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There is a paucity of utility and cost data regarding the launch of 3D printing in a hospital. The objective of this project is to benchmark utility and costs for radiology-based in-hospital 3D printing of anatomic models in a single, adult academic hospital.All consecutive patients for whom 3D printed anatomic models were requested during the first year of operation were included. All 3D printing activities were documented by the 3D printing faculty and referring specialists. For patients who underwent a procedure informed by 3D printing, clinical utility was determined by the specialist who requested the model. A new metric for utility termed Anatomic Model Utility Points with range 0 (lowest utility) to 500 (highest utility) was derived from the specialist answers to Likert statements. Costs expressed in United States dollars were tallied from all 3D printing human resources and overhead. Total costs, focused costs, and outsourced costs were estimated. The specialist estimated the procedure room time saved from the 3D printed model. The time saved was converted to dollars using hospital procedure room costs.The 78 patients referred for 3D printed anatomic models included 11 clinical indications. For the 68 patients who had a procedure, the anatomic model utility points had an overall mean (SD) of 312 (57) per patient (range, 200-450 points). The total operation cost was $213,450. The total cost, focused costs, and outsourced costs were $2,737, $2,180, and $2,467 per model, respectively. Estimated procedure time saved had a mean (SD) of 29.9 (12.1) min (range, 0-60 min). The hospital procedure room cost per minute was $97 (theoretical $2,900 per patient saved with model).Utility and cost benchmarks for anatomic models 3D printed in a hospital can inform health care budgets. Realizing pecuniary benefit from the procedure time saved requires future research.

To study the effectiveness Yoga of Immortals (YOI) intervention in participants with urinary incontinence (UI) of all types. YOI uniquely combines specific yogic postures, breathing exercises, sound therapymeditation and is practiced by many for general well-being.In this App-based cohort study, a survey was sent to the YOI app subscribers. Those who identified with UI and consented were sent the ICIQ-UI- SF (for mean symptom scoreseverity of UI), and the ICIQ-LUTS-QOL (for impact of UI on QOL) Questionnaires at baseline, 4, and 8 weeks. Global impression of improvement was assessed by PGI-I scale.258/422 participants (18-74 years) were included and showed significant decrease in mean scores on the ICIQ-UI-SF (4.06 ± 0.24 at baseline; 2.90 ± 0.22 at 4-weeks [p ≤ 0.001] and 3.44 ± 0.23 at 8 weeks [p ≤ 0.001]) and ICIQ-LUTS-QOL (28.36± 0.74 at baseline; 24.46± 0.70 at 4-weeks [p ≤ 0.001] and 25.78± 0.70 at 8 weeks [p≤ 0.001]). Additionally, the 55-60 year subgroup also had significant decrease in mean scores on ICIQ-LUTS-QOL (25.06 ±1.20 at base line; 21.69 ± 1.07 at 4 weeks [p ≤ 0.01] and 22.28 ± 0.96 at 8 weeks [p ≤ 0.01]).YOI intervention resulted in significant improvement in mean scores on ICIQ-LUTS-QOL; ICIQ-UI-SF; frequency and severity of urinary leak; and daily life activity. Majority of the participants felt 'very much better' on PGI-scale. Being app- based, it has the added advantage of the ability to be used anytime and anywhere.

Purpose: Prostate cancer (PCa) is the second most common oncologic disease among men. Radical treatment with curative intent provides good oncological results for PCa survivors, although definitive therapy is associated with significant number of serious side-effects. In modern-era of medicine tissue-sparing techniques, such as focal HIFU, have been proposed for PCa patients in order to provide cancer control equivalent to the standard-of-care procedures while reducing morbidities and complications. The aim of this systematic review was to summarise the available evidence about focal HIFU therapy as a primary treatment for localized PCa. Material and methods: We conducted a comprehensive literature review of focal HIFU therapy in the MEDLINE database (PROSPERO: CRD42021235581). Articles published in the English language between 2010 and 2020 with more than 50 patients were included. Results: Clinically significant in-field recurrence and out-of-field progression were detected to 22% and 29% PCa patients, respectively. Higher ISUP grade group, more positive cores at biopsy and bilateral disease were identified as the main risk factors for disease recurrence. The most common strategy for recurrence management was definitive therapy. Six months after focal HIFU therapy 98% of patients were totally continent and 80% of patients retained sufficient erections for sexual intercourse. The majority of complications presented in the early postoperative period and were classified as low-grade. Conclusions: This review highlights that focal HIFU therapy appears to be a safe procedure, while short-term cancer control rate is encouraging. Though, second-line treatment or active surveillance seems to be necessary in a significant number of patients.

