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OBJECTIVES To determine the 3-year outcomes of men with prostate cancer managed with active surveillance (AS) in a cohort of geographically diverse community-based urology practices. AS is the management of choice for a majority of men with lower risk prostate cancer.1,2,3 Little is known about the contemporary "real-world" follow-up and adherence rates in the most common setting of urologic care, community (private) practice.4 METHODS: We retrospectively evaluated outcomes for men diagnosed between January 1, 2013 and May 31, 2014 with National Comprehensive Cancer Network (NCCN) very low, low and intermediate risk prostate cancer who selected AS in 9 large community urology practices. We used univariate and multivariate analyses to describe associations between race, age, insurance status, family history, comorbidity, clinical stage, Gleason score, NCCN risk-group, and PSA density with discontinuation of AS. RESULTS Five hundred and forty-eight men on AS were followed for a median of 3.35 years. 89% (492) continued to follow-up with diagnosing practice. 32% (171) discontinued AS. On multivariate analysis, increasing NCCN risk classification (Hazard ratio [HR] 1.65, P = 0.02 and HR 2.09, P < 0.01 for low and intermediate risk vs very low risk) was significantly associated with discontinuation. Among those who discontinued AS, surgery and radiation were utilized equally (47% and 53%, respectively, P = 0.48). CONCLUSION In this community-based cohort of men on AS, a minority was lost to follow-up and adherence to AS was similar to other reports. Disease characteristics more than sociodemographic characteristics correlated with adherence to AS, while surgery and radiotherapy were utilized equally among those discontinuing AS, both suggesting guideline concordant practice of medicine.

Objective To characterize the contemporary management of prostate cancer patients in large community practices. The optimal management of incident prostate cancer has changed in the last decades to include active surveillance for a large number of men. At the same time, many community practices have merged into larger groups. The adoption of evidence-based guidelines is of increasing importance, but poorly understood in this newer practice setting. Methods We conducted a retrospective chart review of men ≤75 years old with very low, low, and intermediate risk incident prostate cancer diagnosed between December 1, 2012 and March 31, 2014, in 9 geographically distributed large urology practices. We used descriptive statistics and multivariable regression to assess predictors of primary management choice. Results 2029 men were in the study cohort. A majority were white (68.7%). Total of 45.7% had intermediate risk, 36.2% low risk, and 17.9% had very low risk disease cancer. Active surveillance (AS) was the initial treatment for 74.7% of men with very low risk disease, 43.5% of men with low risk disease and 10.8% of men with intermediate risk disease. The probability of choosing surgery vs radiation for men with lower and intermediate risk disease was 0.54 (95% confidence interval: 0.42, 0.65) and 0.59 (95% confidence interval: 0.48, 0.69), respectively. Conclusion We found that the initial management of lower risk prostate cancer in large community urology practices largely followed clinical characteristics, widespread adoption of active surveillance, and equal use of surgery and radiation. However, some variation by practice suggested a need for further investigation and continued improvement.

INTRODUCTION AND OBJECTIVE:Active surveillance (AS) is guideline recommended for low risk and some intermediate risk prostate cancer. We previously reported on the use and adherence to AS, but litt...

Despite its established efficacy in reducing recurrence rates for patients with urothelial carcinoma, immediate intravesical chemotherapy is reportedly used infrequently. Accordingly, the Urological Surgery Quality Collaborative implemented a project aimed at understanding and improving the use of immediate intravesical chemotherapy.Surgeons in 5 Urological Surgery Quality Collaborative practices prospectively collected clinical and baseline intravesical chemotherapy use data for patients undergoing bladder biopsy or transurethral bladder tumor resection from September 2010 through January 2012. In the second phase of data collection (June 2011 through January 2012) treating surgeons also documented reasons for not administering intravesical chemotherapy. We defined patients with 1 to 2 clinical stage Ta/T1, completely resected, papillary tumor(s) as ideal candidates for treatment with immediate intravesical chemotherapy. For ideal and nonideal patients we examined baseline use of intravesical chemotherapy across Urological Surgery Quality Collaborative practices as well as reasons for not administering therapy among ideal patients.Among 1,931 patients 37.2% met criteria as ideal cases for intravesical chemotherapy administration. We observed significant variation in the use of intravesical chemotherapy across Urological Surgery Quality Collaborative practices for ideal (range 27% to 50%) and nonideal cases (9% to 24%) (p0.001). Reasons for not treating ideal candidates included lack of confirmation of malignancy (4, 2.8%), uncertainty regarding the benefits of intravesical chemotherapy (28, 19.6%) and logistic factors such as the unavailability of medication (34, 23.8%).Use of immediate intravesical chemotherapy by Urological Surgery Quality Collaborative practices is higher than reported elsewhere but still varies widely, even among ideal candidates. Efforts to optimize use will be aided by disseminating evidence supporting indications and benefits of intravesical chemotherapy, and by addressing local logistic factors that limit access to this evidence-based therapy.

