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Background: This study assessed the use of active surveillance in men with low-risk prostate cancer and evaluated institutional factors associated with the receipt of active surveillance.Methods: A retrospective, hospital-based cohort of 115,208 men with low-risk prostate cancer diagnosed between 2010 and 2014 was used. Multivariate and mixed effects models were used to examine variation and factors associated with active surveillance.Results: During the study period, the use of active surveillance increased from 6.8% in 2010 to 19.9% in 2014 (estimated annual percentage change, +28.8%; 95% confidence interval [CI], + 19.6% to + 38.7%; P = .002). The adjusted probability of active-surveillance receipt by institution was highly variable. Compared with patients treated at comprehensive community cancer centers, patients treated at community cancer programs (odds ratio [OR], 2.00; 95% CI, 1.50-2.67; P < .001) and academic institutions (OR, 2.47; 95%, CI, 1.81-3.37; P < .001) had higher odds of receiving active surveillance. Compared with patients treated at very low-volume facilities, patients treated at very high-volume facilities had higher odds of receiving active surveillance (OR, 3.57; 95% CI, 1.94-6.55; P < .001). Patient and hospital characteristics accounted for 60.2% of the overall variation, whereas the treating institution accounted for 91.5% of the unexplained variability.Conclusions: Within this hospital-based cohort, the use of active surveillance for low-risk prostate cancer increased significantly over time. Significant variation was found in the use of active surveillance. Most of the variation was attributable to facility-related factors such as the facility type, facility volume, and institution. Policies to achieve consistent and higher rates of active surveillance, when appropriate, should be a priority of professional societies and patient advocacy groups. Cancer 2018;124:55-64. © 2017 American Cancer Society. [ABSTRACT FROM AUTHOR]

Background: The objective of this study was to investigate the impact of travel distance to the treating facility on the risk of overall mortality (OM) among US patients with prostate cancer (PCa).Methods: In total, 775,999 patients who had PCa in all stages and received treatment with different strategies (radical prostatectomy, radiation therapy, observation, androgen-deprivation therapy, multimodal treatment, and chemotherapy) were drawn from the National Cancer Data Base from 2004 through 2012. Independent predictors of travel distance (intermediate [12.5-49.9 miles] and long [49.9-249.9 miles] vs short[<12.5 miles]) and its effect on OM were calculated using multivariable regression analyses. Additional analyses evaluated the distance effect on OM in selected subgroups.Results: In total, 54.5%, 33.4%, and 12.1% of patients traveled short, intermediate, and long distances, respectively. Residency in rural areas and the receipt of treatment at academic/high-volume centers independently predicted long travel distance. Non-Hispanic black men and Medicaid-insured men were less likely to travel long distances (all P < .001). Overall, traveling a long distance (hazard ratio, 0.87; 95% confidence interval, 0.83-0.92; P < .001) was associated with lower OM risk compared with traveling a short distance. This held true among non-Hispanic white men; privately insured and Medicare-insured men; those who underwent radical prostatectomy, received radiation therapy, and received multimodal strategies; and those who received treatment at academic/high-volume centers (P < .01), but not among non-Hispanic black men (P = .3). Long travel distance was associated with an increased OM in Medicaid-insured patients (P < .001).Conclusions: An OM benefit was observed among men who traveled long distances for PCa treatment, which is likely to be a reflection of centralization of care and more favorable patient-level characteristics in those travelers. Furthermore, the survival benefit mediated by long travel distances appears to be influenced by baseline socioeconomic, treatment, and facility-level factors. Cancer 2017;123:3241-52. © 2017 American Cancer Society. [ABSTRACT FROM AUTHOR]

