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Prostate cancer (PCa) risk assessment can incorporate clinical features, gene expression, protein ‘biomarkers’ or imaging. In this review the benefits of layering multiparametric magnetic resonance imaging (mpMRI) with other risk assessment methods is considered. mpMRI is an increasingly utilized risk assessment tool in prostate cancer. The European Association of Urology, National Comprehensive Cancer Network (NCCN) and American Urological Association (AUA) guidelines call for mpMRI utilization in the prostate cancer management pathway. As such, the NCCN Guidelines and AUA guidelines emphasize differing levels of reliance on mpMRI preceding prostate biopsy. However, like all risk assessment tools, mpMRI has strengths and limitations. This include dependencies on reader expertise and interpretation, equipment and process standardization, tumor size, tumor multifocality, tissue architecture, ethnic and racial disparity, and cost. Thus, layering complementary risk assessment methods to mitigate the limitations of each approach, enables the most informed clinical management. The goal of ongoing biomarker/mpMRI studies is to provide insight into the clinically helpful integration of the two approaches. For new technologies to be adapted or layered together synergistically, five specific competencies must be considered acceptable: (1) efficacy, (2) potential side effect levels, (3) ease of use of technology, (4) cost vs. clinical benefit, and (5) durability.

Abstract The promise of precision and personalized medicine is rooted in accurate, highly sensitive, and specific disease biomarkers. This is particularly true for cancer-a disease characterized by marked tumor heterogeneity and diverse molecular signatures. Although thousands of biomarkers have been described, only a very small number have been successfully translated into clinical use. Undoubtedly, there is need for rapid, quantitative, and more cost effective biomarkers for tumor diagnosis and prognosis, to allow for better risk stratification and aid clinicians in making personalized treatment decisions. This is particularly true for cancers where specific biomarkers are either not available (e.g., renal cell carcinoma) or where current biomarkers tend to classify individuals into broad risk categories unable to accurately assess individual tumor aggressiveness and adverse pathology potential (e.g., prostate cancer), thereby leading to problems of over-diagnosis and over-treatment of indolent cancer and under-treatment of aggressive cancer. This perspective highlights an emerging class of cancer biomarkers-live-single-cell phenotypic biomarkers, as compared to genomic biomarkers, and their potential application for cancer diagnosis, risk-stratification, and prognosis.

Purpose: Lymph nodes in the prostatic anterior fat pad rarely harbor metastatic disease. Therefore, the characteristics of patients with prostatic anterior fat pad lymph node metastasis are not well described in the literature. We identified the perioperative characteristics and assessed the clinical outcomes of patients with prostatic anterior fat pad lymph node metastasis. Materials and Methods: At 8 tertiary care centers a total of 4,261 patients underwent complete removal and pathological analysis of the prostatic anterior fat pad. We describe preoperative and pathological characteristics, and clinical management and outcomes in patients with metastatic disease to the prostatic anterior fat pad. Results: Metastatic disease to the prostatic anterior fat pad lymph nodes was detected in 40 patients (0.94%), of whom 37 (92.5%) had intermediate or high risk features preoperatively. Most patients with prostatic anterior fat pad metastases underwent concomitant pelvic lymph node dissection, and adjuvant therapy with radiation, androgen ablation and/or chemotherapy. A total of 27 patients (67.5%) with prostatic anterior fat pad metastatic disease were up-staged as a result of prostatic anterior fat pad pathological analysis, of whom 14 (51.8%) remained free of biochemical recurrence with observation and/or definitive adjuvant/salvage therapy. Conclusions: Most patients with prostatic anterior fat pad metastatic disease had intermediate to high risk features preoperatively. In some patients with such lymph node metastasis removing these lymph nodes resulted in pro- longed biochemical recurrence-free survival. Therefore, we recommend that the prostatic anterior fat pad be removed in all patients undergoing radical prostatectomy. However, pathological analysis of the prostatic anterior fat pad may be limited to patients with intermediate to high risk oncological features preoperatively. [ABSTRACT FROM AUTHOR]