We describe findings from a Urological Surgery Quality Collaborative project focused on improving the use of radiographic staging in men with newly diagnosed prostate cancer.From May 2009 through September 2010 Urological Surgery Quality Collaborative surgeons collected uniform data for men with newly diagnosed prostate cancer. During this period we implemented 3 phases of data collection. Unlike the baseline phase, the second and third rounds were preceded by collaborative quality improvement interventions, including comparative performance feedback, and review and dissemination of clinical guidelines. We evaluated the use of bone scans and computerized tomography across prostate cancer risk strata, Urological Surgery Quality Collaborative practice locations, and before and after quality improvement interventions.We collected data for 858 men with prostate cancer. Based on the D'Amico classification 44%, 39% and 17% of the men had low, intermediate and high risk cancer, respectively. Overall 25% and 22% of patients underwent staging with a bone scan or computerized tomography, respectively, ordered by a Urological Surgery Quality Collaborative urologist. Urological Surgery Quality Collaborative practices differed significantly in their baseline use of bone scans and computerized tomography for men with low and intermediate risk cancer (p0.01). Compared with baseline practice patterns (31% bone scans, 28% computerized tomography), urologists in Urological Surgery Quality Collaborative practices ordered fewer bone and computerized tomography scans in post-intervention phases 2 (23%, 21%) and 3 (16%, 13%) of data collection (p0.01), including a significant reduction in the use of these studies in patients with low and intermediate risk cancer (p0.05).Following collaborative feedback on baseline use and review of clinical guidelines, urologists in Urological Surgery Quality Collaborative practices dramatically reduced variations in practice patterns and improved adherence with recommended staging practices.

To evaluate retrospectively the efficacy and durability of a novel approach using ureteroscopic laser papillotomy for the treatment of painful papillary calcifications. Chronic pain due to renal papillary calcifications has not been addressed by current techniques.Ureteroscopic holmium laser lithotripsy and papillotomy were performed on patients with chronic pain and radiographically visible papillary calcifications without free collecting system calculi. The papillary urothelium overlying all cystic dilations and intraductal calcifications was vaporized. Treated patients answered a telephone survey to assess pain scores, duration of response, use of narcotics, and patient satisfaction. We reviewed the medical records to evaluate for procedure-related complications and serum creatinine measurements.Of 20 patients who underwent laser papillotomy and responded to the telephone survey, 7 had bilateral procedures, yielding 27 renal units available for analysis. "Much less pain" was reported after 85% of the procedures, with a durable improvement reported after 59% of the procedures, at a median follow-up of 14.5 months. Significant improvements in the median pain scores were seen at 1 month (1.0, P0.001), 6 months (2.0, P0.001), and 1 year (1.5, P0.001) compared with a median preoperative pain score of 9.0. The mean serum creatinine was unchanged after the procedure.Ureteroscopic laser papillotomy appears to be an effective treatment option for the chronic pain associated with papillary calcifications. Laser papillotomy offers hope to patients who would otherwise have been denied an attempt at treatment because of a lack of free calculi within the collecting system.

We report on endoscopic treatment outcomes for upper tract urothelial carcinoma and identify predictive factors for success.A total of 61 renal units were referred for endoscopic treatment of an upper tract tumor, 69% of which did not have a traditional indication for nephron sparing approaches. Tumor pathology and operative findings were assessed retrospectively for treatment outcomes and influential factors.Initial ureteroscopic inspection was undertaken in 53 renal units with resection attempted in 18 (34%) resulting in an 89% success rate with 16 treated. A percutaneous approach in 19 renal units (11 after ureteroscopy) was 100% successful in achieving tumor-free status, for a total of 35 renal units successfully treated endoscopically. Surveillance then began on 27 renal units with a recurrence rate of 88% and mean time to recurrence of 5.8 months (range 2 to 20). Of patients undergoing surveillance (31% of whom had high grade disease), 54% remain or have died of unrelated disease, during a mean followup of 21.0 months (range 3 to 48). Higher tumor grade, larger size, renal pelvis location (all p0.01) and multifocality (p = 0.05) significantly correlated with decreased recurrence-free survival, but did not predict failure of local control by endoscopic surveillance.Although endoscopic techniques can render most patients tumor-free, there is a high associated recurrence rate and many need repeat procedures. Recurrence-free survival is greater in patients with low grade, solitary or less bulky disease. However, rigorous surveillance after endoscopic resection can lead to success even in patients with high grade, multifocal or large volume disease, resulting in preservation of renal units.

