Search

Objective To assess the association between Genomic Classifier (GC)‐risk group and post‐radical prostatectomy treatment in clinical practice. Methods Two prospective observational cohorts of men with prostate cancer (PCa) who underwent RP in two referral centers and had GC testing post‐prostatectomy between 2013 and 2018 were included. The primary endpoint of the study was to assess the association between GC‐risk group and time to secondary therapy. Univariable (UVA) and multivariable (MVA) Cox proportional hazards models were constructed to assess the association between GC‐risk group and time to receipt of secondary therapy after RP, where secondary therapy is defined as receiving either RT or ADT after RP. Results A total of 398 patients are included in the analysis. Patients with high‐GC risk were more likely to receive any secondary therapy (OR: 6.84) compared to patients with low/intermediate‐GC risk. The proportion of high‐GC risk patients receiving RT at 2 years post‐RP was 31.5%, compared to only 6.3% among the low/intermediate‐GC risk patients. Conclusion This study demonstrates that physicians in routine practice used GC to identify high risk patients who might benefit the most from secondary treatment. As such, GC score was independent predictor of receipt of secondary treatment.

To externally validate a Genomic Classifier (GC) based risk-stratification nomogram identifying candidates who would benefit from adjuvant radiation (aRT) therapy after radical prostatectomy (RP). We identified 350 patients who underwent RP, between 2013 and 2018, and had adverse pathological features (positive margin, and/or pT3a or higher) on final pathology. Genomic profile was available for all these men. The clinical recurrence-free survival was estimated using the Kaplan–Meier method. The external validity of the nomogram was tested using the concordance index (c-index), calibration plot, and decision curve analysis. The median follow-up of the cohort was 26.5 months. Overall, 14% of the patients received aRT. During the follow-up period, 3.4% of the patients developed metastasis. Overall 3-year metastasis-free survival was 95% (95% CI 0.92–0.98). The c-index of the nomogram was 0.84. The calibration of the model was favorable. Decision-curve analysis showed a positive net benefit for probabilities ranging between 0.01 and 0.09, with the highest difference at threshold probability around 0.05. At that threshold, the net benefit is 0.06 for the model and 0 for treating all the patients. Our report is the first to confirm the validity of this genomic-based risk-stratification tool in identifying men who might benefit from aRT after RP. As such, it can be a useful instrument to be incorporated in shared decision making on whether administration of aRT will lead to a clinically meaningful benefit. Such a model can also be useful for patients’ classification in future clinical trials.

We sought to review the appropriate patient selection criteria, available clinical literature, technical modifications, and future directions associated with the use of robotic technology to perform salvage robotic-assisted radical prostatectomy (SRARP). Recent studies have investigated the emerging role of SRARP following primary focal therapies, imaging technologies for preoperative staging and risk assessment, and novel bioengineering and technical modifications to improve postoperative functional outcomes. SRARP represents a potentially curative but underutilized treatment for men who develop localized recurrence of prostate cancer (PCa) following primary radiotherapy treatment or primary focal therapy. While SRARP may be associated with potentially significant complications including rectal injury, erectile dysfunction, and stress urinary incontinence, several centers have published their experience with the procedure and several technical modifications to the standard RALP have been utilized to reduce the risk of these potential treatment side effects. Further standardization of pathology reporting, novel technological and imaging advances, and multi-institutional collaboration will be necessary to improve future SRARP outcomes.

Objective To explore the incidence of and potential risk factors for acute urine retention (AUR) after robot-assisted radical prostatectomy (RARP) and its effect on early urine continence. Methods A retrospective analysis of patients who underwent RARP by a single surgeon between July 2016 and June 2017 was performed to assess the incidence of AUR and its effect on early continence. Continence was assessed through self-reported questionnaires completed approximately three months after surgery. Early urine continence was defined as using zero pads per day at the time of the three-month follow-up. Descriptive statistics and logistic regression analysis were used to assess independent predictor of AUR. Results Of 379 patients, 19 (5%) developed AUR after RARP. No significant difference in baseline characteristics between those who developed AUR post-RARP and those who did not. There was no statistically significant difference in the reported early continence and number of pads used per day between patients with AUR and patients without AUR (31.6% vs. 23.1%, P = 0.39), (1.6 vs. 1.4, P = 0.913), respectively. Conclusion AUR post-RARP is an infrequent postoperative complication with no impact on early continence rate. No patient-related factors were associated with the development of AUR.

Purpose: Several case series have demonstrated the safety and feasibility of outpatient robot-assisted radical prostatectomy (RARP) in well-selected patients; however, the patient perspective of th...

Robot-assisted radical prostatectomy (RARP) can generally be performed with 1–2 nights of postoperative monitoring before discharge from the hospital. Little is known about what causes individual patients to remain in hospital beyond the second postoperative day. Data for RARPs performed between 2013 and 2015 were extracted from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. The fraction of cases with prolonged length of stay (PLOS) that can be reasonably attributed to complications was examined. Logistic regression was performed to identify risk factors for PLOS in the overall population and separately in the population of patients with PLOS without any perioperative complications. Of 11,440 patients, 10,342 (90.4%) were discharged on postoperative days 0–2; 80.6% (887/1101) of patients with PLOS did not experience any perioperative complications. The most common complication was bleeding requiring transfusion, but this was present in only 5.6% (62/1101) of patients with PLOS. Logistic regression identified predictors of PLOS as age, race, wound class, American Society of Anesthesiologists class, smoking, diabetes, dyspnea, dependent functional health status, congestive heart failure, operative time, and pelvic lymph node dissection. Results of this regression were insensitive to the exclusion of patients who experienced no perioperative complications. This study utilizes logistic regression on NSQIP data to identify risk factors for PLOS after RARP and, in particular, to evaluate the role of postoperative complications in PLOS. The analysis shows that postoperative complications account for a small minority of cases of PLOS after RARP.

Multiple genomic tests are available following radical prostatectomy (RP), however, there is a lack of head-to-head evidence for these tests. We sought to compare the performance of two genomic tests in predicting post-RP oncological outcomes. A cohort of 16 post-RP patients with adverse pathological features who had obtained both Decipher (D) and Prolaris (P) testing. The Pearson correlation was used to compare scores from D and cell cycle progression (CCP) from P. Then, we derived a microarray CCP (mCCP) from D and correlated with P-CCP. The associations of D and mCCP with biochemical recurrence (BCR) and metastasis (M) was evaluated in multivariable survival analysis (MVA) in a large cohort of RP patients treated at Johns Hopkins University (1992–2010). In addition, we characterized the expression of the 31 P-CCP genes and mCCP scores in a cohort of 17,967 RP samples from Decipher platform. There was significant correlation between the D score and P-CCP (r = 0.67, p = 0.004), and between the 10-year probability of BCR reported by P and 5-year probability of M reported by D (r = 0.69, p = 0.003). In this cohort, mCCP derived from the D platform was highly correlated to the reported P-CCP scores from the P platform (r = 0.88, p = 6.7e−6). In a comparative retrospective RP cohort, both mCCP and D were significantly associated with M outcome (p

Introduction:This study analyzed longitudinal growth trends, intra-resident variability and adult case volume performed at the completion of urology residency training.Methods:National case...