Background Focal Therapy (FT) for Prostate Cancer (PCa) is promising. However, long-term oncological results are awaited and there is no consensus on follow-up strategies. Molecular biomarkers (MB) may be useful in selecting, treating and following up men undergoing FT, though there is limited evidence in this field to guide practice. We aimed to conduct a consensus meeting, endorsed by the Focal Therapy Society, amongst a large group of experts, to understand the potential utility of MB in FT for localised PCa. Materials and methods A 38-item questionnaire was built following a literature search. The authors then performed three rounds of a Delphi Consensus using DelphiManager, using the GRADE grid scoring system, followed by a face-to-face expert meeting. Three areas of interest were identified and covered concerning MB for FT, i) the current/present role; ii) the potential/future role; iii) the recommended features for future studies. Consensus was defined using a 70% agreement threshold. Results Of 95 invited experts, 42 (44.2%) completed the three Delphi rounds. Twenty-four items reached a consensus and they were then approved at the meeting involving (n=15) experts. Fourteen items reached a consensus on uncertainty, or they did not reach a consensus. They were re-discussed, resulting in a consensus (n=3), a consensus on a partial agreement (n=1), and a consensus on uncertainty (n=10). A final list of statements were derived from the approved and discussed items, with the addition of three generated statements, to provide guidance regarding MB in the context of FT for localised PCa. Research efforts in this field should be considered a priority. Conclusions The present study detailed an initial consensus on the use of MB in FT for PCa. This is until evidence becomes available on the subject.

Context: Focal therapy (FT) has been gaining popularity as a treatment option for localized intermediate-risk prostate cancer (PCa) due to the associated lower morbidity compared to whole-gland treatment. However, there is an increased risk of local cancer recurrence requiring subsequent treatment in a small proportion of patients. Objective: To conduct a systematic review and meta-analysis to better describe and analyze patient postoperative, oncologic, and functional outcomes for those who underwent salvage radical prostatectomy (sRP) to manage their primary FT failure. Evidence acquisition: A systematic review was completed using three databases (PubMed, Embase, and CINAHL) from October to December 2021 to identify data on outcomes in patients who received sRP for cancer recurrence after prior focal treatment. Evidence synthesis: 12 articles (482 patients) were included. Median time to sRP was 24 months. Median follow-up time was 27 months. A meta-analysis revealed a postoperative complication rate of 15% (95% CI: 0.09, 0.24), with 4.6% meeting criteria for a major complication Clavien (CG) grade ≥3. Severe GU toxicity was seen in 3.6% of the patients, and no patients had severe GI toxicity. Positive surgical margins (PSM) were found in 27% (95% CI: 0.19, 0.37). Biochemical recurrence (BCR) after sRP occurred in 23% (95% CI: 0.17, 0.30), indicating a BCR-free probability of 77% at 2 years. Continence (pad-free) and potency (ability to have penetrative sex) were maintained in 67% (95% CI: 0.53, 0.78) and 37% (95% CI: 0.18, 0.62) at 12 months, respectively. Conclusion: Our evidence shows acceptable complication rates and oncologic outcomes; however, with suboptimal functional outcomes for patients undergoing sRP for recurrent PCa after prior FT. Inferior outcomes were observed for salvage treatment compared to primary radical prostatectomy (pRP). More high-quality studies are needed to better characterize outcomes after this sequence of PCa treatments. Patient summary: We looked at treatment outcomes and toxicity for men treated with sRP for prior FT failure. We conclude that these patients will have significant detriment to genitourinary function, with outcomes being worse than those for pRP patients.

Multiparametric magnetic resonance imaging (mpMRI)-ultrasound (US) fusion prostate biopsy (FBx) has demonstrated increased accuracy for prostate cancer detection at designated centers of excellence. There is a concern if their results can be reproduced in smaller centers. Here, we evaluate the outcomes of FBx from a smaller academic center.A retrospective review of patients without a prior diagnosis of prostate cancer undergoing FBx from January 2014 to November 2019 was performed. Histopathological results were grouped into low-risk disease (Grade Group 1), intermediate-risk disease (Grade Group 2 and 3), and high-risk disease (Grade Group 4 or 5). Clinically significant (CS) prostate cancer was defined as Grade Group ≥ 2.Five hundred and six men were included. Median age (IQR) and PSA (IQR) were 65.2 (60.3-70.2) years and 6.9 (5.2-9.7) ng/ml, respectively. There was no difference in overall cancer detection between FBx and SBx (53.6% vs 56.4%FBx detects a higher proportion of clinically significant disease and a lower proportion of clinically insignificant disease compared to SBx, in line with outcomes demonstrated by centers of excellence.

PURPOSE: Currently, there is a dearth of data concerning the impact of hypogonadism on prostate cancer detection by imaging. In this study, we evaluated the performance of multiparametric MRI (mpMRI) and mpMRI-TRUS fusion biopsy in hypogonadal patients. MATERIALS AND METHODS: Clinical and pathologic data from a prospectively maintained, single-institution database of patients who underwent 3T mpMRI and fusion biopsy between 2007 and 2016 were analyzed. Hypogonadism was defined by an institutional cutoff of serum testosterone ≤ 180 ng/dL; T2, DWI, and DCE scores were calculated from mpMRI. Cancer detection rates were compared by Chi-square tests. Multivariate logistic regression was undertaken to evaluate the impact of hypogonadism on clinically significant cancer detection by systematic and fusion biopsy. RESULTS: We included 522 patients in our study who had total testosterone levels measured within 90 days of mpMRI. Of these, 49 (9.4%) were hypogonadal. Median total testosterone was 148 ng/dL (IQR 41) in the hypogonadal group, and 304 ng/dL (IQR 132) in the normogonadal group (p < 0.001). Imaging results were comparable between the hypo and normogonadal groups. In the hypogonadal group, systematic biopsy detected clinically significant cancer in 28.6% of patients compared to 40.8% with fusion biopsy. In the normogonadal cohort, systematic and fusion biopsy detected 37.3% and 43.2% CS cancer, respectively. In the hypogonadal cohort, fusion biopsy detected 12.2% more CS cancers compared to systematic biopsy, while it detected only 5.9% more in the normogonadal cohort. On multivariate analysis, hypogonadism was found to be an independent predictor of decreased CS cancer detection on systematic (p = 0.048), but not on fusion biopsy (p = 0.170). CONCLUSIONS: Hypogonadism is an independent predictor of lower CS cancer detection on systematic biopsy. However, it fails to significantly impact CS detection on fusion biopsy with comparable cancer detection rates in both groups. Patients with hypogonadism may benefit more from fusion biopsy than normogonadal patients.