Background The role of local treatment (LT) in patients with metastatic prostate cancer (mPCa) at diagnosis is controversial. Objective We set to evaluate the potential impact of LT on overall mortality (OM) in men with mPCa, and how this impact is influenced by tumor and patient characteristics. Design, settings, and participants A total of 15 501 patients with mPCa were identified in the National Cancer Data Base (2004–2012) and categorized in LT (radical prostatectomy or radiation therapy targeted to prostate) versus nonlocal treatment (NLT; all other patients). Outcome measurements and statistical analysis The two arms (LT vs NLT) were matched using propensity scores to minimize selection bias. To evaluate LT impact on OM in relation to baseline characteristics, first multivariable Cox regression analysis was used to predict OM in patients treated with NLT, then interaction between predicted OM risk and LT status was tested. Results and limitations Overall, 9.5% ( n = 1470) of patients received LT. In the postpropensity matched cohorts, 3-yr OM-free survival was higher in the LT group versus the NLT group (69% vs 54%; p < 0.001). In multivariable Cox regression, the NLT group, age, and Charlson comorbidity index were predictors of OM (all p ≤ 0.03). This model was used to predict the 3-yr OM risk. The interaction between predicted OM and LT status was significant ( p < 0.001). The benefit of LT on OM decreased progressively as predicted OM risk increased. Specifically, the 3-yr absolute improvement in OM-free survival was 15.7%, for patients with predicted OM risk ≤20% versus 0% for those with predicted OM risk ≥72%. Conclusions Men with mPCa at diagnosis benefit from LT in terms of OM. This is largely affected by baseline characteristics. Specifically, patients with a relatively low tumor risk and good general health status appear to benefit the most. Patient summary We used a large hospital-based database to evaluate which patients might benefit from local therapy when metastasized prostate cancer was present at diagnosis. Local therapy is associated with a survival benefit in men with less aggressive tumors and good general health. [ABSTRACT FROM AUTHOR]

Objective: Previous studies have investigated the effect of resident involvement (RI) on surgical complications in minimally invasive and complex surgical cases. This study evaluates the effect of surgical education on outcomes in a simple general urologic procedure, unilateral and bilateral hydrocele repair, in a large prospectively collected multi-institutional database.Methods: Relying on the American College of Surgeons National Surgical Quality Improvement Program Participant User files (2005-2013), we extracted patients who underwent unilateral or bilateral hydrocele repair using Current Procedural Terminology codes 55040, 55041, and 55060. Cases with missing information on RI were excluded. Descriptive and logistic regression analyses were performed to assess the impact of RI on perioperative outcomes. A prolonged operative time (pOT) was defined as operative time >75th percentile.Results: Overall, 1378 cases were available for final analyses. The overall complication, readmission, and reoperation rates were 2.3% (32/1378), 0.5% (7/1378), and 1.4% (19/1378), respectively. A pOT was more frequently observed in bilateral procedures (35.2% vs 21.3%, P < .0001) and with RI (33.8% vs 19.0%, P < .0001). Procedures with RI had a 2.2-fold higher odds of pOT (95% confidence interval 1.7-2.8, P < .0001). Overall complications (odds ratio 1.1, 95% confidence interval 0.5-2.3) were not associated with RI (P = .789). In sensitivity analyses, all postgraduate years of training were associated with a pOT (P < .0001).Conclusion: Although the involvement of a resident in hydrocele repairs leads to higher odds of pOT, it does not affect patient safety, as evidenced by similar complication rates. [ABSTRACT FROM AUTHOR]

We performed a systematic literature search to identify original articles and editorials about the Decipher® Prostate Cancer Test (GenomeDx Biosciences, San Diego, CA) to provide an overview of the current literature and its present role in urologic clinical practice. The Decipher test, which uses the expression of 22 selected RNA markers (from a total of over 1.4 million), showed a very high discrimination in predicting clinical metastasis (0.75-0.83) and cancer-specific mortality (0.78) in external validation studies, outperforming all routinely available clinicopathologic characteristics. Further, the timing of postoperative radiotherapy (adjuvant vs salvage) may be guided based on Decipher scores. The Decipher test was also the only independent predictor of clinical metastasis in patients with biochemical recurrence after surgery. The Decipher Genomic Resource Information Database (GRID) is a novel research tool that captures 1.4 million marker expressions per patient and may facilitate precision-guided, individualized care to patients with prostate cancer. In this era of precision medicine, Decipher, along with the Decipher GRID platform, is a promising genomic tool that may aid in managing prostate cancer patients throughout the continuum of care and delivering appropriate treatment at an individualized level. [ABSTRACT FROM AUTHOR]