Background and Aims The novel use of peroral endoscopic myotomy (POEM) in the treatment of Zenker’s diverticulum (ZD) was recently described in case reports. The aim of this study is to report a multicenter experience with the POEM technique in the management of ZD. Methods This is a multicenter international retrospective study involving 10 centers. The Zenker’s POEM technique was performed using principles of submucosal endoscopy. Results Seventy-five patients (73.3 ± 1.2 years, 33 women) were included with a mean Charleson comorbidity index of 4 ± .2. The mean size of ZD was 31.3 ± 1.6 mm (range, 10-89). The overall technical success rate was 97.3% (73/75). There were 2 technical failures because of the inability to locate the septum and failed tunnel creation. Adverse events occurred in 6.7% (5/75): 1 bleed (mild) conservatively managed and 4 perforations (1 severe, 3 moderate). The mean procedure time was 52.4 ± 2.9 minutes, and mean length of hospital stay was 1.8 ± .2 days. Clinical success was achieved in 92% (69/75) with a decrease in mean dysphagia score from 1.96 to .25 (P Conclusions Endoscopic management of ZD using the POEM technique is novel and feasible with promising efficacy and safety results. Long-term follow-up is needed to ensure durability of response. In addition, comparative studies with other treatment modalities are warranted.

Background and Aims Differentiating pancreatic cystic lesions remains a challenge when the current technique of EUS-guided FNA is used. Recently, a miniaturized biopsy forceps with an outer diameter of 0.8 mm has been developed, thus allowing it to be passed through the bore of a standard 19-gauge FNA needle to acquire tissue. Methods This study consisted of a retrospective review of all cases of EUS-guided through-the-needle forceps biopsy technique (TTNFB) performed for pancreatic cystic lesions at a single academic tertiary care center over a 12-month period. Technical success was defined as acquisition of adequate tissue for formal histologic analysis. Safety was assessed through the monitoring and recording of periprocedural and postprocedural adverse events. Results The technical success of EUS-guided TTNFB was 87% (13/15). EUS-guided TTNFB with histologic analysis yielded pancreatic cyst diagnoses in 11 of 15 (73%) patients, compared with 0 of 15 (0%) patients with the use of EUS-FNA and cytologic analysis (P < .001). Of the 15 cystic lesions, 8 were diagnosed as intrapapillary mucinous neoplasm based on EUS-TTNFB. Conclusion This TTNFB technique has the potential to improve the diagnostic yield of EUS-FNA for pancreatic cystic neoplasms.

To understand trends in pediatric cases performed during urology residency including intraresident variability and cases performed relative to required minimums.Case logs of urology residents graduating from 2010 to 2018 were analyzed. Temporal trends in reported pediatric case volume were assessed via ANOVA tests and calculation of compound annual growth rates (CAGRs). Percent differences between the 90th and 10th percentiles of residents were calculated to assess intraresident variability. Reported case volumes were compared with minimum requirements with t tests.1072 residents from 306 urology residency programs were represented in this study. Minor pediatriccases increased from 2010 to 2018 (105.4 ± 54vs 124.6 ± 65, P = .004, CAGR = 2.1%) while major pediatric cases decreased (83.9 ± 40vs 60.8 ± 30, P.001, CAGR = -3.9%). Orchiopexy (range, 23%-27%), hypospadias (range, 19%-21%), and hydrocele / hernia (range, 15%-19%) were the highest volume case categories. Mean intraresident variability in reported case volumeswas 338% for minor pediatric (CAGR = 0%) and 382% for major pediatric (CAGR = 1.8%). Mean reported case volumes exceeded the minimum requirement for each case category by several fold (P.001, range, percent difference 232-675%). All urology residents reported minimum pediatric case requirements in 2018.Urology residents report more cases than minimum requirements for pediatric urology by several folds. Future research is needed to understand the implications of increasing intraresident case volume variabilities on residency training in pediatric urology.

PURPOSE To study the effectiveness of the Patient Preferences for Prostate Cancer Care (PreProCare) intervention in improving the primary outcome of satisfaction with care and secondary outcomes of satisfaction with decision, decision regret, and treatment choice among patients with localized prostate cancer. METHODS In this multicenter randomized controlled study, we randomly assigned patients with localized prostate cancer to the PreProCare intervention or usual care. Outcomes were satisfaction with care, satisfaction with decision, decision regret, and treatment choice. Assessments were performed at baseline and at 3, 6, 12, and 24 months, and were analyzed using repeated measures. We compared treatment choice across intervention groups by prostate cancer risk categories. RESULTS Between January 2014 and March 2015, 743 patients with localized prostate cancer were recruited and randomly assigned to receive PreProCare (n = 372) or usual care (n = 371). For the general satisfaction subscale, improvement at 24 months from baseline was significantly different between groups ( P < .001). For the intervention group, mean scores at 24 months improved by 0.44 (SE, 0.06; P < .001) from baseline. This improvement was 0.5 standard deviation, which was clinically significant. The proportion reporting satisfaction with decision and no regret increased over time and was higher for the intervention group, compared with the usual care group at 24 months ( P < .05). Among low-risk patients, a higher proportion of the intervention group was receiving active surveillance, compared with the usual care group ( P < .001). CONCLUSION Our patient-centered PreProCare intervention improved satisfaction with care, satisfaction with decision, reduced regrets, and aligned treatment choice with risk category. The majority of our participants had a high income, with implications for generalizability. Additional studies can evaluate the effectiveness of PreProCare as a mechanism for improving clinical and patient-reported outcomes in different settings.