Biochemical recurrence of prostate cancer occurs in 25-33% of patients who undergo radiation therapy (RT). Unfortunately, greater than 90% of patients with radiation recurrence undergo androgen deprivation therapy (ADT), despite the detrimental side effect profile and the lack of supporting evidence for ADT use in local recurrence. In patients who experience recurrence after treatment with RT, options for treatment include salvage radical prostatectomy (SRP), salvage cryotherapy (SCT), salvage brachytherapy (SBT), and high-intensity focused ultrasound (HIFU). These salvage treatments provide recurrence-free survival in almost half of the patients with an acceptable safety profile. However, it is important to note that approximately 20-40% of radio-recurrent prostate cancers are isolated and local. Recent studies have shown salvage focal treatments to have encouraging outcomes with significantly less side effects. This article summarizes the outcomes of currently used salvage treatment options for radio-recurrent prostate cancer and focuses on recent advancements in image-guided focal salvage therapies.

Objective: To compare the detection rate of clinically significant cancer (CSCa) by magnetic resonance imaging-targeted biopsy (MRI-TB) with that by standard systematic biopsy (SB) and to evaluate the role of MRI-TB as a replacement from SB in men at clinical risk of prostate cancer. Methods: The non-systematic literature was searched for peer-reviewed English-language articles using PubMed, including the prospective paired studies, where the index test was MRI-TB and the comparator text was SB. Also the randomized clinical trials (RCTs) are included if one arm was MRI-TB and another arm was SB. Results: Eighteen prospective studies used both MRI-TB and TRUS-SB, and eight RCT received one of the tests for prostate cancer detection. In most prospective trials to compare MRI-TB vs. SB, there was no significant difference in any cancer detection rate; however, MRI-TB detected more men with CSCa and fewer men with CISCa than SB. Conclusion: MRI-TB is superior to SB in detection of CSCa. Since some significant cancer was detected by SB only, a combination of SB with the TB technique would avoid the underdiagnosis of CSCa.

Several advancements have been made in recent years with regards to the detection and evaluation of prostate cancer (PCa). The low specificity of prostate specific antigen (PSA) has left much to be desired in a test, but a boom in novel biomarkers has made screening and surveillance more complicated. Several attempts at identifying a niche for these tests has helped somewhat, but much is still undetermined about the benefit that each test provides. In addition to laboratory tests, advancements in multiparametric magnetic resonance imaging (mpMRI) and PIRADSv.2 scoring have provided significant benefit to the evaluation of PCa. With the widespread use of prostate imaging, it is important to re-evaluate the impact of novel biomarkers in the context of furthering PCa screening and management. In this review, we aim to assess the influence mpMRI has on the role of nine different novel biomarkers in the detection and evaluation of PCa. We performed a review of current peer-reviewed literature to assess this question. Much data has been published on the role of these tests, allowing for their placement into one of three best-fit categories: tests for biopsy-naïve men (Prostate Health Index, Mi Prostate Score, 4K Score); tests for men with prior negative biopsies (ConfirmMDx, Progensa PCA3); and men on active surveillance (OncotypeDx, Prolaris, Decipher). Data on the role of these tests with the use of mpMRI have not been comprehensive and excludes several of the markers. More research is needed to determine the combined impact mpMRI and the novel biomarkers on the evaluation and management of PCa.

BACKGROUND: Clear cell renal cell carcinoma (ccRCC) is the most common histologically defined renal cancer. However, it is not a uniform disease and includes several genetic subtypes with different prognoses. ccRCC is also characterized by distinctive metabolic reprogramming. Tobacco smoking (TS) is an established risk factor for ccRCC, with unknown effects on tumor pathobiology. METHODS: We investigated the landscape of ccRCCs and paired normal kidney tissues using integrated transcriptomic, metabolomic, and metallomic approaches in a cohort of white males who were long-term current smokers (LTS) or were never smokers (NS). RESULTS: All 3 Omics domains consistently identified a distinct metabolic subtype of ccRCCs in LTS, characterized by activation of oxidative phosphorylation (OXPHOS) coupled with reprogramming of the malate-aspartate shuttle and metabolism of aspartate, glutamate, glutamine, and histidine. Cadmium, copper, and inorganic arsenic accumulated in LTS tumors, showing redistribution among intracellular pools, including relocation of copper into the cytochrome c oxidase complex. A gene expression signature based on the LTS metabolic subtype provided prognostic stratification of The Cancer Genome Atlas ccRCC tumors that was independent of genomic alterations. CONCLUSION: The work identified the TS-related metabolic subtype of ccRCC with vulnerabilities that can be exploited for precision medicine approaches targeting metabolic pathways. The results provided rationale for the development of metabolic biomarkers with diagnostic and prognostic applications using evaluation of OXPHOS status. The metallomic analysis revealed the role of disrupted metal homeostasis in ccRCC, highlighting the importance of studying effects of metals from e-cigarettes and environmental exposures. FUNDING: Department of Defense, Veteran Administration, NIH, ACS, and University of Cincinnati Cancer Institute.