Purpose: Radical prostatectomy is a commonly performed procedure with perioperative complication rates of 30 % using standardized reporting methodology. We aim to determine whether perioperative complications and functional outcomes impact quality of life 1 year after surgical treatment. Patients and methods: Quality of life, functional and oncological outcomes were assessed in patients who underwent open retropubic radical prostatectomy at a single academic institution between 2003 and 2009, preoperatively and 1 year after surgery using the EORTC QLQ-C30, the IIEF-5 and an institutional questionnaire. Perioperative complications were recorded using the Clavien-Dindo classification. Patients without complications were compared to patients with any, low- or high-grade complications. The global health score domain of the EORTC QLQ-C30 is reported for various oncological and functional outcomes and contrasted to stratified categories of complications and functional outcomes. Results: A full dataset was available for 29.5 % ( n = 856) of all patients. The overall complication rate was 27.5 % (235/856). A total of 307 complications were recorded of whom 88.9 % (273/307) were low grade. In this study, population global health perception did not decline after surgery (70.5 ± 21.2 vs. 74.4 ± 19.7; p < 0.0001). Complications showed only statistical but no clinical meaningful influence on global health perception as well as on functional and symptom scales. Patients who met combined outcome criteria experienced the best postoperative global health score (86.0 ± 13.1 and 86.0 ± 14.2). Conclusions: Perioperative complications and functional outcomes have a measurable impact on quality of life 1 year following surgery. While perioperative complications have a statistical effect, functional outcomes showed a clinically more profound effect on postoperative global health perception. [ABSTRACT FROM AUTHOR]

Introduction: We aimed to assess the contemporary knowledge of human papillomavirus (HPV) and its association with penile cancer in a nationwide cohort from the U.S. Methods: We used the Health Information National Trends Survey (HINTS), a cross-sectional telephone survey performed in the U.S. initiated by the National Cancer Institute. The most recent iteration, HINTS 4 Cycle 4, was conducted in mail format between August 19 and November 17, 2014. Primary endpoints included knowledge of HPV and its causal relationship to penile cancer. Baseline characteristics included sex, age, education, race and ethnicity, income, residency, personal or family history of cancer, health insurance status, and internet use. Multivariable logistic regression assessed predictors of HPV and penile cancer knowledge. Results: An unweighted sample of 3376 respondents was extracted from the HINTS 4, Cycle 4. Whereas 64.4% of respondents had heard of HPV, only 29.5% of these were aware that it could cause penile cancer. Men were significantly less likely to have heard of HPV than women (odds ratio [OR] 0.32; 95% confidence interval [CI] 0.24-0.43). Older age; African-American, Asian, and "other race"; being married; from a lower education bracket; having a personal cancer history; and those without internet access were significantly less likely to have heard of HPV. None of our examined variables were independent predictors for the knowledge of the association of penile cancer and HPV. Conclusions: Our analysis of a large, nationally representative survey demonstrates that the majority of the American public is familiar with HPV, but lack a meaningful understanding between this virus and penile cancer. Primary care providers and specialists should be encouraged to intensify counselling about this significant association as a primary preventive measure of this potentially fatal disease. [ABSTRACT FROM AUTHOR]

Introduction: To evaluate perioperative outcomes related to resident involvement (RI) in a large and prospectively collected multi-institutional database of patients undergoing orchiectomy for testicular cancer. Materials and Methods: Using current procedural terminology and ICD-9 codes, information about patients with testicular cancer were abstracted from the American College of Surgeons National Surgical Quality Improvement Program database (2006-2013). Multivariable analyses evaluated the impact of RI on outcomes after orchiectomy. Prolonged operative time (pOT) and prolonged length of stay were defined by the 75th percentile (59 min) and postoperative inpatient stay ≥ 2 days, respectively. Results: Overall, 267 patients underwent orchiectomy either with (38.6%) or without (61.4%) RI. In all, 89.1% of patients underwent an outpatient procedure. The median body mass index was 26.8 and baseline characteristics between the 2 groups were similar. Overall complications, re-intervention, and bleeding-related complication rates were 2.6, 0.7, and 0.4%, respectively. Although there was no difference in terms of overall complications between the groups (3.9 vs. 1.8%; p = 0.44), RI resulted in pOT (32 vs. 19.5%; p = 0.028). In multivariable analyses, RI predicted pOT (OR 1.89, 95% CI 1.06-3.37; p = 0.031), without association with prolonged length of stay and overall complications. Conclusions: RI during orchiectomy for testicular cancer does not undermine patient safety at the cost of pOT. [ABSTRACT FROM AUTHOR]