Objectives Few couple-focused interventions have improved psychological and relationship functioning among men diagnosed with localized prostate cancer and their spouses. This study compared the impact of intimacy-enhancing therapy (IET), a general health and wellness intervention (GHW), and usual care (UC) on the psychological and relationship functioning of localized prostate cancer patients and their partners. Relationship length, relationship satisfaction, and patient masculinity were evaluated as moderators. Design This study was a randomized clinical trial with three study arms and four assessment time points. Methods A total of 237 patients and partners were randomly assigned to receive IET, GHW, or UC. Participants completed measures of psychological functioning and relationship satisfaction at baseline, 5 weeks, 3 months, and 6 months post-baseline. Primary outcomes were psychological adjustment, depression, cancer-specific distress, cancer concerns, and relationship satisfaction. Results Spouses in IET showed greater increases in relationship satisfaction than spouses in GHW and UC between the baseline and 5-week follow-up. Among patients in longer relationships, significant increases in psychological adjustment were found in both treatments compared to UC. Among spouses in longer relationships, psychological adjustment increased in both IET and UC but declined in GHW. Conclusions Intimacy-enhancing therapy did not show an impact on general or cancer-specific distress, but did show an early impact on relationship satisfaction among spouses. IET was superior to UC for patients in longer relationships. It will be important for researchers to understand which couple-focused interventions benefits both patients and spouses and to identify characteristics of patients, partners, and couples who may not benefit from psychological treatments. Statement of contribution What is already known on this subject? Men diagnosed with localized prostate cancer report lower health-related quality of life and both patients and spouses report elevated distress. Relationship communication plays a role in couples' psychological adaptation to prostate cancer. Couple-focused interventions have illustrated an impact on relationship communication. There are no studies comparing different couple-focused interventions. What does this study add? Intimacy-enhancing therapy was not superior to no treatment or a comparison treatment for the broad range of psychological and relationship outcomes. Intimacy-enhancing therapy was superior to no treatment for patients in longer-term relationship. The general health and wellness intervention was not beneficial for men in shorter relationships and for men who did not endorse traditional masculine norms.

Objective How couples communicate about cancer is an important predictor of psychological outcomes for men diagnosed with localised prostate cancer and their spouses. We examined the predictive role of disclosure, responsiveness, mutual avoidance, and holding back on depressive symptoms, psychological adjustment, cancer-specific distress, and cancer concerns. Methods Eighty-one prostate cancer patients and their spouses completed measures of communication at baseline and measures of four psychological outcomes at baseline, five, 12, and 26 weeks after baseline. Dyadic growth models tested the effects of time and role on each outcome over time. Results Higher disclosure and responsiveness predicted better psychological outcomes. Less mutual avoidance and holding back predicted poorer psychological outcomes. Across communication variables, individuals who engaged in poorer communication initially had poorer psychological outcomes that improved over time, whereas individuals who engaged in better communication initially maintained their more positive standing without change or changed in the positive direction. For all outcomes, those with better communication still had better psychological outcomes at six months. Conclusion Couples' cancer-specific relationship communication predicts their psychological outcomes. More research is needed to identify effective interventions, including a longer therapy course, individual communication training, or greater focus on addressing barriers to sharing and responsiveness.

Author(s): Hale, Graham R; Shahait, Mohammed; Lee, David I; Lee, Daniel J; Dobbs, Ryan W | Abstract: BackgroundProstate cancer (PCa) represents the most common solid organ malignancy in men. Fortunately, at the time of diagnosis, the majority of cases are staged as localized or regional disease, conferring excellent 5- and 10-year cure rates. There are several first line treatment options including surgical approaches such as robot-assisted radical prostatectomy (RARP) and radiation therapy (RT) available to patients with localized disease that offer similar PCa oncologic outcomes but are associated with potentially significant side effects which may impact health-related quality of life (HRQOL) domains. Recently, clinicians and investigators have sought to better understand these changes in HRQOL metrics with the utilization of patient-reported outcomes (PRO). Given that RARP represents the most common surgical treatment for PCa in the United States, there has been a particular interest in assessing these outcomes derived by patient perspectives to more fully appreciate treatment-related impact on quality of life following RARP.ObjectiveThis narrative review sought to explore the instruments available to measure quality of life after RARP, a review of the PRO data after RARP, and future directions for assessing and improving quality of life outcomes following this surgery.Clinical useThere are several treatment options for men diagnosed with local and regional prostate cancer with similar oncologic outcomes but differing patterns of side effects affecting post-treatment quality of life. Understanding data reported directly by patients following RARP about their side effects and quality of life gives providers additional information for appropriate preoperative counseling for patients choosing between treatment options for their prostate cancer.

Background The presence of invasive cribriform adenocarcinoma (ICC), an expanse of cells containing punched-out lumina uninterrupted by stroma, in radical prostatectomy (RP) specimens has been associated with biochemical recurrence (BCR). However, ICC identification has only moderate inter-reviewer agreement. Objective To investigate quantitative machine-based assessment of the extent and prognostic utility of ICC, especially within individual Gleason grade groups. Design, setting, and participants A machine learning approach was developed for ICC segmentation using 70 RP patients and validated in a cohort of 749 patients from four sites whose median year of surgery was 2007 and with median follow-up of 28 mo. ICC was segmented on one representative hematoxylin and eosin RP slide per patient and the fraction of tumor area composed of ICC, the cribriform area index (CAI), was measured. Outcome measurements and statistical analysis The association between CAI and BCR was measured in terms of the concordance index (c index) and hazard ratio (HR). Results and limitations CAI was correlated with BCR (c index 0.62) in the validation set of 411 patients with ICC morphology, especially those with Gleason grade group 2 cancer (n = 192; c index 0.66), and was less prognostic when patients without ICC were included (c index 0.54). A doubling of CAI in the group with ICC morphology was prognostic after controlling for Gleason grade, surgical margin positivity, preoperative prostate-specific antigen level, pathological T stage, and age (HR 1.19, 95% confidence interval 1.03–1.38; p = 0.018). Conclusions Automated image analysis and machine learning could provide an objective, quantitative, reproducible, and high-throughput method of quantifying ICC area. The performance of CAI for grade group 2 cancer suggests that for patients with little Gleason 4 pattern, the ICC fraction has a strong prognostic role. Patient summary Machine-based measurement of a specific cell pattern (cribriform; sieve-like, with lots of spaces) in images of prostate specimens could improve risk stratification for patients with prostate cancer. In the future, this could help in expanding the criteria for active surveillance.

Background: The functional and oncologic outcomes of robot-assisted radical prostatectomy (RARP) in octogenarians are not well studied. We sought to study the perioperative, functional, and oncologic outcomes of RARP in octogenarian men. Methods: Between January 2009 and 2019, 46 patients ≥80 years with localized prostate cancer (PCa) underwent RARP in three high-volume robotic urologic practices in the United States. Clinical and pathologic features, and perioperative and postoperative complications were retrospectively evaluated. Functional outcomes for urinary and sexual function were collected via patient-reported questionnaires. Continence was defined as the use of zero or one safety pad per day. Results: The median (interquartile range) age was 81 (80-82), the mean (standard deviation [SD]) operative time was 116.5 (36.4) minutes, and the mean (SD) blood loss was 132 (35.6) mL. All cases were completed robotically, no intraoperative complications were encountered, and the mean length of stay was 1.21 (0.78) days. Regarding 30- and 90-day complication, nine patients had postoperative complications; seven were Clavien-Dindo grade I-II, and two were Clavien-Dindo grade ≥III. Post-RARP continence rates at 3 and 12 months were 68.4% and 84.8%, respectively. Conclusions: RARP represents a feasible option to treat PCa in well-selected octogenarian men. Careful patient selection and counseling are critical before offering surgical treatment for these men.