Background: With the advancement of imaging technology, focal therapy (FT) has been gaining acceptance for the treatment of select patients with localized prostate cancer (CaP). We aim to provide details of a formal physician consensus on the utilization of FT for patients with CaP who are discontinuing active surveillance (AS). Methods: A 3-stage Delphi consensus on CaP and FT was conducted. Consensus was defined as agreement by >= 80% of physicians. An in-person meeting was attended by 17 panelists to formulate the consensus statement. Results: Fifty-six respondents participated in this interdisciplinary consensus study (82% urologist, 16% radiologist, 2% radiation oncology). The participants confirmed that there is a role for FT in men discontinuing AS (48% strongly agree, 39% agree). The benefit of FT over radical therapy for men coming off AS is: less invasive (91%), has a greater likelihood to preserve erectile function (91%), has a greater likelihood to preserve urinary continence (91%), has fewer side effects (86%), and has early recovery post-treatment (80%). Patients will need to undergo mpMRI of the prostate and/or a saturation biopsy to determine if they are potential candidates for FT. Our limitations include respondent's biases and that the participants of this consensus may not represent the larger medical community. Conclusions: FT can be offered to men coming off AS between the age of 60 to 80 with grade group 2 localized cancer. This consensus from a multidisciplinary, multi-institutional, international expert panel provides a contemporary insight utilizing FT for CaP in select patients who are discontinuing AS. United States Department of Health & Human Services National Institutes of Health (NIH) - USA ; European Urological Scholarship Programme (EUSP)

Background To compare the pathologic upgrade and downgrade rates after radical prostatectomy (RP) between patients diagnosed by prebiopsy prostate MRI followed by a combination of systematic and fusion biopsy (ComBx) versus patients undergoing systematic biopsy only (SBx). Methods A retrospective review of men undergoing RP at our institution between Jan 2014 and Mar 2020 was performed. These patients were separated into two independent cohorts based on two approaches: Patients receiving prebiopsy prostate MRI during initial evaluation and those who did not receive MRI. Patients with positive MRI findings underwent subsequent ComBx to confirm diagnosis while those without MRI underwent standard trans-rectal ultrasound (TRUS) guided systematic 12-core biopsy (SBx). Primary outcomes were rates of pathological upgrade (prostatectomy grade higher than grade determined at time of biopsy) and downgrade (prostatectomy grade lower than biopsy grade). Results A total of 213 patients undergoing radical prostatectomy, 91 diagnosed via a prebiopsy MRI and ComBx approach and 122 diagnosed by a traditional SBx approach, were included in the study. There was no significant difference between age, PSA, or positive family history between the two cohorts. Of the 91 patients who received prebiopsy MRI, 88 patients were determined to have a PIRADS 4 or 5 lesion. Patients who received MRI and subsequent ComBx had a lower rate of any pathological upgrade after RP (9.89% vs. 22.13%, P = 0.018) without a significant difference in pathologic downgrade rate (28.57% vs. 18.85%, P = 0.095). On multivariable logistic regression, receiving prebiopsy MRI during initial evaluation was the single negative independent predictor of pathologic upgrade (OR = 0.23, P = 0.017). A prebiopsy MRI approach was also the single predictor of pathologic downgrade (OR = 3.13, P = 0.041). Conclusions Patients receiving prebiopsy MRI during prostate cancer evaluation were less likely to have their PCa upgraded. Furthermore, although diagnosis via MRI and subsequent ComBx was associated with an increased rate of downgrades after RP, relatively few resulted in a downgrade from clinically significant to clinically insignificant cancer.

Objective: To demonstrate the utility of cold ischemia during robotic-assisted laparoscopic partial nephrectomy (RAPN). Patients and surgical procedure: Patients that are eligible for nephron-sparing surgery for management of renal neoplasms include those with solitary anatomical or functioning kidney, chronic kidney disease (CKD) and bilateral renal masses. The utilization of hilar clamping and resultant ischemia time is an inherent limitation of partial nephrectomy. We present a case of a large, complex unilateral renal mass in a patient with stage III CKD that required hilar clamping. In an effort to maximally preserve post-operative renal function, we performed RAPN utilizing cold ischemia for definitive surgical management. Finding an optimal method for laparoscopic ice delivery to induce ischemia has been challenging with many mechanisms proposed (Ramani et al., 2006). To date, a general consensus has not been reached on which method supersedes others. Results: Cold ischemia was accomplished using a modified 10 cc syringe to deliver 300 cc of ice through a dedicated 12 mm trocar. A clamp time of 32 min was necessary for tumor enucleation and renorraphy. Estimated blood loss was 200 cc and final pathology showed Fuhrman grade 3 clear cell RCC (pT1aNxM0) with negative margins. The patient was discharged after an uneventful hospitalization on post-operative day 3. At 2-week follow-up his renal function was comparable to preoperative values. Conclusions: Cold ischemia during RAPN is feasible and may facilitate prolonged ischemia time in the setting of a complex renal mass and the decision to pursue nephron-sparing surgery.