Study Type - Prognosis (prospective cohort) Level of Evidence 2a What's known on the subject? and What does the study add? Fournier's gangrene (FG) is a rare but life-threatening disease challenging the treating medical staff. Despite the fact that antibiotic therapy combined with surgery and intensive care surveillance are performed as standard treatment, mortality rates remain high. There have been efforts to develop a reliable tool to predict severity of the disease, not only to identify patients at highest risk of major complications or death but also to provide a target for medical teams and researchers aiming to improve outcome and to gather information for counselling patients. Laor et al. published the FG severity index (FGSI) in 1995 presenting a complex prediction score solely for patients with FG. Fifteen years later, Yilmazlar et al. suggested a new and supposedly more powerful scoring system, the Uludag FGSI (UFGSI), adding an age score and an extent of disease score to the FGSI. In the present study population we applied two scoring systems for outcome prediction that are solitarily applicable in patients with FG (FGSI, UFGSI), as well as two general scoring systems such as the established age-adjusted Charlson Comorbidity Index (ACCI) and the recently introduced surgical Apgar Score (sAPGAR) to compare them and to test whether one system might be superior to the other. In addition, we identified potential prognostic factors in the study population. By contrast to many earlier studies, we performed a combined prospective and retrospective analysis and provided a 30-day follow up. In the cohort of the present study, older patients with comorbidities as well as a need for mechanical ventilation and blood transfusion are at higher risk of lethal outcome. All scores are useful to predict mortality. Despite including more variables, the UFGSI does not seem to be more powerful than the FGSI. In daily routine we suggest applying ACCI and sAPGAR, as they are more easily calculated, generally applicable and well validated. OBJECTIVE To compare four published scoring systems for outcome prediction (Fournier's gangrene severity index [FGSI], Uludag FGSI [UFGSI], age-adjusted Charlson Comorbidity Index [ACCI] and surgical Apgar Score [sAPGAR]) and evaluate risk factors in patients with Fournier's gangrene (FG)., PATIENTS AND METHODS In all, 44 patients were analysed. The scores were applied., A Mann-Whitney U-test, Fisher's exact test, receiver operator characteristic (ROC) analysis and Pearson correlation analysis were performed., RESULTS The results of the present study show a significant association among FGSI ( P= 0.002), UFGSI ( P= 0.002), ACCI ( P= 0.004), sAPGAR ( P= 0.018) and death., The differences between the area under the receiver operating characteristic curve of the scores were not significant., Non-survivors were older ( P= 0.046), had a greater incidence of acute renal failure ( P < 0.001) and coagulopathy ( P= 0.041), were treated more often with mechanical ventilation ( P= 0.001) and received more packed red blood cells (RBCs; P= 0.001)., CONCLUSION Older patients with comorbidities and need for mechanical ventilation and RBCs are at higher risk for death., In the present cohort, scores calculated easily at the bedside, such as ACCI and sAPGAR, seemed to be as good at predicting outcome in patients with FG as FGSI and UFGSI. [ABSTRACT FROM AUTHOR]

