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Objective To interrogate the National Veterans Health Administration (VA) database to determine if beta-blocker use at time of initiation of androgen therapy deprivation (ADT) would result in improved oncological outcomes in advanced prostate cancer (PCa). Methods All men diagnosed with high risk PCa (PSA >20) from 2000-2008 who were on ADT ≥ 6 months were identified. Patients receiving ADT concurrently with primary radiation therapy were excluded. Pharmacy data was interrogated for all beta-blockers, but then focused on the selective beta-1 blocker metoprolol. Cox proportional hazards ratios were calculated for overall survival (OS), PCa specific survival (CSS) and skeletal related events (SREs). Results In 39,198 patients with high risk PCa on ADT, use of any beta-blocker was not associated with improvement in OS, CSS, or SREs. Further analyses focusing on metoprolol found that 10,224 (31.9%) had used metoprolol while 21,834 had no beta-blocker use. Multivariable analysis with Inverse Propensity Score Weighting, adjusted for factors including PSA, Gleason score, and duration ADT, found that utilization of metoprolol was not associated with improvement in OS (hazard ratio [HR] 0.97, P = .19), CSS (HR 0.94, P = .23) or SREs (HR 0.98, P = .79). Conclusion In this large cohort, metoprolol use in conjunction with ADT in high risk PCa was not associated with improvement in OS, CSS, or risk of SRE. In contrast to a recent smaller clinical study, our data strongly suggests no cancer specific benefit to beta-blocker use in advanced PCa.

INTRODUCTION AND OBJECTIVE:The COVID-19 pandemic has affected all aspects of healthcare including surgical training. The impact on resident and fellow education has yet to be measured. Urologic onc...

INTRODUCTION AND OBJECTIVE:Current guidelines recommend neoadjuvant chemotherapy (NAC) prior to radical cystectomy (RC) for muscle invasive bladder cancer (MIBC). NAC has been shown to confer a sur...

To evaluate the impact of anterior tumor location on oncologic efficacy, complication rates, and procedure duration for 151 consecutive biopsy-proven clinical T1a renal cell carcinoma (RCC) treated with percutaneous microwave (MW) ablation. This single-center retrospective study was performed under a waiver of informed consent. One hundred forty-eight consecutive patients (103 M/45 F; median age 67 years, IQR 61–73) with 151 cT1a biopsy-proven RCC (median diameter 2.4 cm, IQR 1.9–3.0) were treated with percutaneous MW ablation between March 2011 and August 2017. Patient and procedural data collected included Charlson comorbidity index (CCI), RENAL nephrometry score (NS), use of hydrodisplacement, MW antennas/generator output/time, and procedure time (PT). Data were stratified by anterior, posterior, and midline tumor location and compared with the Kruskal–Wallis or chi-squared tests. The Kaplan–Meier method was used for survival analyses. Tumor size, NS, and use/volume of hydrodisplacement were similar for posterior and anterior tumors (p > 0.05). Patients with anterior tumors had a higher CCI (3 vs 4, p = 0.001). Median PT for posterior and anterior tumors was similar (100 vs 108 min, p = 0.26). Single session technical success and primary efficacy were achieved for all 151 tumors including 61 posterior and 67 anterior tumors. The 4 (3%) Clavien III–IV complications and 6 (4%) local recurrences were not associated with tumor location (p > 0.05). Three-year RFS, CSS, and OS were 95% (95% CI 0.87, 0.98), 100% (95% CI 1.0, 1.0), and 96% (95% CI 0.89, 0.98), respectively. The safety and efficacy of percutaneous microwave ablation for anterior and posterior RCC are similar. • The safety profile for percutaneous microwave ablation of anterior and posterior T1a renal cell carcinoma is equivalent. • Percutaneous microwave ablation of T1a renal cell carcinoma provides durable oncologic control regardless of tumor location. • Placement of additional microwave antennas and use of hydrodisplacement are associated with longer procedure times.