Introduction: Current preoperative evaluation methods fail to detect the difference in frailty among patients with the same chronological age. Hence, we sought to assess the ability of a simple 5-i...

Background: To present a stepwise description and outcomes of bladder neck sparing (BNS) robot-assisted simple prostatectomy (RASP). Methods: Between March 2015 and December 2018, 30 consecutive patients with benign prostate hyperplasia underwent BNS RASP. Baseline characteristics, and intraoperative and postoperative variables were retrospectively abstracted. Descriptive statistics were used to report the variables. Results: The median age was 66.5 (59.3-72.3) years, and median body mass index was 27.6 (24.5-72.3) kg/m2. The median preoperative International Prostate Symptoms Score was 23 (17.5-27), and median prostate size was 97 (74-148.75) mL. The mean (standard deviation [SD]) operative time was 107.5 (22.2) minutes, and the mean (SD) estimated blood loss was 132.4 (35.4) mL. All cases were completed robotically without any intraoperative complications, and continuous bladder irrigation was not necessary for any patient postoperatively. All patients were able to void after catheter removal except one patient with a preexisting diagnosis of neurogenic bladder who resumed clean intermittent catheterization. All patients were continent as defined as using 0 pads postoperatively. Of the 19 patients who had antegrade ejaculation before the operation, 8 patients (42%) reported of continued antegrade ejaculation after the operation. Conclusions: In this report, we demonstrate a simplified approach of BNS RASP that is reproducible with a favorable perioperative complication rates and acceptable postoperative functional outcomes. This technique obviates the need for continuous bladder irrigation and intraperitoneal drain.

Background and study aims Accurate diagnosis and classification of pancreatic cysts (PCs) remains a challenge. The aims of this study were to: (1) evaluate the safety and technical success of a novel microforceps for EUS-guided through-the-needle biopsy (TTNB) of PCs; and (2) assess its diagnostic yield for mucinous PCs when compared to FNA cyst fluid analysis and cytology. Patients and methods This was a multicenter retrospective analysis of 47 patients who underwent EUS-FNA and TTNB for PCs between January 2014 and June 2017. Technical success was defined as acquisition of a specimen adequate for cytologic or histological evaluation. Cyst fluid carcinoembryonic antigen (CEA) was used to initially categorize cysts as non-mucinous (CEA Results Forty-seven patients with PCs (mean size 30.7 mm) were included. TTNB was successfully performed in 46 of 47 (97.9 %). Technical success was significantly lower with FNA (48.9 %) compared to TTNB (85.1 %) (P Conclusions EUS-TTNB is safe and effective for evaluating PCs. TTNB may help increase the diagnostic yield of mucinous PCs.

Robot-assisted radical prostatectomy (RARP) has become the preferred surgical treatment for localized prostate cancer in the United States. Little is reported about the association between predischarge outcomes and postdischarge outcomes following RARP. The objective of this study was to explore the predischarge predictors of readmissions and postdischarge complications in RARP.The National Surgery Quality Improvement Program (NSQIP) database was used to identify prostate cancer patients who underwent elective RARP from 2012 to 2014. Multivariable logistic regression was performed to assess potential predischarge predictors of readmissions and NSQIP-defined postdischarge complications within 30 days of RARP. To test the robustness of primary analysis, a secondary multivariable logistic regression was performed in the cohort of patients without any NSQIP-defined predischarge complications.A total of 9975 patients were included. The readmission rate in the cohort was 3.3% (n = 332), and 4.4% (n = 441) had at least one complication. Multivariable logistic regression showed that American Society of Anesthesiologists (ASA) score of 3-4 (odds ratio [OR] = 1.27, 95% confidence interval [CI] = 1.00-1.62, p = 0.050), increasing operative time (OT, per minute) (OR = 1.002, 95% CI = 1.000-1.003, p = 0.012), increasing length of hospital stay (LOS, per day) (OR = 1.36, 95% CI = 1.23-1.49, p 0.001), and predischarge complication (OR = 2.15, 95% CI = 1.27-3.65, p = 0.004) were associated with readmission. Increasing OT (OR = 1.002, 95% CI = 1.001-1.004, p = 0.002) and increasing LOS (OR = 1.16, 95% CI = 1.02-1.30, p = 0.020) were associated with postdischarge complications. Logistic regression in patients without predischarge complications (n = 9804) confirmed that ASA score of 3-4 (OR = 1.37, 95% CI = 1.07-1.75, p = 0.013), increasing OT (OR = 1.002, 95% CI = 1.000-1.003, p = 0.022), and increasing LOS (OR = 1.34, 95% CI = 1.21-1.49, p 0.001) were associated with readmissions. Secondary analyses also confirmed that increasing OT (OR = 1.002, 95% CI = 1.001-1.004, p = 0.002) and increasing LOS (OR = 1.18, 95% CI = 1.04-1.34, p = 0.011) were associated with postdischarge complications.Predischarge complications, OT, and LOS are associated with readmissions and postdischarge complications after RARP. It may be possible to identify patients at a higher risk of postdischarge adverse events to direct prevention interventions. Further prospective studies are needed to validate our findings.

Robot-assisted radical prostatectomy has become the predominant surgical modality to manage localized prostate cancer in the U.S. However, there are few studies focusing on the associations between hospital volume and outcomes of robot-assisted radical prostatectomy.We identified robot-assisted radical prostatectomies for clinically localized (cT1-2N0M0) prostate cancer diagnosed between 2010 and 2014 in the National Cancer Database. We categorized annual average hospital robot-assisted radical prostatectomy volume into very low, low, medium, high and very high by most closely sorting the final included patients into 5 equal-sized groups (quintiles). Outcomes included 30-day mortality, 90-day mortality, conversion (to open), prolonged length of stay (more than 2 days), 30-day (unplanned) readmission, positive surgical margin and lymph node dissection rates.A total of 114,957 patients were included in the study, and hospital volume was categorized into very low (3 to 45 cases per year), low (46 to 72), medium (73 to 113), high (114 to 218) and very high (219 or more). Overall 30-day mortality (0.12%), 90-day mortality (0.16%) and conversion rates (0.65%) were low. Multivariable logistic regressions showed that compared with the very low volume group, higher hospital volume was associated with lower odds of conversion to open surgery (OR 0.23, p0.001 for very high), prolonged length of stay (OR 0.25, p0.001 for very high), 30-day readmission (OR 0.53, p0.001 for very high) and positive surgical margins (OR 0.61, p0.001 for very high). Higher hospital volume was also associated with higher odds of lymph node dissection in the intermediate/high risk cohort (OR 3.23, p0.001 for very high).Patients undergoing robot-assisted radical prostatectomy at higher volume hospitals are likely to have improved perioperative and superior oncologic outcomes compared to lower volume hospitals.