Background Focal therapy (FT) and partial gland ablation (PGA) are quickly adopted by urologists and radiologists as an option for the management of localized prostate cancer. Objective To find consensus on a standardized nomenclature and to define a follow-up guideline after FT and PGA for localized prostate cancer in clinical practice. Design, setting, and participants A review of the literature identified controversial topics in the field of FT. Online questionnaires were distributed to experts during three rounds, with the goal to achieve consensus on debated topics. The consensus project was concluded with a face-to-face meeting in which final conclusions were formulated. Outcome measurements and statistical analysis Controlled feedback of responses of previous rounds were summarized and returned to the participants allowing them to re-evaluate their decisions. The level of agreement to achieve consensus on a topic was set at 80%. Results and limitations Sixty-five experts participated in this interdisciplinary consensus study (72% urologists; 28% radiologists). The experts propose the use of the herein standardized nomenclature for ablative procedures. After FT/PGA, the following tests should be performed to assess treatment outcomes: prostate-specific antigen (PSA), imaging, biopsies, and functional outcome assessment. Although not a reliable marker for treatment failure, PSA should be measured every 3 mo in the 1st year and every 6 mo thereafter. Magnetic resonance imaging is the preferred image modality and should be performed at 6 and 18 mo after treatment. A systematic 12-core transrectal ultrasound-guided biopsy combined with a targeted biopsy of the treated area should be performed 6–12 mo after treatment. Functional outcomes should be obtained 3–6 mo after treatment for the first time and until stability is attained. Conclusions The panel recommends the use of the proposed nomenclature and follow-up protocols to generate reliable data supporting a broader implementation of FT as a standard of care for select patients with localized prostate cancer. Patient summary In this report, we present expert opinion on the use of a standardized nomenclature, and surveillance methodologies after focal therapy and partial gland ablation for localized prostate cancer.

Introduction: Focal therapy of prostate cancer aims to destroy known cancer while preserving uninvolved prostatic tissue with the goal of preserving genitourinary function.1,2 Previous methods of f...

Introduction: There are reports that the 12-core template systematic biopsies (SBx) obtained by using software registration machines (e.g., Artemis) have higher cancer detection rates (CDRs) of pro...

Black men have significantly higher incidence and are up to three times more likely to die of prostate cancer (PCa) than White men. Multiparametric magnetic resonance imaging-ultrasound fusion biopsy (FBx) has emerged as a promising modality for the detection of PCa. The goal of our study is to identify differences in utilization of FBx between Black and White men presenting with suspicion of PCa. We performed a retrospective review of Black and White men who presented with suspicion of PCa and required biopsy from January 2014 to December 2018. Multivariate logistic regression analysis was done to study the influence of race on the utilization of FBx. Six hundred nineteen (Black: 182, White: 437) men were included in the study. Forty-one out of 182 (22.5%) Black men underwent FBx compared with 225/437 (51.5%) of White men (P

Magnetic resonance imaging of prostate is currently widely used for diagnosis and staging of prostate cancer. First utilized in the early 1980s, MRI technology was rapidly recognized as a promising technique for characterizing pelvic and specifically prostatic anatomy. Further advancements, including the addition of diffusion weighted imaging and dynamic contrast enhanced imaging have continued to propel MRI into the forefront of prostate cancer care, notably with the development of the multiparametric MRI. This article reviews past advancements and performance in MRI in the screening and management of prostate cancer, as well as current thought on its place in contemporary urology. Future developments and avenues for advancement are described.

BACKGROUND Prostate Imaging-Reporting and Data System v. 2 (PI-RADSv2) provides standardized nomenclature for interpretation of prostate multiparametric MRI (mpMRI). Inclusion of additional features for categorization may provide benefit to stratification of disease. PURPOSE To prospectively compare PI-RADSv2 to a qualitative in-house system for detecting prostate cancer on mpMRI. STUDY TYPE Prospective. POPULATION In all, 338 patients who underwent mpMRI May 2015-May 2016, with subsequent MRI/transrectal ultrasound fusion-guided biopsy. FIELD STRENGTH 3T mpMRI (T2 W, diffusion-weighted [DW], apparent diffusion coefficient [ADC] map, b-2000 DWI acquisition, and dynamic contrast-enhanced [DCE] MRI). ASSESSMENT One genitourinary radiologist prospectively read mpMRIs using both in-house and PI-RADSv2 5-category systems. STATISTICAL TEST In lesion-based analysis, overall and clinically significant (CS) tumor detection rates (TDR) were calculated for all PI-RADSv2 and in-house categories. The ability of each scoring system to detect cancer was assessed by area under receiver operator characteristic curve (AUC). Within each PI-RADSv2 category, lesions were further stratified by their in-house categories to determine if TDRs can be increased by combining features of both systems. RESULTS In 338 patients (median prostate-specific antigen [PSA] 6.5 [0.6-113.6] ng/mL; age 64 [44-84] years), 733 lesions were identified (47% tumor-positive). Predictive abilities of both systems were comparable for all (AUC 76-78%) and CS cancers (AUCs 79%). The in-house system had higher overall and CS TDRs than PI-RADSv2 for categories 3 and 4 (P