To investigate impact of age and race on health-related quality of life (HRQoL) in men undergoing radical prostatectomy (RP) using a prospectively maintained, racially diverse cohort.The Center for Prostate Disease Research Multicenter National Database was used to identify patients receiving RP from 2007-2017. The Expanded PCa Index Composite and 36 Item Short-Form Health Survey were completed at baseline and regular intervals. Groups were stratified based on age:60, 60-70,70. Longitudinal patterns in HRQoL were assessed using linear regression models, adjusting for baseline HRQoL, demographics, and clinical characteristics.In 626 patients undergoing RP, 278 (44.4%) were60, 291 (46.5%) were 60-70, 57 (9.1%) were70. Older men had worse baseline urinary bother (P.01) and sexual HRQoL (P.01). Baseline urinary function was similar for older and younger men. Post-RP urinary and sexual HRQoL was significantly lower in men70. However, when adjusting for baseline HRQoL, race, NCCN risk, and comorbidities, no difference was found between age groups in urinary function or bother, or sexual function. Sexual bother was worse in older men until 48 months post-operatively but subsequently improved to levels similar to younger patients. Race independently affected HRQoL outcomes with older African American men reporting worse urinary function and sexual bother.When accounting for baseline HRQoL, age does not independently predict worse HRQoL outcomes. Older and younger men experience similar declines in urinary and sexual domain scores after RP. Our findings may be used to better inform patients regarding their expected post RP HRQoL and guide treatment decision-making.

Stone size guides treatment decisions, yet there is no standard method for measuring stone size. Prior work has shown significant variability in manual stone measurements. We tested a novel stone software program designed to provide an automated and objective comprehensive CT-based stone profile.Urinary stones identified on CT imaging were manually measured to obtain linear size and maximal stone density (in Hounsfield unit [HU]). Manual stone volume was calculated using the formula 0.52 × length × width × height. The same stones were assessed with computer software capable of automatically providing stone length, density, and volume. Computer measurements were compared with manual measurements.Eighty-five stones were identified on 42 CT scans from 17 patients. Manual measurements showed an average length of 8 mm (range 1.9-21 mm), average maximal density of 686 HU (126-1492 HU), and average stone volume of 192 mmAutomated stone measurements can be accomplished quickly and precisely with dedicated software that can assess stones of varying size as well as stones with complex geometry. This software eliminates interobserver variability and offers a comprehensive stone profile with which to make clinical decisions.

INTRODUCTION AND OBJECTIVES:Osteocalcin (OC) has been shown to regulate testosterone (T) production in mice and may offer a promising target for treatment of hypogonadal men. Yet, the relationship ...

The purpose of this study was to evaluate patient, tumor and technical factors associated with procedural complications and nondiagnostic findings following percutaneous core renal mass biopsy.We reviewed core renal mass biopsies from 2000 to 2017. Complications at 30 days or less were graded using the Clavien-Dindo system. Univariate and multivariable analyses were done to evaluate associations between clinical characteristics and the risk of complications or nondiagnostic findings.Of the 1,155 biopsies performed in a total of 965 patients procedural complications were identified in 24 patients (2.2%), including 5 (0.4%) with major complications (Clavien 3a or greater). No patients were identified with tumor seeding of the biopsy tract. Patient age, body mass index, gender, Charlson comorbidity index, smoking, mass diameter, nephrometry score, number of cores and prior biopsy were not associated with complication risk (p = 0.06 to 0.53). Complications were not increased for patients on aspirin or those with low platelets (25,000 to 160,000/μl blood) or a mildly elevated INR (international normalized ratio) (1.2 to 2.0, p = 0.16, 0.07 and 0.50, respectively). The complication risk was not increased during the initial 50 cases of a radiologist or when a trainee was present (p = 0.35 and 0.12, respectively). Nondiagnostic findings were present in 14.6% of biopsies. Independent predictors included cystic features, contrast enhancement, mass diameter and skin-to-mass distance (p0.001, 0.002, 0.02 and 0.049, respectively). Radiologist experience was not associated with the nondiagnostic rate (p = 0.23). Prior nondiagnostic biopsy was not associated with an increased nondiagnostic rate on subsequent attempts (19.2% vs 14.2%, p = 0.23).Procedural complications following biopsy are rare even with low serum platelets, a mildly elevated INR or when the patient remains on aspirin. Cystic features, hypo-enhancement on imaging, a smaller mass diameter and a longer skin-to-tumor distance increase the risk of nondiagnostic findings.