HER2-positive breast cancer is an aggressive subtype of breast cancer that overexpresses human epidermal growth factor receptor 2 promoting cancer cell growth. Monoclonal antibodies targeting the HER2 receptor have improved survival for this patient population. Achieving pathologic complete response (pCR) to neoadjuvant chemotherapy (NAC) has correlated with disease-free survival in multiple trials, but we do not know why some HER2-positive tumors respond better to these therapies. We evaluated the correlation between HER2/CEP17 ratio and partial versus complete response following NAC. We evaluated whether patients with higher HER2/CEP17 ratios would have higher rates of pCR after NAC. Using the National Cancer Database (NCDB), we performed a retrospective review comparing pCR rates after NAC based on HER2 ratio between 2005 and 2014. Patients were excluded if they were HER2 negative, did not undergo NAC, or if the HER2 ratio was not recorded. Trends in percentage of pCR versus partial response were analyzed using SPSS. The NCDB included 237,118 patients with HER2 equivocal or HER2-positive breast tumors. 29,291 of these patients underwent NAC, and HER2/CEP17 ratios were recorded in 14,597 of the NAC cases. A pCR was noted in 9752 patients and 11,402 patients had a partial response. The ratios were significantly different between complete vs. partial response groups (include ratios), P

Amid the opioid crisis, postoperative pain management is a major challenge for practitioners. Recent pain management guidelines emphasize the importance of using regional anesthesia as part of opioid-sparing multimodal analgesia. This report aims to review recent evidence regarding the utilization of transversus abdominis plane (TAP) block in minimally invasive urologic surgery. TAP block has been shown to improve early and late pain at rest, and to reduce opioid consumption after minimally invasive surgery. These benefits have indirectly reduced the incidence of postoperative delirium, pneumonia, urinary retention, and falls. Compared to epidural analgesia, TAP block provides similar pain control, has a lower incidence of hypotension, and is associated with a shorter length of stay. Few studies focus specifically on the outcomes of TAP block in minimally invasive urologic surgery. TAP block decreases postoperative pain and reduces opioid consumption without increasing complications. TAP block should be integrated as an indispensable component in enhanced recovery after surgery protocols.

Objectives: To use real-world data to better understand the temporal impact of COVID-19 on frequency of outpatient visits in urology clinics and apply a data quality framework to identify and resolve issues that could influence the validity of analyses. Methods: We examined visit trends from 157 outpatient urologic practices and 3,165 providers included in the American Urological Association Quality (AQUA) Registry, a national Qualified Clinical Data Registry designed to measure, report and improve healthcare quality and patient outcomes. As of December 2020, 50 million patient visits from 7.3 million unique patients exist in the database. We used a data quality framework to assess issues related to data completeness and timeliness. Past data lag trends were assessed to determine a temporal cutoff point that minimized lag. To account for missing data, a comprehensive visit definition that went beyond E/M (Evaluation and Management) coding was applied and compared to results using the E/M-only definition. Results: Correlating with the onset of the COVID-19 pandemic in the US in mid-March 2020, outpatient visits declined for five weeks, resulting in a 47.7% drop from the February 2020 baseline, followed by an 83.1% recovery back to baseline by July 31. Based on timeliness scores, which consider the average time between visit date and the visit data processing date from the selected practices, a 90-day buffer between data cutoff and the end of the analysis’s observation period was necessary to minimize data lag. Total patient encounters increased by more than 20% when using a more comprehensive visit definition Conclusions: The COVID-19 pandemic contributed to a reduction in outpatient visits, followed by a recovery close to baseline. Our data quality framework identified and informed key study design decisions to account for inadequate data timeliness and completeness. These methods prevented an overestimation of the true decline in patient encounters and missed patient encounters.

Author(s): Shahait, Mohammed; Majali, Fawaz Al; Dobbs, Ryan W; Sandberg, Alex; El-Achkar, Adnan; El-Fahmawi, Ayah; Mucksavage, Philip; Lee, David I | Abstract: ObjectiveManagement of prostate cancer in kidney transplant recipients presents a unique surgical challenge due to the risk of direct or indirect injury to the transplanted kidney. Herein, we report the largest single center study of Robot-assisted Radical prostatectomy (RARP) in kidney transplant recipients.MethodsBetween Jan 2014-2019, 14 kidney transplant recipients with prostate cancer underwent RARP. Clinical and pathological features, perioperative and postoperative complications were retrospectively evaluated. Continence was defined as by patient utilization of zero urinary pads postoperatively.ResultsThe median (IQR) age at RARP was 60.2 (57.8-61.3) years, the interval between kidney transplant and RARP was 8.1 ± 7.5 years. The median (IQR) PSA was 6.9 (4-8.6); 10 of 14 patients had intermediate or high-risk prostate cancer. The median ASA score was 3, the mean (SD) operative time was 129.7 (26.3) minutes, and mean (SD) blood loss was 110 (44.6) ml. All cases were completed robotically, there was no graft loss or injury to transplanted ureter, and the mean length of stay was 1 (0.26) day.Final pathology demonstrated that 42.8% (6/14) of the patients had nonorgan confined disease (pT3a/T3b). 50% (7/14) of the patients were upgraded to higher risk Gleason disease on final surgical pathology. Post-RARP continence rate at 3 months, and 12 months were 45.5% (5/11) and 87.5% (7/8), respectively.ConclusionRARP following kidney transplantation represents a safe and feasible operation which does not appear to compromise oncological or transplant outcomes.

Several randomized clinical trials have shown the efficacy of percutaneous transversus abdominis plane (TAP) block in decreasing pain after open and minimally invasive surgeries. We postulated that TAP block could be performed by a robot-assisted transperitoneal approach and provide postoperative pain control equivalent to local anesthetic port infiltration.To compare different indicators of postoperative pain between robot-assisted TAP and local anesthetic port infiltration in patients who had undergone robot-assisted radical prostatectomy (RARP).A retrospective comparison of 214 consecutive patients undergoing RARP over a 1-year period was conducted. Patient demographics, comorbidities, operative details, and outcomes, including time to ambulation, pain score, narcotic usage, and length of stay, were compared.In total, 206 patients were included: 101 received local anesthetic port infiltration and 105 robot-assisted TAP block. There were no differences in estimated blood loss, operative time, time to ambulation, and length of stay between the two groups. The robot-assisted TAP block cohort experienced lesser pain than the local anesthetic port infiltration cohort in the intervals of 6 to 12 hours (2.05 vs 3.21, p = 0.0016) and 12 to 18 hours (2.19 vs 2.97, p = 0.0495) postoperation.Robot-assisted TAP block is a safe alternative to local anesthetic port-site infiltration. Robot-assisted TAP is associated with lower postoperative pain scores and less narcotic use than local anesthetic port-site infiltration.