PURPOSE: Population studies of patients undergoing radical cystectomy (RC) for bladder cancer (BC) suggest that a more extended lymph node dissection (LND) increases survival. However, information regarding LNDs of patients undergoing RC with a history of radiation therapy for BC is largely unknown. This study aims to define the lymph node yield (LNY) in patients undergoing RC for BC following radiation of the bladder using the surveillance epidemiology and end results (SEER) database. METHODS: Data were collected using SEER 18 registries from 1988 to 2013 to identify patients undergoing RC for BC. Data on extent and yield of LND were obtained. Logistic regression and multivariate Cox proportional hazard regression were done to identify predictors of adequate LND and all-cause mortality, respectively. RESULTS: In total, 27,451 patients were identified, of which, 27,362 (99.7%) were radiation naïve and 89 (0.3%) had prior radiation therapy for BC. The average LNY in radiation naïve patients (15, SD [13.5]) was slightly higher than the LNY in patients with prior radiation (12.3 SD [9.2], p = 0.157). Prior radiation was not an independent predictor of overall mortality (HR = 1.3, 95% CI [0.98–1.7]; p = 0.076). CONCLUSIONS: A lower proportion of patients with a history of radiation underwent a LND. The LNYs of radiation naïve patients, and those with a history of radiation, were not statistically different; however, the proportion of irradiated patients was small. Further investigation will be required to elucidate the patient and provider characteristics that contribute to the similar LNYs.

The PRECISION trial demonstrated the ability of using multiparametric MRI to improve the diagnosis of clinically significant prostate cancer whilst reducing over-diagnosis of clinically insignificant cancer compared with systematic biopsy. Concerns remained about patients who were not biopsied owing to negative scans. A new study applies the PRECISION strategy to a contemporary cohort to answer these concerns.

There is great a potential for mpMRI to improve outcomes and quality of treatment. The major roles of MRI will continue to expand and its emerging use in standard of care approaches becomes more clearly defined and supported by increasing levels of data. Active surveillance has gained popularity as an acceptable management option for men with low-risk prostate cancer. Successful utilization of this strategy can delay or prevent unnecessary interventions - thereby reducing morbidity associated with overtreatment. The usefulness of active surveillance primarily depends on correct identification of patients with low-risk disease. However, current population-wide algorithms and tools do not adequately exclude high-risk disease, thereby limiting the confidence of clinicians and patients to go on active surveillance. Novel imaging tools such as mpMRI provide information about the size and location of potential cancers enabling more informed treatment decisions. The term "multiparametric" in prostate mpMRI refers to the summation of several MRI series into one examination whose initial goal is to identify potential clinically-significant lesions suitable for targeted biopsy. The main advantages of MRI are its superior anatomic resolution and the lack of ionizing radiation. Recently, the Prostate Imaging-Reporting and Data System has been instituted as an international standard for unifying mpMRI results. The imaging sequences in mpMRI defined by Prostate Imaging Reporting and Data System version 2 includes: T2-weighted MRI, diffusion-weighted MRI, derived apparent-diffusion coefficient from diffusion-weighted MRI, and dynamic contrast-enhanced MRI. The use of mpMRI prior to starting active surveillance could prevent those with missed, high-grade lesions from going on active surveillance, and reassure those with minimal disease who may be hesitant to take part in active surveillance. Although larger validation studies are still necessary, preliminary results suggest mpMRI has a role in selecting patients for active surveillance. Less certain is the role of mpMRI in monitoring patients on active surveillance, as data on this will take a long time to mature. The biggest obstacles to routine use of prostate MRI are quality control, cost, reproducibility, and access. Nevertheless, there is great a potential for mpMRI to improve outcomes and quality of treatment. The major roles of MRI will continue to expand and its emerging use in standard of care approaches becomes more clearly defined and supported by increasing levels of data.