e16530 Background: National Comprehensive Cancer Network (NCCN) guidelines state partial cystectomy (PC) may be offered in select patients with clinical T2 (cT2) muscle invasive bladder cancer (MIBC) utilizing neoadjuvant chemotherapy (NAC) and pelvic lymphadenectomy (PLND). Our objective was to investigate utilization and survival outcomes of PC in a large contemporary cohort. Methods: Propensity matching was used to compare pathological and surgical outcomes in non-metastatic MIBC patients in the National Cancer Database undergoing PC or radical cystectomy (RC). Multivariate logistic regression was used to determine predictors of NAC, LND, peri-operative morbidity and mortality outcomes. This analysis was repeated in the subset with cT2 MIBC. Results: Of 31,306 T2-T4N0M0 patients, 1543 (4.9%) underwent PC. PC use was higher in older patients and most often (85%) performed for cT2 disease. The PC group was less likely to receive standard of care including NAC (11.4 vs 27.9%, p

4536 Background: Current guidelines recommend neoadjuvant chemotherapy (NAC) prior to radical cystectomy (RC) for muscle invasive bladder cancer (MIBC). NAC has been shown to confer a survival benefit across all ages. Yet, many elderly patients are not offered NAC due to concern regarding physiologic reserve and postoperative complications. Our objective was to evaluate age-based disparity in treatment and outcomes of MIBC. Methods: Using the National Cancer Database, we identified patients with MIBC from 2006-2017. First, use of different treatments, RC, RC and adjuvant chemotherapy, RC with NAC (“optimal treatment”), chemo-radiation, and no treatment, was compared between age groups. A second analysis was performed in the cohort of elderly patients, ≥70, undergoing cystectomy. Propensity weighting was used to compare peri-operative and mortality outcomes in those who received NAC vs. no NAC. Results: In 70,911 patients with non-metastatic MIBC, use of RC with NAC was lower in patients ≥70, 7.2 vs. 20.9%, p

BACKGROUND: Statins are thought to possess antineoplastic properties related to their effect on cell proliferation and steroidogenesis. Progression to castrate resistant prostate cancer (CaP) includes de-regulation of androgen synthesis suggesting a role for statins in this setting. Our goal was to assess the role of statin use on oncologic outcomes in patients with advanced CaP being treated with androgen deprivation therapy (ADT). METHODS: The national VA database was used to identify all men diagnosed with CaP who were treated with ADT for at least 6 months between 2000 and 2008 with follow-up through May 2016. Our cohort was stratified based on statin use of at least 6 months duration during the same time. Multivariable Cox proportional hazards analyses with inverse propensity score weighted (IPSW) adjustment were calculated to assess for primary outcomes of CaP-specific survival (CSS), overall survival (OS) and skeletal related events (SREs). RESULTS: A total of 87,346 patients on ADT were included in the study cohort, 53,360 patients used statins and 33,986 did not. Statin users were younger in age (median 73 vs. 76, P < 0.001), more likely to have a higher Charlson comorbidity index (CCI) >3 (3.1% vs. 2.5%, P < 0.001) and more likely to have a high grade (Gleason score 8–10) cancer (12.3% vs. 10.9%, P < 0.001). Statin users had longer OS (median 6.5 vs. 4.0 years P < 0.001) and decreased death from CaP (5-year CSS 94.0% vs. 87.3%, P < 0.001). Statin use was also associated with longer time to a SRE (median 5.9 vs. 3.7 years, P < 0.001). On multivariable Cox proportional hazards analysis with inverse propensity score weighted, statin use was an independent predictor of improved OS (hazard ratio [HR] 0.66, confidence interval [CI] 0.63–0.68; P < 0.001), CSS (HR 0.56, 95% CI 0.53–0.60; P < 0.001), and SREs (HR 0.64, 95%CI 0.59–0.71; P < 0.001) when controlling for age, race, Charlson comorbidity index, prostate-specific antigen, and Gleason score. CONCLUSION: The use of statins in men on ADT for CaP is associated with improved CSS and OS. Statins are inexpensive, well-tolerated medications that offer a promising adjunct to ADT, but require further prospective studies.