348 Background: Several post-prostatectomy genomic tests are available; which are used to improve prognostication and to guide additional treatment after radical prostatectomy (RP). There has been no head to head comparison between these tests. The objective of this study is to compare the performance of two genomic tests in predicting oncological outcomes. Methods: 16 patients who underwent RP at the University of Pennsylvania (UPenn) (2013-2018), had adverse pathology (margin, and/or pT3a/b) and had each been tested with both Decipher (D) and Prolaris (P). Pearson correlation was used to compare scores from D and P as well as CCP scores and microarray derived CCP (mCCP). The associations of D and P with biochemical recurrence (BCR) and metastasis (M) was evaluated in survival analysis in a large cohort of RP patients treated at Johns Hopkins University (1992-2010) (JHU). Results: The median follow-up of the UPenn cohort was 24 months. 6 patients developed BCR and two distant M. There was a significant correlation between the D and P score (r=0.67,p=0.004), and between the 10-year BCR risk reported by P and the 5-year M risk reported by D (r=0.69, p=0.003). Each test called 7 patients to be high risk; 5 were in common. Both tests correctly called the 2 M cases as high risk and 4/6 BCR patients to be high risk. A microarray-derived CCP (mCCP) was highly correlated to the CCP scores reported from P (r=0.88, p=6.7e-6) in the UPenn cohort. To compare the prognostic performance of mCCP to D for predicting BCR and M, we used Post-RP cohort from JHU (N=355). Both scores were correlated (r=0.36, p2e-12). D and mCCP were stratified into 5 groups of incremental 20%. When including mCCP groups, D groups, Gleason score, SVI, EPE, LNI, and PSA; D remained independent prognostic variable of BCR (HR 1.16, 95%CI [1.05-1.3], p=0.005) and M (HR 1.3, 95%CI [1.12-1.52], p=0.0005). However, mCCP was not prognostic of BCR (p=0.59) nor M (p=0.62). Conclusions: The findings from this study show that P and D scores post-RP were highly correlated and help in identifying patients who at high risk of progression in this small cohort with short follow up. However, D outperformed mCCP for predicting BCR and M in larger cohorts with longer follow up.

Background To determine the comparative effectiveness of primary radical prostatectomy (RP) compared to external bean radiation therapy (EBRT) with androgen deprivation therapy (ADT), or EBRT plus brachytherapy (BT) with or without ADT among Medicare fee-for-service beneficiaries with high-risk prostate cancer, for 10-year, mortality (overall and prostate cancer-specific), complications, health service use, and cost. Methods This population-based cohort study used Surveillance, Epidemiology, and End Results – Medicare data. Eligible patients were men aged 66 or older and diagnosed with high-risk prostate cancer between 1996 and 2003. Outcomes evaluated were 10-year overall mortality and prostate cancer-specific mortality, complications, health service use, and cost. We used Cox regression, Poisson regression, and Generalized Linear Model (GLM) log-link models to assess the outcomes. Main findings The 10-year overall mortality of EBRT + ADT was comparable to that of the RP group (hazard ratio [HR] = 1.09, confidence interval [CI] = 0.72–1.66). The EBRT + BT ± ADT group had overall survival advantage compared to RP (HR = 0.47, CI = 0.31–0.73). Compared to the RP group, EBRT + ADT group had higher 10-year prostate cancer-specific mortality (HR = 2.19, CI = 1.92–5.21). Both EBRT + ADT and EBRT + BT ± ADT were associated with higher 10-year cost (odds ratio = 1.72, CI = 1.35–2.20; and odds ratio = 1.63, CI = 1.29–2.04), compared to RP group. Complications and health service use varied across 3 treatment groups and across phases of care. Principal conclusions Our results also demonstrate long-term overall survival benefits for EBRT + BT ± ADT, and greater bowel and bladder side effects over a decade, compared to RP. The RP group had advantage for long-term prostate-cancer specific mortality, compared to EBRT + ADT group. Thus, RP can provide superior cancer control with clear cost advantage for older men with high-risk disease. In terms of value proposition, our results support RP as preferred treatment option, compared to EBRT + ADT and EBRT + BT ± ADT for high-risk prostate cancer patients.

We tested for associations between socioeconomic status (SES) and adverse prostate cancer pathology in a population of African American (AA) men treated with radical prostatectomy (RP).We retrospectively reviewed data from 2 institutions for AA men who underwent RP between 2010 and 2015. Household incomes were estimated using census tract data, and patients were stratified into income groups relative to the study population median. Pathologic outcomes after RP were assessed, including the postsurgical Cancer of the Prostate Risk Assessment (CAPRA-S) score and a definition of adverse pathology (stage ≥ pT3, Gleason score ≥ 4+3, or positive lymph nodes), and compared between income groups.We analyzed data of 347 AA men. Median household income was $37,954. Low-SES men had significantly higher prostate-specific antigen values (mean 10.2 vs. 7.3; P .01) and CAPRA-S scores (mean 3.4 vs. 2.5; P .01), more advanced pathologic stage (T3-T4 31.8% vs. 21.5%; P = .03), and higher rates of seminal vesicle invasion (17.3% vs. 8.2%; P .01), positive surgical margins (35.3% vs. 22.1%; P .01), and adverse pathology (41.4% vs. 30.1%; P = .03). Linear and logistic regression showed significant inverse associations of SES with CAPRA-S score (P .01) and adverse pathology (P = .03).In a population of AA men who underwent RP, we observed an independent association of low SES with advanced stage or aggressive prostate cancer. By including only patients in a single racial demographic group, we eliminated the potential confounding effect of race on the association between SES and prostate cancer risk. These findings suggest that impoverished populations might benefit from more intensive screening and early, aggressive treatment of prostatic malignancies.

Radiofrequency ablation (RFA) has emerged as one of the main treatment modalities for Barrett’s esophagus within the past decade. Its use has been shown in multiple studies to decrease progression of low-grade dysplasia to high-grade dysplasia and adenocarcinoma, while having a lower rate of complications and adverse events when compared against other ablative strategies. In this chapter, we discuss the development of radiofrequency ablation, proper RFA technique, and its current use in the treatment of Barrett’s esophagus.

Background: The impact of treatment delays on prostate cancer–specific outcomes remains ill-defined. This study investigates the effect of time to treatment on biochemical disease control after prostatectomy. Methods: This retrospective study includes 1,807 patients who received a prostatectomy as a primary treatment at two large tertiary referral centers from 1987 to 2015. Multivariate cox model with restricted cubic spline was used to identify optimal time to receive treatment and estimate the risk of biochemical recurrence. Results: Median follow-up time of the study was 46 (interquartile range, 18–86) months. Time to treatment was subcategorized based on multivariate cubic spline cox model. In multivariate spline model, adjusted for all the pertinent pretreatment variables, inflection point in the risk of biochemical recurrence was observed around 3 months, which further increased after 6 months. Based on spline model, time to treatment was then divided into 0 to 3 months (61.5%), >3 to 6 months (31.1%), and 6 months (7.4%). In the adjusted cox model, initial delays up to 6 months did not adversely affect the outcome; however, time to treatment >6 months had significantly higher risk of biochemical recurrence (HR, 1.84; 95% confidence interval, 1.30–2.60; P < 0.01). Conclusions: The initial delays up to 6 months in prostate cancer primary treatment may be sustainable without adversely affecting the outcome. However, significant delays beyond 6 months can unfavorably affect biochemical disease control. Impact: Time to treatment can aid clinicians in the decision-making of prostate cancer treatment recommendation and educate patients against unintentional treatment delays.