Study Type - Prognosis (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Prostate cancer characterisation, based on laboratory findings, clinical examination and histopathological cancer features that are used to define selection criteria for AS, is not ideal. Consequently, a panel of strict or more lenient criteria to select patients for AS have been published. Studies investigating the relationship between pretreatment variables and final pathology have been done in the past showing the risk of cancer misclassification for some criteria. No study has presented an overview of cancer selection using a panel of 16 currently used AS criteria that is presented in the present study. In an exactly defined cohort after radical prostatectomy, each set of criteria was used as a diagnostic test to separate between patients with more favourable (pT2, no Gleason upgrade between biopsy grading and final pathology) and unfavourable cancer features (pT3, pN+, Gleason upgrade). To the best of our knowledge a comparison of test quality criteria for AS criteria given by sensitivity, specificity, positive and negative predictive value and likelihood ratio has not yet been reported. Moreover, we showed that tumour characterisation, by a formally sufficient 12-core biopsy, in the present dataset harboured a risk of ≈20% that unfavourable cancer features were missed regardless of whether strict or more lenient selection criteria for AS were chosen. OBJECTIVE To evaluate final histopathological features among men diagnosed with prostate cancer eligible for low-risk (LR) or active surveillance (AS) criteria., PATIENTS AND METHODS Retrospective application of 16 definitions for AS or LR prostate cancer to a contemporary (January 2008 to March 2011) open retropubic radical prostatectomy (RRP) series of 1745 patients., Exclusion criteria: neoadjuvant hormones, radiotherapy, inadequate histopathological reports, <10 biopsy cores., Report on the number of men with insignificant tumours (defined as: ≤pT2, Gleason score ≤6, tumour volume <0.5 mL) and men who had unfavourable tumour characteristics on final pathology (defined as: extracapsular extension or seminal vesicle invasion or lymph node metastasis or Gleason upgrading)., Sensitivity, specificity, positive predictive value (PPV) and negative predictive values (NPV) were calculated., RESULTS Eligibility of patients in the final study cohort ( n= 1070) varied from 5.1% to 92.7% depending on the AS or LR criteria used., Final pathology revealed 77 insignificant cancers and 578 patients who had unfavourable histopathological criteria., The detection rate for insignificant cancers on final pathology was variable ranging from 7.8% to 28.3% depending on the AS- or LR-prediction tool used; unfavourable tumour characteristics were found in up to 33.5% on final pathology., The sensitivity, specificity, PPV and NPV were 8.5-97.9%, 24.7-97.8%, 67.7-89.1% and 45.3-78.2%, respectively., The likelihood ratio to correctly identify a patient with LR disease on final pathology ranged from 1.3 to 8., CONCLUSIONS AS or LR criteria have a significant risk of cancer misclassification., Better prediction tools are needed to improve these criteria., Re-biopsy might improve safety and should be considered more frequently in patients who opt for AS. [ABSTRACT FROM AUTHOR]

Objective: To evaluate state-by-state trends in prostate-specific antigen (PSA) screening prevalence after the 2011 United States Preventive Services Task Force (USPSTF) recommendation against this practice.Methods: We included 222,475 men who responded to the Behavioral Risk Factor Surveillance System 2012 and 2014 surveys, corresponding to early and late post-USPSTF populations. Logistic regression was used to identify predictors of PSA screening and to calculate the adjusted and weighted state-by-state PSA screening prevalence and respective relative percent changes between 2012 and 2014. To account for unmeasured factors, the correlation between changes in PSA screening over time and changes in screening for colorectal and breast cancer were assessed. All analyses were conducted in 2016.Results: Overall, 38.9% (95% confidence interval [CI] = 38.6%-39.2%) reported receiving PSA screening in 2012 vs 35.8% (95% CI = 35.1%-36.2%) in 2014. State of residence, age, race, education, income, insurance, access to care, marital status, and smoking status were independent predictors of PSA screening in both years (all P <.001). In adjusted analyses, the nationwide PSA screening prevalence decreased by a relative 8.5% (95% CI = 6.4%-10.5%; P <.001) between 2012 and 2014. There was a vast state-by-state heterogeneity, ranging from a relative 26.6% decrease in Vermont to 10.2% increase in Hawaii. Overall, 81.5% and 84.0% of the observed changes were not accompanied by matching changes in respective colorectal and breast cancer screening utilization, for which there were no updates in USPSTF recommendations.Conclusion: There is a significant state-by-state variation in PSA screening trends following the 2011 USPSTF recommendation. Further research is needed to elucidate the reasons for this heterogeneity in screening behavior among the states. [ABSTRACT FROM AUTHOR]