PURPOSE: To describe and validate a novel CT approach using volumetric analysis for renal stone surveillance. MATERIALS AND METHODS: This prospective trial consisted of a standard low-dose non-contrast CT (SLD) of the abdomen and pelvis, immediately followed by an ultra-low-dose non-contrast CT (ULD) with reconstruction limited to the kidneys. A novel dedicated software tool was applied that automates stone volume, density, and maximum linear size. Manual linear stone size was measured by a radiology fellow and urology resident for comparison. CT dose and clinical charges were considered. RESULTS: 28 stones in 16 patients were analyzed. Mean effective dose of ULD CT was 0.57 mSv, an average 92% lower than the SLD CT dose. For SLD, mean size ± SD (range) (mm) was 7.9 ± 6.2 (2.6–30.5) for Reader 1, 7.3 ± 6 (2.4–30.7) for Reader 2, and 9.3 ± 6.4 (3.7–33.1) for the automated software. For ULD, mean size ± SD (range) (mm) was 7.3 ± 6 (2.5–30.5) for Reader 1, 7.2 ± 6.1 (2.1–30.7) for Reader 2, and 9.1 ± 6.4 (4.2–32.8) for the automated software. Automated stone diameters were larger than manual diameters for 27/28 stones (mean difference, 23%); difference was ≥2mm in 30%. Average variability between manual measurements was 8.6% (SLD) and 7.8% (ULD), but was 0% for the automated technique. Our institutional charge for ULD renal CT is slightly less than renal US, and >4x less than SLD CT. The Medicare global fee for the ULD renal CT is less than the SLD CT of the abdomen and pelvis. CONCLUSIONS: This focused stone surveillance CT protocol is lower cost and lower dose compared to the standard CT approach. Automated assessment of stone burden provides improved reproducibility over manual linear measurement and offers the advantages of 3D measurements and volumetry. We now offer and perform this protocol in routine clinical practice for stone surveillance.

The absence of a standardized classification scheme for ventral hernias hinders comparisons within the literature, indirectly delaying meaningful discussions regarding technique. We aimed to generate a comprehensive staging system that stratifies patients by risk of developing wound morbidity and hernia recurrence. Our prospective database of all ventral hernia repairs (2006–2013) was reviewed with no exclusion based on technique or prosthetic. The presence of patient comorbidities, contamination and hernia dimensions—width/location on computed topography—was evaluated to identify variables most closely associated with surgical site occurrence (SSO) and recurrence. Predicted odds ratios and relative hazards, for SSO and recurrence, respectively, were used to partition patients into stages corresponding with increasing levels of risk. Hernia width (OR 2.24, HR 1.73) and the presence of contamination (OR 1.81, HR 2.04) were most significantly associated with increased risk of SSO and recurrence, while hernia location and the presence of comorbidities were not. Stage I hernias are

The aim of this study was to reveal the effect of fibroblast or mesenchymal stem cell (MSC) coating on the mesh-induced production of IL-1β, IL-6, and VEGF by macrophages. Four commonly used surgical meshes were tested in this study, including Parietex, SoftMesh, TIGR, and Strattice. One-square-centimeter pieces of each mesh were placed on top of a monolayer of human fibroblasts or rat MSCs. The coating status was monitored with a light microscope. The human promonocytic cell line U937 was induced to differentiate into macrophages (MΦ). Three weeks later, meshes were transferred to new 24-well plates and cocultured with the MΦs for 72 h. Culture medium was collected and analyzed for IL-1β, IL-6, and VEGF production using standard ELISA essays. Parallel mesh samples were fixed with paraformaldehyde or glutaraldehyde for histology or transmission electronic microscopy (TEM) analyses, respectively. Uncoated meshes induced increased production of all three cytokines compared with macrophages cultured alone. HF coating further increased the production of both IL-6 and VEGF but reduced IL-1β production. Except for the SoftMesh group, MSC coating significantly blunted release of all cytokines to levels even lower than with MΦs cultured alone. MΦs tended to deteriorate in the presence of MSCs. Both histology and TEM revealed intimate interactions between cell-coated meshes and MΦs. Cytokine response to fibroblast coating varied, while MSC coating blunted the immunogenic effect of both synthetic and biologic meshes in vitro. Cell coating appears to affect mesh biocompatibility and may become a key process in mesh evolution.