In May 2012, the US Preventive Services Task Force issued a grade D recommendation against PSA-based prostate cancer screening. Epidemiologists have concerns that an unintended consequence is a problematic increase in high-risk disease and subsequent prostate cancer-specific mortality. To assess the effect of decreased PSA screening on the presentation of high-risk prostate cancer post-radical prostatectomy (RP). Nine high-volume referral centers throughout the United States (n = 19,602) from October 2008 through September 2016 were assessed and absolute number of men presenting with GS ≥ 8, seminal vesicle and lymph node invasion were compared with propensity score matching. Compared to the 4-year average pre-(Oct. 2008–Sept. 2012) versus post-(Oct. 2012–Sept. 2016) recommendation, a 22.6% reduction in surgical volume and increases in median PSA (5.1–5.8 ng/mL) and mean age (60.8–62.0 years) were observed. The proportion of low-grade GS 3 + 3 cancers decreased significantly (30.2–17.1%) while high-grade GS 8 + cancers increased (8.4–13.5%). There was a 24% increase in absolute numbers of GS 8+ cancers. One-year biochemical recurrence rose from 6.2 to 17.5%. To discern whether increases in high-risk disease were due to referral patterns, propensity score matching was performed. Forest plots of odds ratios adjusted for age and PSA showed significant increases in pathologic stage, grade, and lymph node involvement. All centers experienced consistent decreases of low-grade disease and absolute increases in intermediate and high-risk cancer. For any given age and PSA, propensity matching demonstrates more aggressive disease in the post-recommendation era.

We evaluated the internal and construct validity of an assessment tool for cystoscopic and ureteroscopic cognitive and psychomotor skills at a multi-institutional level.Subjects included a total of 30 urology residents at Ohio State University, Columbus, Ohio; Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Mayo Clinic, Rochester, Minnesota. A single external blinded reviewer evaluated cognitive and psychomotor skills associated with cystoscopic and ureteroscopic surgery using high fidelity bench models. Exercises included navigation, basketing and relocation; holmium laser lithotripsy; and cystoscope assembly. Each resident received a total cognitive score, checklist score and global psychomotor skills score. Construct validity was assessed by calculating correlations between training year and performance scores (both cognitive and psychomotor). Internal validity was confirmed by calculating correlations between test components.The median total cognitive score was 91 (IQR 86.25, 97). For psychomotor performance residents had a median total checklist score of 7 (IQR 5, 8) and a median global psychomotor skills score of 21 (IQR 18, 24.5). Construct validity was supported by the positive and statistically significant correlations between training year and total cognitive score (r = 0.66, 95% CI 0.39-0.82, p = 0.01), checklist scores (r = 0.66, 95% CI 0.35-0.84, p = 0.32) and global psychomotor skills score (r = 0.76, 95% CI 0.55-0.88, p = 0.002). The internal validity of OSATS was supported since total cognitive and checklist scores correlated with the global psychomotor skills score.In this multi-institutional study we successfully demonstrated the construct and internal validity of an objective assessment of cystoscopic and ureteroscopic cognitive and technical skills, including laser lithotripsy.

We examined the effect of previous transurethral resection of the prostate (TURP) on multiple oncologic and continence outcomes after robotic-assisted radical prostatectomy (RARP). We performed a retrospective cohort study of a total of 2693 patients from 2007 to 2014 who underwent RARP. Patients were stratified into 49 patients who had previous TURP prior to RARP (group 1) and 2644 patients who had no TURP prior to RARP (group 2). We collected operative variables including estimated blood loss, operative time, and positive surgical margin (PSM) rates. Urinary continence, defined as 0 pads per day (PPD), and social continence, defined as 1-PPD, were also assessed. American Urological Association Symptoms Score (AUASS), overall ability to function sexually, and Expanded Prostate Cancer Index Composite (EPIC) questionnaire were evaluated at 3 and 12 months after RARP. Weakness of urinary stream (EPIC #4d) at 12 months imposed a greater problem for group 1 patients with prior TURP compared to group 2 patients without prior TURP (p = 0.012). PSM was not statistically significant between the two groups (p = 0.110). Group 1 patients had a greater PSM rate (30.61 %) as compared to group 2 (20.95 %). PSM locations in group 1 patients showed the most common locations at the posterior and apex. The difference between the two groups for AUASS, overall sexual function, estimated blood loss, operative time, urinary continence, and social continence was not statistically significant. We examined the effect of previous TURP on postoperative RARP continence and oncologic outcomes. This data can be used to counsel those with prior TURP before RARP.

PurposeTo determine whether robot-assisted radical prostatectomy (RARP) may be taught to chief residents and fellows without influencing operative outcomes.MethodsBetween August 2011 and June 2012, 388 patients underwent RARP by a single primary surgeon (DIL) at our institution. Our teaching algorithm divides RARP into five stages, and each trainee progresses through the stages in a sequential manner. Statistical analysis was conducted after grouping the cohort according to the surgeons operating the robotic console: attending only (n=91), attending and fellow (n=152), and attending and chief resident (n=145). Approximately normal variables were compared utilizing one-way analysis of variance, and categorical variables were compared utilizing two-tailed χ(2) test; P&nbsp

Objective To develop and validate an assessment tool for the performance of urethrovesical anastomosis (UVA). Methods A multicenter, prospective, observational study was conducted in 2 phases. Phase 1, development and content validation, used a panel of 5 experienced robotic surgeons to develop a 6-domain scoring system, Robotic Anastomosis Competence Evaluation (RACE), to assess technical skills for performing UVA. Phase 2, construct validation and reliability, used 5 blinded experienced robotic surgeons to rate UVA recordings of expert, advanced beginner, and novice groups. Content validation index was determined to report consensus in phase 1. Phase 2 involved comparison of RACE scores among the 3 groups. Wilcoxon rank-sum tests were used to compare RACE scores. Results Two rounds of Delphi methodology achieved consensus on language and content of RACE. Eight experts, 10 advanced beginners, and 10 novice robotic surgeons participated in the validation study. The overall score for the expert group (27.3) was higher than that of the advanced beginner (19.5; P = .04) and novice groups (13.6; P = .001). The advanced beginner and novice groups differed in overall scores ( P = .03). Conclusion RACE allows evaluation of surgical competence to perform UVA for robot-assisted radical prostatectomy, when using an inanimate model.