BACKGROUND: Analysis of systematic 12-core biopsies (SBx) has shown that African-American (AA) men tend to harbor higher risk prostate cancer (PCa) at presentation relative to other races. Multiparametric magnetic resonance imaging (mpMRI) and MRI-ultrasound fusion-guided biopsy (FBx) have been shown to diagnose more intermediate- and high-risk PCa in the general population; however, the efficacy in AA remains largely uncharacterized. We aim to evaluate the utility of FBx in an AA patient cohort. METHODS: Men suspected of PCa underwent an mpMRI and FBx with concurrent SBx from 2007 to 2015 in this institutional review board-approved prospective cohort study. Patient demographics, imaging and fusion biopsy variables were collected. χ(2), Mann–Whitney U-test and McNemar’s tests were performed to compare proportions, means and paired variables, respectively. Clinically significant PCa (CSPCa) was defined as Gleason score ≥ 3+4. RESULTS: Fusion biopsy demonstrated exact agreement with SBx risk categories in 64% of AA men. There was no statistically significant difference in the detection of CSPCa between FBx vs SBx (68 vs 62 cases, P = 0.36). However, FBx detected 41% fewer cases of clinically insignificant PCa (CIPCa) compared with SBx (FBx 30 vs SBx 51 cases, P = 0.0004). The combined FBx/SBx biopsy approach detected significantly more cases of CSPCa (FBx/SBx 80 vs SBx 62 cases, P = 0.004) while detecting comparable number of cases of CIPCa (FBx/SBx 45 vs SBx 51 cases, P = 0.37) compared with SBx alone. FBx/SBx also detected more CSPCa in patients with a history of prior negative SBx (FBx/SBx 28 vs 19 cases, P = 0.003). CONCLUSIONS: FBx when used in combination with SBx detected more cases of CSPCa while not significantly increasing the diagnosis of CIPCa in AA men. Future multicenter studies will be needed to validate ultimately the clinical implications of FBx in AA patients.

BACKGROUND: The Prostate Cancer Prevention Trial Risk Calculator 2.0 (PCPTRC) is a widely used risk-based calculator used to assess a man’s risk of prostate cancer (PCa) before biopsy. This risk calculator was created from data of a patient cohort undergoing a 6-core sextant biopsy, and subsequently validated in men undergoing 12-core systematic biopsy (SBx). The accuracy of the PCPTRC has not been studied in patients undergoing magnetic resonance imaging/ultrasound (MRI/US) fusion-guided biopsy (FBx). We sought to assess the performance of the PCPTRC for straitifying PCa risk in a FBx cohort. METHODS: A review of a prospective cohort undergoing MRI and FBx/SBx was conducted. Data from consecutive FBx/SBx were collected between August 2007 and February 2014, and PCPTRC scores using the PCPTRC2.0R-code were calculated. The risk of positive biopsy and high-grade cancer (Gleason ≥ 7) on biopsy was calculated and compared with overall and high-grade cancer detection rates (CDRs). Receiver operating characteristic curves were generated and the areas under the curves (AUCs) were compared using DeLong’s test. RESULTS: Of 595 men included in the study, PCa was detected in 39% (232) by SBx compared with 48% (287) on combined FBx/SBx biopsy. The PCPTRC AUCs for the CDR were similar (P = 0.70) for SBx (0.69) and combined biopsy (0.70). For high-grade disease, AUCs for SBx (0.71) and combined biopsy (0.70) were slightly higher, but were not statistically different (P = 0.55). CONCLUSIONS: In an MRI-screened population of men undergoing FBx, PCPTRC continues to represent a practical method of accurately stratifying PCa risk.

Multifocal and hereditary kidney cancers often require repeated ipsilateral nephron sparing procedures with higher blood loss and complication rates compared to first time renal surgery. Consequently, many surgeons avoid minimally invasive techniques in the setting. We present the characteristics, complications, and short-term renal functional outcomes of patients who underwent a repeat robotic partial nephrectomy (rRPNx).A database was retrospectively reviewed to identify patients who underwent robotic partial nephrectomies between January 2007 and December 2013. Selection criteria for the rRPNx cohort included patients who had undergone at least two ipsilateral renal surgeries, with the second procedure being an rRPNx. All other patients comprised the initial robotic partial nephrectomy (iRPNx) group.One hundred twenty-four patients who underwent robotic partial nephrectomy during the study period were identified. rRPNx constituted 26 (21%) of the total cases. Age of the rRPNx cohort was similar (p = 0.56), but number of tumors resected was two-fold greater in the rRPNx group (p = 0.44). Neither surgery time nor renal clamp time was significantly longer in either group (p = 0.18 and p = 0.65, respectively). Importantly, estimated blood loss (EBL) was significantly larger than in the iRPNx group (p = 0.01). Both groups had similar intravenous pain medication administration durations (p = 0.32), but postsurgical length of stay was greater for the rRPNx patients (p = 0.011). There were no significant differences in clavian complication rates (p = 0.17-0.39), with the exception of urine leak which occurred more frequently in the rRPNx group (p = 0.01). There was no difference in percent change in serum creatinine or estimated glomerular filtration rate (p = 0.89 and p = 0.67, respectively).rRPNx is safe and feasible in select patients. EBL, postoperative lengths of stay, and urine leak were the only factors significantly associated with rRPNx compared to iRPNx. Patient 3-month follow-up revealed excellent and comparable outcomes between the two groups.

The clinical role of fluorine-18 fluoro-2-deoxyglucose (FDG)-positron emission tomography (PET) in renal cell carcinoma (RCC) is still evolving. Use of FDG PET in RCC is currently not a standard investigation in the diagnosis and staging of RCC due to its renal excretion. This review focuses on the clinical role and current status of FDG PET and PET/CT in RCC. Studies investigating the role of FDG PET in localized RCC were largely disappointing. Several studies have demonstrated that the use of hybrid imaging PET/CT is feasible in evaluating the extra-renal disease. A current review of the literature determines PET/CT to be a valuable tool both in treatment decision-making and monitoring and in predicting the survival in recurrent and metastatic RCC. PET/CT might be a viable option in the evaluation of RCC, especially recurrent and metastatic disease. PET/CT has also shown to play a role in predicting survival and monitoring therapy response.