Urologists perform the majority of vasectomies in the United States; however, family medicine physicians (FMPs) perform up to 35%. We hypothesized that differences exist in practice patterns and outcomes between urologists and FMPs. Patients who underwent a vasectomy from 2010 to 2016 were identified. Postvasectomy semen analysis (PVSA) practices were compared between urologists and FMPs, before and after release of the 2012 AUA vasectomy guidelines. From 2010 to 2016, FMPs performed 1435 (35.1%) of all vasectomies. PVSA follow-up rates were similar between the two groups (63.4% vs 64.8%, P = 0.18). Of the patients with follow-up, the median number of PVSAs obtained was 1 (range 1–6) in both groups (P = 0.22). Following the release of guidelines, fewer urologists obtained multiple PVSAs (69.8% vs 28.9% pre- and post-2012, P < 0.01). FMPs had a significant but lesser change in the use of multiple PVSAs (47.5% vs 38.4%, P < 0.01). Both groups made appropriate changes in the timing of the first PVSA, but FMPs continued to obtain PVSAs before 8 weeks (15.0% vs 6.5%, P < 0.01). FMPs had a higher rate of positive results in PVSAs obtained after 8 weeks, the earliest recommended by the AUA guidelines (4.1% vs 1.3%, P < 0.01). Significant differences in PVSA utilization between FMPs and urologists were identified and were impacted by the release of AUA guidelines in 2012. In summary, FMPs obtained multiple PVSAs more frequently and continued to obtain PVSAs prior to the 8-week recommendation, suggesting less penetration of AUA guidelines to nonurology specialties. Furthermore, FMPs had more positive results on PVSAs obtained within the recommended window.

Retrorectus repairs (RR) of abdominal wall hernias are growing in popularity, yet wound morbidity and predictors in this context have been characterized poorly. Models aimed at predicting wound morbidity typically do not control for technique and/or location of mesh. Our aim was to describe wound morbidity and risk factors specifically in the context of RR hernia repair. Our hypothesis was that the incidence of wound morbidity with mesh sublay would be less than predicted by a model that does not control for mesh position.Consecutive RR hernia repairs with at least a 90-day follow-up were identified in our prospective database and analyzed. The primary outcome measures were the incidence of surgical-site occurrence (SSO) and surgical-site infection (SSI) via modern, standardized definitions. For predictors of SSO, statistical analysis was performed with univariate analysis, χ(2), and logistic regression as well as multivariate regression.A total of 306 patients met the inclusion criteria. Eighty-four SSOs identified in 72 (23.5%) patients included 48 (15.7%) SSIs, 14 (4.6%) instances of wound cellulitis, 12 (3.9%) skin dehiscences, 6 (2.0%) seromas, and 4 (1.3%) hematomas but no instances of mesh excision or fistula formation. Treatment entailed antibiotics alone in 30 patients, 14 bedside drainage procedures, 9 radiographically assisted drainage procedures, and 10 returns to the operating room for debridement. After multivariate analysis, diabetes (OR 2.41), hernia width20 cm (OR 2.49), and use of biologic mesh (OR 2.93) were statistically associated with the development of a SSO (P.05). Notably, the mere presence of contamination was not independently associated with wound morbidity (OR 1.83, P = .11). SSO and SSI rates anticipated by a recent risk prediction model were 50-80% and 17-83%, respectively, compared with our actual rates of 20-46% and 7-32%.Based on a large cohort of patients, we identified factors contributing to SSOs specifically for RR hernia repairs. Paradoxically, biologic mesh was an independent predictor of wound morbidity. The development of clinically important mesh complications and rates of wound morbidity less than anticipated by recent predictive models suggest that the retromuscular (sublay) mesh position may be more advantageous.