In the current literature, there are a number of cognitive training studies that use N-back tasks as their training vehicle; however, the interventions are often bland, and many studies suffer from considerable attrition rates. An increasingly common approach to increase participant engagement has been the implementation of motivational features in training tasks; yet, the effects of such “gamification” on learning have been inconsistent. To shed more light on those issues, here, we report the results of a training study conducted at two Universities in Southern California. A total of 115 participants completed 4 weeks (20 sessions) of N-back training in the laboratory. We varied the amount of “gamification” and the motivational features that might make the training more engaging and, potentially, more effective. Thus, 47 participants trained on a basic color/identity N-back version with no motivational features, whereas 68 participants trained on a gamified version that translated the basic mechanics of the N-back task into an engaging 3D space-themed “collection” game (Deveau et al. Frontiers in Systems Neuroscience, 8, 243, 2015). Both versions used similar adaptive algorithms to increase the difficulty level as participants became more proficient. Participants’ self-reports indicated that the group who trained on the gamified version enjoyed the intervention more than the group who trained on the non-gamified version. Furthermore, the participants who trained on the gamified version exerted more effort and also improved more during training. However, despite the differential training effects, there were no significant group differences in any of the outcome measures at post-test, suggesting that the inclusion of motivational features neither substantially benefited nor hurt broader learning. Overall, our findings provide guidelines for task implementation to optimally target participants’ interest and engagement to promote learning, which may lead to broader adoption and adherence of cognitive training.

Supplemental Digital Content is available in the text, Background: In the context of prostate cancer (PCa) characterized by the multiple alternative treatment strategies, comparative effectiveness analysis is essential for informed decision-making. We analyzed the comparative effectiveness of PCa treatments through systematic review and meta-analysis with a focus on outcomes that matter most to newly diagnosed localized PCa patients. Methods: We performed a systematic review of literature published in English from 1995 to October 2016. A search strategy was employed using terms “prostate cancer,” “localized,” “outcomes,” “mortality,” “health related quality of life,” and “complications” to identify relevant randomized controlled trials (RCTs), prospective, and retrospective studies. For observational studies, only those adjusting for selection bias using propensity-score or instrumental-variables approaches were included. Multivariable adjusted hazard ratio was used to assess all-cause and disease-specific mortality. Funnel plots were used to assess the level of bias. Results: Our search strategy yielded 58 articles, of which 29 were RCTs, 6 were prospective studies, and 23 were retrospective studies. The studies provided moderate data for the patient-centered outcome of mortality. Radical prostatectomy demonstrated mortality benefit compared to watchful waiting (all-cause HR = 0.63 CI = 0.45, 0.87; disease-specific HR = 0.48 CI = 0.40, 0.58), and radiation therapy (all-cause HR = 0.65 CI = 0.57, 0.74; disease-specific HR = 0.51 CI = 0.40, 0.65). However, we had minimal comparative information about tradeoffs between and within treatment for other patient-centered outcomes in the short and long-term. Conclusion: Lack of patient-centered outcomes in comparative effectiveness research in localized PCa is a major hurdle to informed and shared decision-making. More rigorous studies that can integrate patient-centered and intermediate outcomes in addition to mortality are needed.

This study seeks to determine whether there is a delay in time to surgery in breast cancer patients with panel tests compared with traditional BRCA testing. This study was a retrospective review of women diagnosed with breast cancer who underwent genetic evaluation from our institution’s Genetic Counselor Database from January 2013 to August 2015. Patients were excluded if they were male, clinical information was unavailable, the patient underwent neoadjuvant chemotherapy, had a diagnosis of recurrent breast cancer during time of study, or had postoperative genetics evaluation. Included in the study were 138 patients. The time from diagnosis to surgery for BRCA1/2 tested patients was 43.5 days compared with 51.0 days in the panel group (p = 0.186). Turnaround time for genetic testing decreased during the period studied and was approximately 6 days longer for panel testing than BRCA testing. It took 12.2 days for BRCA results and 18.9 days for the panel results (p

The leading cause of voiding dysfunction in older men is benign prostatic obstruction. In the setting of a grossly enlarged prostate (>80cm3), an open simple prostatectomy has been the gold standard for surgical treatment. Here, we will discuss the minimally invasive robot-assisted approach and compare it to the classic open approach and holmium laser enucleation of the prostate. Literature on robot-assisted simple prostatectomy, in concurrence with our institutional experience, has shown an overall lower morbidity, shorter hospital stay, and decreased indwelling catheter time, with equivalent functional outcomes compared to open simple prostatectomy. Similar operative times and hospital stays were found compared to holmium laser enucleation of the prostate, although a steep learning curve and cost of new equipment hinder the wide spread use of this transurethral approach. On review of current literature in addition to our institutional experience, we favor robot-assisted simple prostatectomy over open simple, based on associated increased morbidity/catheter time/hospital stay, and holium laser enucleation of the prostate, based on steep learning curve and cost of new equipment.

Robot-assisted radical prostatectomy has been shown to have comparable and possibly improved postoperative continent rates compared with retropubic and laparoscopic radical prostatectomy. However, postoperative urinary incontinence has remained one of the most bothersome postoperative complications. The basic concept of the intraoperative technique to improve postoperative urinary continence is to maintain as normal anatomical and functional structure in the pelvis as possible. Therefore, improved knowledge of the normal structure in the pelvis should lead to a greater understanding of the pathophysiology of urinary incontinence, and further development of intraoperative techniques to improve the outcomes of urinary continence. It might be necessary to carry out three steps to realize improvement of the early return of urinary continence after robot-assisted radical prostatectomy: (i) preservation (bladder neck, neurovascular bundle, puboprostatic ligament, pubovesical complex, and/or urethral length, etc.); (ii) reconstruction (posterior and/or anterior reconstruction, and/or reattachment of the arcus tendineus to the bladder neck, etc.); and (iii) reinforcement (bladder neck plication and/or sling suspension, etc.). On the basis of these steps, further modifications during robot-assisted radical prostatectomy should be developed to improve urinary continence and quality of life after robot-assisted radical prostatectomy.

Urinary incontinence is one of the most common adverse effects after radical prostatectomy (RP). Preoperative lower urinary tract symptoms (LUTS), which increase in prevalence with advancing age, have been hypothesized to be related to postoperative urinary continence. We review the literature on the role of preoperative LUTS on postoperative urinary function after RP in patients with clinically localized prostate cancer. The precise role of preoperative LUTS on postoperative urinary continence after RP is unclear due to conflicting conclusions from numerous reports. However, correlating preoperative LUTS to postoperative urinary incontinence may be particularly relevant in three instances: in patients with preoperative voiding or emptying LUTS, in predicting early postoperative urinary continence, and in patients with preoperative urinary incontinence. Also, RP in patients with moderate to severe preexisting LUTS may improve postoperatively as a result of relief of obstruction.