IVF remains one of the most exciting modern scientific developments and continues to have a tremendous impact on people's lives. Since its beginnings, scientists have studied and critically analysed the techniques in order to find ways to improve outcomes; however, little has changed with the actual technology and equipment of IVF. Semen is still processed in test tubes and fertilization and culture still occurs in culture dishes. New technological possibilities exist with the burgeoning advancement of microfluidic technology. Microfluidics is based on the behaviour of liquids in a microenvironment. Although a young field, many developments have occurred which demonstrate the potential of this technology for IVF. In this review, we briefly discuss the physical principles of microfluidics and highlight some previous utilizations of this technology, ranging from chemical analysis to cell sorting. We then present the designs and outcomes for microfluidic devices utilized thus far for each step in IVF: gamete isolation and processing, fertilization, and embryo culture. Finally, we discuss and speculate on the ultimate goal of this technology--development of a single, integrated unit for in-vitro assisted reproduction techniques.

Perioperative instillation of intravesical chemotherapy after bladder tumor resection is supported by level I evidence showing a 30% decrease in tumor recurrence. However, studies of administrative data sets show poor use in practice.We prospectively evaluated the use of perioperative intravesical chemotherapy in a multipractice quality improvement collaborative. Cases were categorized as ideal for intravesical chemotherapy (1 or 2 papillary tumors, cTa/cT1 and completely resected) and nonideal. The reasons for not administering intravesical chemotherapy in ideal cases were classified as appropriate or modifiable. Before and after comparative feedback and educational interventions we calculated judicious use of intravesical chemotherapy (nonuse in nonideal cases plus use in ideal cases plus appropriate nonuse in ideal cases) and quality improvement potential (use in nonideal cases plus nonuse in ideal cases attributable to modifiable factors).We accrued a total of 2,794 cases at the 5 sites in 22 months. The rate of use in ideal cases was 38% before and 34.8% after intervention (p=0.36), while use in nonideal cases decreased from 15% to 12% (p=0.08). Overall, intravesical chemotherapy was used judiciously in 83.0% to 85.7% of cases, while the remaining 14.3% to 17.0% represented quality improvement potential.Judicious use of perioperative intravesical chemotherapy is relatively high in routine practice. Most instances of nonuse represent appropriate clinical judgment. Utilization did not change after quality improvement interventions, suggesting that there may a ceiling effect that makes it difficult to improve care that is high quality at baseline. Moreover, decreasing unnecessary use of an intervention may be easier than encouraging appropriate use of potentially toxic therapy.

The purpose of this study was to determine the discrepancy rate between the preliminary interpretation of abdominal radiographs by emergency physicians compared to the final report rendered by gastrointestinal radiologists, and to assess the impact of such discrepancies on patient management. A retrospective analysis was performed on a sample of abdominal plain radiographs obtained in the emergency department of a private urban teaching hospital. Written preliminary interpretations by the emergency physician were compared to the final dictated reports of the gastrointestinal radiologist. An emergency physician determined whether availability of the final interpretation would have changed patient management. There were 387 abdominal plain film studies that satisfied the criteria for inclusion. Of these, 98 discordant interpretations were noted (an interpretive discrepancy rate of 25.3%). In 16 of the 98 cases (16%), the interpretive discrepancy was deemed to have resulted in a difference in patient management, i.e., a management-relevant discrepancy rate of 4.1% of the total study population. This analysis shows a higher interpretive discrepancy rate for emergency department interpretation of abdominal radiographs than has been reported with emergency department interpretations of other types of radiographs. The most common clinically relevant interpretive discrepancies were misinterpretation of intestinal obstruction and unrecognized urinary tract calculi.

We describe the establishment of the Urological Surgery Quality Collaborative including our pilot project to improve radiographic staging for men with prostate cancer.The Urological Surgery Quality Collaborative comprises more than 60 urologists from 3 group practices. From May through September 2009 Urological Surgery Quality Collaborative surgeons collected a uniform set of data (eg prostate specific antigen, clinical stage) for men with newly diagnosed prostate cancer. After categorizing the cancer of each patient as low, intermediate or high risk, we analyzed baseline use of staging studies across prostate cancer risk strata and Urological Surgery Quality Collaborative practice locations.Of 215 men with prostate cancer 34%, 42% and 24% had low, intermediate and high risk cancer, respectively. Overall 44% and 43% of patients underwent staging with a bone scan or computerized tomography, respectively, and only 9% and 7% of these studies, respectively, were positive for metastases. Use of staging studies increased across risk strata as bone scans or computerized tomography were performed in 17% and 18%, 41% and 40%, and 88% and 86% of patients, respectively, with low, intermediate and high risk tumors (p0.01). For men with low risk prostate cancer the use of bone scans and computerized tomography differed significantly across Urological Surgery Quality Collaborative practices (p0.01) and for this group only 1 bone scan (and no computerized tomography) was positive for metastases.Use of staging evaluations varies by prostate cancer risk strata and across Urological Surgery Quality Collaborative practices. By feeding these data back to surgeons we may be able to improve practice patterns and avoid unnecessary studies in low risk patients. Attainment of this goal would establish the Urological Surgery Quality Collaborative as a viable infrastructure for collaborative quality improvement in urology.