Background: Neoadjuvant chemotherapy in pure urothelial bladder cancer provides a significant survival benefit. However, to the authors' knowledge, it is unknown whether this benefit persists in histological variants. The objective of the current study was to assess the effect of neoadjuvant chemotherapy on the probability of non-organ-confined disease and overall survival after radical cystectomy (RC) in patients with histological variants.Methods: Querying the National Cancer Data Base, the authors identified 2018 patients with histological variants who were undergoing RC for bladder cancer between 2003 and 2012. Variants were categorized as micropapillary or sarcomatoid differentiation, squamous cell carcinoma, adenocarcinoma, neuroendocrine tumors, and other histology. Logistic regression models estimated the odds of non-organ-confined disease at the time of RC for each histological variant, stratified by the receipt of neoadjuvant chemotherapy. Cox regression models were used to examine the effect of neoadjuvant chemotherapy on overall mortality in each variant subgroup.Results: Patients with neuroendocrine tumors (odds ratio [OR], 0.16; 95% confidence interval [95% CI], 0.08-0.32 [P<.001]), micropapillary differentiation (OR, 0.30; 95% CI, 0.10-0.95 [P=.041]), sarcomatoid urothelial carcinoma (OR, 0.40; 95% CI, 0.17-0.94 [P=.035]), and adenocarcinoma (OR, 0.24; 95% CI, 0.06-0.91 [P=.035]) were less likely to harbor non-organ-confined disease at the time of RC when treated with neoadjuvant chemotherapy. An overall survival benefit for neoadjuvant chemotherapy was only found in patients with neuroendocrine tumors (hazard ratio, 0.49; 95% CI, 0.33-0.74 [P=.001]).Conclusions: Patients with neuroendocrine tumors benefit from neoadjuvant chemotherapy, as evidenced by better overall survival and lower rates of non-organ-confined disease at the time of RC. For tumors with micropapillary differentiation, sarcomatoid differentiation, or adenocarcinoma, neoadjuvant chemotherapy decreased the frequency of non-organ-confined disease at the time of RC. However, this favorable effect did not translate into a statistically significant overall survival benefit for these patients, potentially due to the aggressive tumor biology. Cancer 2017;123:4346-55. © 2017 American Cancer Society. [ABSTRACT FROM AUTHOR]

Objective: To examine time-to-event data for 19 common postoperative complications within 30 days following radical cystectomy (RC).Methods: Patients undergoing RC were identified within the American College of Surgeons National Surgical Quality Improvement Program database (2005-2011). The primary end point was time-to-complication; secondary end points included length of stay (LOS), reintervention, readmission, and 30-day mortality. Further, the complications were stratified into pre- and postdischarge, and the predictors were identified. Lastly, the effect of time-to-complication on secondary outcomes was evaluated.Results: Overall, 1118 patients underwent RC. The overall complication rate was 52.1%; the median LOS was 8 days. The vast majority of complications (85.2%) were contained within the first 2 weeks of surgery with a median time-to-complication of 8.5 days; 31.4% of the complications occurred post discharge. In adjusted analyses, increasing age (odds ratio [OR] = 1.02, P < .001), black race (OR = 1.67, P = .001), and creatinine ≥1.2 mg/dL (OR = 1.26, P = .002) were significant predictors of predischarge complications, whereas diabetes (OR = 1.40, P < .001), cardiopulmonary disease (OR = 1.27, P = .005), neoadjuvant therapy (OR = 1.35, P = .007), and continent diversions (OR = 1.30, P = .004) were significant predictors of postdischarge complications. A body mass index of ≥30 was associated with increased odds of pre- as well as postdischarge complications (P < .01). For a given complication, timing did not affect the mortality odds (P = .310), but the risk of reintervention, readmission, and prolonged LOS varied.Conclusion: One in 2 patients suffers a complication within 30 days of undergoing RC. A vast majority of complications occur early on postoperatively, either pre- or post discharge, highlighting the need for rigorous inpatient as well as outpatient surveillance during this period-knowledge regarding the time-to-complications, the effect of time-to-complications, and risk factors may facilitate improved patient-physician communication and allow patient-tailored follow-up. [ABSTRACT FROM AUTHOR]

