patients, 111.6mL in long-term SUI, and 87.9mL in others (p 100g and catheter dependency are associated with increased risk tSUI. Larger prostate volume is an independent predictor of any SUI, and tSUI.

To analyze gender-based differences in distress symptoms in patients with non-metastatic renal cell carcinoma (RCC) at different stages of disease. The Edmonton Symptom Assessment System—revised (ESAS-r) questionnaire includes a physical (PHSDSS) and a psychological distress sub-score (PDSS). The ESAS-r was used to measure psychological and physical distress symptoms in localized RCC patients in a major cancer referral center between 2014 and 2017 at four predefined time points: (a) diagnosis, (b) biopsy, (c) surgery, and (d) last follow-up. Results were gender stratified, and multivariable linear regression models were used to determine associations with increased sub-scores. Overall, 495 patients were included with 37.2% females. No significant gender differences were seen in mean age, relevant clinical parameters, and treatment. PDSS was significantly higher in females after diagnosis (8.5 vs. 5.1, p = 0.018), biopsy (8.9 vs. 4.1, p = 0.003), and surgery (6.5 vs. 4.4, p = 0.007), while being similar at the last follow-up. The multivariable model demonstrated a statistically significant association of female gender with higher PDSS after diagnosis (B = 3.755, 95% CI 0.761–6.750), biopsy (B = 6.076, 95% CI 2.701–9.451), and surgery (B = 1.974, 95% CI 0.406–3.542). PHSDSS was significantly higher in females after biopsy (10.0 vs. 5.7, p = 0.028) and surgery (8.6 vs. 6.1, p = 0.022). In the multivariable model, female gender conferred a higher PHSDSS only after surgery (B = 2.384, 95% CI 0.208–4.560). Gender-associated psychological distress differences exist in non-metastatic RCC patients throughout treatment, while dissipating at last follow-up. Emphasis should be placed on screening for distress symptoms and providing psychological support continuously, particularly for female patients.

Objective To assess age-based differences in psychological and physical symptoms of bladder cancer (BC) patients at different disease stages. Methods This was a cross-sectional single-center retrospective study between 2014 and 2017, assessing BC patients at different time points of their disease trajectory, after completing the Edmonton Symptom Assessment System-revised questionnaire. The questionnaire was filled at 3 predefined time points: (a) following diagnosis, (b) after radical cystectomy (RC), and (c) at last follow-up. The Edmonton Symptom Assessment System-revised consists of the physical distress sub-score (PHSDSS), entailing scores of 6 physical symptoms, and the psychological distress sub-score (PDSS), entailing scores of 3 psychological symptoms. Patients were stratified to those younger and older than 65 years. Multivariable linear regression models assessed predictors of increased PDSS and PHSDSS. Results A total of 232 patients were analyzed. No significant baseline clinical differences were demonstrated between both groups, excepting a higher Charlson comorbidity score (4.85 vs 3.87, P = .004), and a higher rate of muscle-invasive disease (71.7% vs 52.1%, P = .008) in older patients. PHSDSS scores remained similar throughout all time points in both groups. In contrast, younger patients had a significantly higher PDSS score at diagnosis, and after RC. Multivariable models demonstrated that an increased PDSS score (B = 2.372, 95% CI 0.36-4.385) was more likely in younger patients at diagnosis and after RC. An increased PHSDSS (B = 5.118, 95% CI 0.462-9.774) was more likely in younger patients only after RC. Conclusion Younger BC patients may benefit from access to psychological support services as part of a comprehensive treatment regimen, especially after diagnosis and RC.

OBJECTIVE To provide the first comprehensive analysis of the Twitterverse amongst academic urologists and programmes in North America. METHODS Using national accreditation and individual programme websites, all active urology residency programmes (USA and Canada) and academic Urology faculty at these programmes were identified. Demographic data for each programme American Urological Association [AUA] section, resident class size) and physician (title, fellowship training, Scopus Hirsch index [H-index] and citations) were documented. Twitter metrics (Twitter handle, date joined, # tweets, # followers, # following, likes) for programmes and physicians were catalogued (data capture: March-April 2019). Descriptive analyses and temporal trends in Twitter utilisation amongst programmes and physicians were assessed. Multivariable logistic regression was used to identify predictors of Twitter use. RESULTS In all, 156 academic programmes (143 USA, 13 Canada) and 2214 academic faculty (2015 USA, 199 Canada) were identified. Twitter utilisation is currently 49.3% and 34.1% amongst programmes and physicians, respectively, and continues to increase. On multivariable analysis, programmes with 3-5 residents/year and programmes with a higher percentage of faculty Twitter engagement were more likely to have Twitter accounts. From a physician perspective, those with fellowship training, lower academic rank (Clinical Instructor, Assistant Professor, Associate Professor vs Professor) and higher H-indices were more likely to have individual Twitter accounts. CONCLUSION There is a steady increase in Twitter engagement amongst Urology programmes and academic physicians. Faculty Twitter utilisation is an important driver of programme Twitter engagement. Twitter social media activity is strongly associated with academic productivity, and may in fact drive academic metrics. Within Urology, social media presence appears to be proportional to academic activity.

Introduction: This was a secondary analysis aiming to assess whether hydrophilic or hydrophobic statins have a differential effect on urinary retention (UR) and lower urinary tract symptoms (LUTS) in men following a prostate biopsy (PB), who were at risk for prostate cancer development. Methods: This was a population-based cohort study with data incorporated from the Institute for Clinical and Evaluative Sciences database to identify all Ontarian men aged 66 and above with a history of a single negative PB between 1994 and 2016, with no drug prescription history of any of several putative chemopreventative medications (statins, proton pump inhibitors, five-alpha-reductase inhibitors, and alpha-blockers). Multivariable Cox regression models with time-dependent covariates were used to assess the association of hydrophilic and hydrophobic statins with UR and LUTS within 30 days of a PB. All models were adjusted for other known putative chemopreventive medications, age, rurality, pharmacologically treated diabetes, comorbidity score, and study inclusion year. Results: Overall, 21 512 men were included, with a median followup time of 9.4 years (interquartile range [IQR] 5.4–13.4 years). Hydrophobic and hydrophilic statins were initiated by 30.7% and 19.6% of men, respectively, after the first negative PB. UR and LUTS were experienced by 2.2% and 10% of men, respectively. Cox models demonstrated hydrophilic statins were associated with a lower risk of UR (hazard ratio [HR] 0.56, 95% confidence interval [CI] 0.38–0.83, p=0.0038) and LUTS (HR 0.86, 95% CI 0.76–0.98, p=0.022), while no such association was shown for hydrophobic statins. Conclusions: Initiation of hydrophilic statins in men older than 66 appears to be inversely associated with the risk of UR and LUTS within 30 days of a PB.