Background and PurposeDietary intake of citrate in the form of citrus juices (eg, lemonade, orange juice) will enhance urinary citrate excretion, a valuable benefit for patients with hypocitraturic calcium oxalate nephrolithiasis. While information on citrate concentrations in select citrus juices is available, data on citrate concentrations of commercially available beverages (juice and otherwise) are limited. Using nuclear magnetic resonance spectroscopy (1H NMR), we report citrate concentrations of several beverages to help guide dietary recommendations aimed at increasing urinary citrate excretion and correcting hypocitraturia.MethodsCitrate concentrations of a squeezed lemon, several fruit juices, and common beverages were measured using 1H NMR. Spectra for each sample were obtained in duplicate; citrate peak was identified, measured, and quantified and compared with the citrate concentration in the juice of 1 medium lemon.ResultsQuantitative analysis revealed the highest concentration of citrate was in grapefruit juice (64.7 mmolL), followed in decreasing concentrations by lemon juice (47.66mmolL), orange juice (47.36 mmolL), pineapple juice (41.57 mmolL), reconstituted lemonade (38.65 mmolL), lemonade flavored Crystal Light (38.39 mmolL), ready to consume not from concentrate lemonade (38.24 mmolL), cranberry juice (19.87 mmolL), lemon-flavored Gatorade (19.82 mmolL), homemade lemonade (17.42 mmolL), Mountain Dew (8.84 mmolL), and Diet 7Up (7.98 mmolL), respectively.ConclusionsAccording to 1H NMR, all of the tested “natural” citrus juices have high concentrations of citrate (38.3–67.4 mmolL), with grapefruit juice having the highest concentration of the beverages chosen. Lemonade flavored Crystal Light had the highest concentration of citrate in the nonjuice category of tested beverages. In patients with mild to moderate hypocitraturia, dietary supplementation with citrus-based juices may be an effective alternative to medical management while not requiring large serving sizes. Further prospective studies are warranted to evaluate the clinical significance of these findings. [ABSTRACT FROM AUTHOR]

The literature on standard laparoscopic radical prostatectomy (LRP) and robot-assisted radical prostatectomy (RARP) is replete with technical descriptions of the primary surgeon's responsibility, but deficient with regard to the detailed role of the assistant surgeon. This video paper describes the critical role of the assistant surgeon and provides tips for the assistant to facilitate these operations. [ABSTRACT FROM AUTHOR]

PurposePrevious studies suggest that intravesical administration of nonsteroidal anti-inflammatory drugs may reduce the troublesome voiding symptoms and pain related to ureteral stenting. The objective of this study was to investigate the effectiveness of a long-acting local anesthetic, ropivacaine, injected submucosally into the bladder to control ureteral stent-associated symptoms.Materials and MethodsA randomized, single-blinded, study approved by our Institutional Review Board of adult patients scheduled for ureteroscopic stone surgery and possible stent placement was conducted. Patients were randomized to either the treatment cohort, who received five injections of 2 mL 0.5 ropivacaine around the ureteral orifice or to the control cohort, who received five injections of 2 mL of 0.9 normal saline in identical locations. Pain scale questionnaires were provided to each subject preoperatively and at postoperative hours 2, 4, 8, 24, and 48 as well as on the day of stent removal. Student''s ttest and Wilcoxon signed rank sum tests were used for Gaussian and nonparametric data, respectively.ResultsTwenty-two patients were randomized evenly into the two cohorts. The ropivacaine group consisted of 11 patients (eight men and three women) with a mean age of 56.2 years (standard deviation [SD] 12, range 2769), and the saline group consisted of eleven patients (six men and five women) with a mean age of 47.8 years (SD 6.6, range 3758). Intraoperative parameters appeared similar between the two cohorts. Intraoperative and postoperative narcotic usage was not different between the two groups, except at postoperative hour 2 when it favored the ropivacaine cohort (P0.05). Trends favoring ropivacaine in flank pain, bladder pain, genitalia pain, and hematuria domains were seen as long as 8 hours and up to the day of stent removal. Trends of less magnitude and duration were seen in the dysuria domain. No differences were seen in the frequency and urgency domains.ConclusionsOur preliminary investigation with intravesical injection of ropivacaine before ureteroscopic surgery demonstrated trends toward decreased pain and voiding symptoms in this small-sample study. Inclusion of a larger sample should definitively address the effectiveness of intravesical ropivacaine and its impact on stent-related symptoms. [ABSTRACT FROM AUTHOR]

Background and PurposeWe investigate a ureteral stent with radially expanding baskets producing passive dilation of the ureter for passage, capture, and removal of small ureteral stones.Patients and MethodsPolyurethane ureteral stents were slit to open 15 to 17 baskets along the length. The baskets are designed to dilate the ureter passively and capture stones ≤5 mm. Forty-two patients had these stents placed for stones at nine medical centers. Stone size ranged from 2 to 30 mm, while fragment size ranged from 1 to 8 mm. The locations of the stones ranged from the kidney to the lower ureter. The Ureteral Expanding Stent was inserted in the closed position, similar to a standard ureteral stent, and left in place for an average of 11 days.ResultsThe device was inserted and extracted safely in all patients. Most patients experienced pain at an average rating of 3.7 of 10 on a visual analog scale. All stents were removed without significant morbidity. In 36 patients (86), stones were removed with the stent (n 18) or passed while the stent was in place (n 18). The largest stone captured was 6 mm.ConclusionsThe Ureteral Expanding Stent (OPEN-PassTM) was used safely in 42 patients with stones. The device captured ureteral stones and facilitated stone passage around it. Stent retention or ureteral injury as a result of stone entrapment did not occur. The Ureteral Expanding Stent represents a new stone-removal and ureteral-dilation tool worthy of further clinical study. [ABSTRACT FROM AUTHOR]