The Prostate Cancer Intervention Versus Observation Trial (PIVOT) concluded that radical prostatectomy (RP) offered no survival benefit compared with observation in men with clinically localized prostate cancer (PCa). We identified patients within the National Cancer Database (NCDB) for the period 2004-2012 who met the inclusion criteria of PIVOT (ie, histologically confirmed PCa, clinical stage T1–2NxM0, prostate-specific antigen <50 ng/ml, age <75 yr, estimated life expectancy >10 yr, and undergoing RP or observation as initial treatment within 12 mo of diagnosis) to confirm the generalizability of the PIVOT results to the US population. Life expectancy was calculated using the US Social Security Administration life tables and was adjusted for comorbidities at diagnosis. Compared with PIVOT, men in the NCDB were younger (mean age 60.3 vs 67.0 yr) and healthier (Charlson-Deyo comorbidity index of 0: 93% vs 56%; both p < 0.001). Furthermore, 42% of men randomized to receive RP in PIVOT harbored D’Amico low-risk PCa, whereas 32% of men undergoing RP in the NCDB had low-risk disease. Our findings were confirmed in a sensitivity analysis including men regardless of life expectancy but satisfying all other inclusion criteria of PIVOT. Given that the NCDB represents nearly 70% of all incident cancers diagnosed in the United States, our data provide further evidence that PIVOT results may not be generalizable to contemporary clinical practice. Patient summary We observed that men diagnosed with clinically localized prostate cancer within the National Cancer Database (2004–2012) were younger, healthier, and more likely to have radical prostatectomy for higher risk disease than men in the Prostate Cancer Intervention Versus Observation Trial (PIVOT), raising questions about the applicability of PIVOT conclusions to the contemporary US population. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether the Surgical Apgar Score (SAS) can identify patients who are at risk for perioperative adverse events (PAE) following radical prostatectomy for prostate cancer. Patients and Methods: At a single academic institution, 994 patients undergoing radical prostatectomy between 2010 and 2013 were analyzed retrospectively. The SAS was calculated from anesthesia records, evaluated to predict PAE within a 30-day time period postoperatively; these events were classified according to standardized classification systems. Results: We observed adverse events in 45.4% (451/994) of patients with a total of 694 events. Overall, 41% (408/994) had low- and 9.9% (98/994) had highgrade events. A lower SAS was identified as an independent predictor of any (p < 0.001) and low-grade adverse events (p = 0.001) for those patients who had undergone open retropubic radical prostatectomy (ORRP). Each 1-point increment resulted in a 24% decrease in the odds of any (95% CI 0.66-0.88) and a 21% decrease in the odds of a low-grade (95% CI 0.69-0.91) event. Adverse events of robot-assisted prostatectomy were not associated with the SAS. Conclusions: Lower SAS values indicate patients at risk for adverse events after ORRP. The SAS might serve as one variable for outcome assessment, reflecting the challenge of mutual surgical and anesthesiology procedure management. [ABSTRACT FROM AUTHOR]

Objectives To examine temporal trends in inpatient testicular torsion ( TT) treatment and testicular loss ( TL), and to identify risk factors for TL using a large nationally representative paediatric cohort, stratified to established high prevalence TT cohorts (neonatal TT [ NTT]; age <1 years) and adolescent TT ( ATT; age 12-17 years). Methods Boys (age ≤17 years, n = 17 478) undergoing surgical exploration for TT were identified within the Nationwide Inpatient Sample (1998-2010). Temporal trends in inpatient TT management (salvage surgery vs orchiectomy) and TL were examined using estimated annual percent change methodology. Multivariable logistic regression models were used to identify risk factors for TL. Results Teaching hospitals treated 90% of boys with NTT, compared with 55% with ATT ( P < 0.001). Of boys with NTT, 85% lost their testis, compared with 35% with ATT ( P < 0.001). Inpatient management of NTT declined during the study period, from 7.5/100 000 children in 1998 to 3/100 000 in 2010 (estimated annual percent change −4.95%; P < 0.001). The decrease was similar but less dramatic in ATT. TL patterns did not improve. In adjusted analyses, for NTT, orchiectomy was more likely at teaching hospitals. For ATT, orchiectomy was more likely in children with comorbidities (odds ratio 5.42; P = 0.045), Medicaid coverage or self-pay ( P < 0.05) and weekday presentation ( P = 0.001). Regional or racial disposition was not associated with TL. Conclusions There has been a gradual decrease in inpatient surgical treatment for both NTT and ATT, presumably as a result of increased outpatient and/or non-operative management of these children. Concerningly, TL patterns have not improved; targeted interventions such as parental and adolescent male health education may lead to timely recognition/intervention in children at-risk for ATT. We noted no regional/racial disparities in contrast to earlier studies. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate treatment variables for early urinary continence status 6 weeks following radical prostatectomy. Methods: In this retrospective analysis, 4,028 consecutive patients underwent open radical retropubic (RRP) or robot-assisted transperitoneal prostatectomy (RARP) at a single academic institution (07/2003-07/2013). After discharge, patients were offered 3-week treatment in a rehabilitation facility. Patients who opted for rehabilitation ( n = 2,998, 74.4 %) represent our study cohort. Exclusion criteria were acute urinary retention after catheter removal ( n = 55, 1.4 %), incomplete datasets ( n = 50, 1.2 %) or refusal of rehabilitation ( n = 925, 23.0 %). Results of urinary continence were evaluated from final rehabilitation reports. Twenty-two clinical and oncological variables were statistically analysed in uni- and multivariable analyses to determine whether they were associated with early urinary continence status six weeks after radical prostatectomy. Odds ratios and 95 % CI as well as p values were calculated. A p level of 0.05 was considered as significant. Results: Six weeks after surgery, 1,962 (65.4 %) patients were continent (≤1 pad/day) and 1,036 (34.6 %) patients were considered incontinent. Age, clinical stage, PSA, ASA score, prior TURP, seminal vesicle invasion, Gleason score, nerve-sparing status, intraoperative blood loss, catheterisation time, OR time, surgical caseload >1,000 and the surgeon were associated with continence status on univariable analysis ( p < 0.05). On multivariable analysis, nerve-sparing procedure (NS), clinical stage, individual surgeon, patient age, surgical procedure (RARP vs. RRP) and duration of catheterisation were independent predictors ( p < 0.05) of incontinence status. Conclusions: Strategies that can ensure NS procedures and early catheter removal should be applied to enable early recovery of urinary continence. [ABSTRACT FROM AUTHOR]

Study Type - Diagnostic (exploratory cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Current studies evaluating real-time elastography in patients prior to radical prostatectomy reported sensitivities between 57% and 100% for detection of prostate cancer. This is the first prospective study comparing the findings of real-time elastography and conventional gray-scale ultrasound with final pathology. A significant improvement for cancer detection as well as detection of extra capsular is shown by adding the attributes of tissue elasticity to current gray-scale imaging. OBJECTIVE • To evaluate whether transrectal real-time elastography (RTE) improves the detection of intraprostatic prostate cancer (PCa) lesions and extracapsular extension (ECE) compared with conventional grey-scale ultrasonography (GSU). PATIENTS AND METHODS • In total, 229 patients with biopsy-proven PCa were prospectively screened for cancer-suspicious areas and ECE using GSU and RTE. • The largest tumour focus detected by RTE was defined as the index lesion. • The prostate gland was stratified into six sectors on GSU and RTE, which were compared with histopathological whole mount sections after radical prostatectomy. RESULTS • Histopathologically, PCa was confirmed in 894 out of 1374 (61.8%) evaluated sectors and ECE was identified in 47 (21%) patients. • Of these 894 sectors, RTE correctly detected 594 (66.4%) and GSU 215 (24.0%) cancer suspicious lesions. • Sensitivity was 51% and specificity 72% using RTE compared to 18% and 90% for GSU. • RTE identified the largest side specific tumour focus in 68% of patients. • ECE was identified with a sensitivity of 38% and specificity of 96% using RTE compared to 15% and 97% using GSU. CONCLUSIONS • Compared with GSU, RTE provides a statistically significant improvement in detection of PCa lesions and ECE. • RTE enhances GSU, although improvement is still needed to achieve a clinically meaningful sensitivity. [ABSTRACT FROM AUTHOR]