PURPOSE: Index tumor volume (ITV) measured on radical prostatectomy (RP) specimens has been shown to be associated with adverse pathologic and oncologic outcomes. We evaluate the value of ITV calculated from prostate multiparametric MRI (mpMRI) in predicting adverse clinical and pathologic outcomes. MATERIALS AND METHODS: Data from a prospectively maintained, single-institution database were analyzed for patients who underwent mpMRI prior to RP (2007–2016). Index tumor was defined as a T2-visible lesion with the longest diameter. Adverse pathologic outcomes were extraprostatic extension (EPE), lymph node invasion (LNI), seminal vesicle invasion (SVI), and positive margins (PM). Logistic and Cox proportional hazard regression were used to assess associations with adverse pathology and biochemical recurrence (BCR), respectively. RESULTS: Of the 455 patients included, EPE, LNI, SVI and PM were present in 23.5%, 6.2%, 5.5% and 15.7% patients, respectively. Patients with adverse pathologic outcomes had larger median ITV. ITV was found to be an independent predictor of EPE (OR 1.22, p = 0.010), LNI (OR 1.39, p = 0.001), and SVI (OR 1.28, p = 0.009), but not PM (OR 1.03, p = 0.522). Combination of ITV and PSA was found to have predictive ability comparable to that of modified Partin tables (EPE:ITV + PSA(AUC) = 0.71 vs. Partin(AUC) = 0.71; LNI:ITV + PSA(AUC) = 0.92 vs. Partin(AUC) = 0.90, SVI:ITV + PSA(AUC) = 0.78 vs. Partin(AUC) = 0.82). 5 year BCR-free survival (median follow-up 24.9 months) was higher for patients with ITV < 2 cc (84.1% vs. 58.5%, p = 0.001). However, ITV was not found to be an independent predictor of BCR (HR 1.69, p = 0.130). CONCLUSIONS: We demonstrate that ITV measured on mpMRI is a predictor of adverse pathologic and clinical outcomes and can aid in preoperative risk assessment.

INTRODUCTION AND OBJECTIVE: Focal therapy (FT) for localized prostate cancer (CaP) has been shown to have encouraging short-term oncological outcomes, excellent preservation of functional outcomes and is increasing in popularity in urologic community. We aim to evaluate the preferences and practice trends among urologists regarding this treatment strategy. METHODS: A 20 item online questionnaire was designed to collect information on urologists’ views and use of FT. The survey was sent to the members of the Endourological Society and the American Urological Association. Multivariate logistic regression analysis was done to determine predictors for utilization of FT. RESULTS: A total of 425 responses were received [American Urological Association: 319, Endourological Society: 106]. Mean age of respondents was 53(SD: 11.3) years. Although half of the respondents (50.8%) believed FT to be moderate to extremely beneficial in the treatment of CaP, only 24.2% (103) of the respondents currently utilize FT in their practice. Respondents who were fellowship trained in urologic oncology were more likely to consider FT to be at least moderately beneficial (P < 0.001). Surgeon’s experience (greater than 15 years in urology practice) (P = 0.025) and seeing more than 10 patients with new CaP diagnosis per month (P = 0.002) were independent predictors of FT utilization for localized CaP. While the most common setting for utilization of FT was in patients with unilateral intermediate-risk (72.8%) CaP, a small percentage of respondents also used FT for patients with unilateral high-risk CaP and bilateral intermediate risk (21.4% and 10.7%, respectively). Most common reasons for not using FT were the lack of belief in ‘index lesion theory’ (63.2%), lack of experience (41.3%), lack of belief in FT’s efficacy (41.1%), lack of infrastructure (35.8%), difficult salvage treatment in cases of recurrence (22.7%) and high cost (21.8%). About 57.6% would use FT more often in an office or outpatient setting if they had access to reliable and cost-effective options. CONCLUSIONS: Only a quarter of our respondents utilize FT in their practice with surgeon’s experience being the important independent predictor for using FT. Majority of respondents though consider FT to be beneficial in CaP management, would use it more often if provided more reliable and cost-effective options. Over time, experience and accessibility to reliable methods to perform FT may lead to further utilization of this novel treatment strategy.

PURPOSE: MRI-TRUS fusion biopsy (FBx) has proven efficacy in targeting suspicious areas that are traditionally missed by systematic 12-core biopsy (SBx). Midline prostate lesions are undersampled during SBx, as traditional approaches aim laterally during TRUS biopsy. The aim of our study was to determine the utility of FBx for targeting midline lesions identified on multiparametric MRI (mpMRI). METHODS: A review was performed of a prospectively maintained database of patients undergoing mpMRI followed by FBx and SBx from 2007 to 2015. Midline location was defined as any lesion crossing the midline on axial imaging and involving both prostatic lobes. Index lesion was defined as lesion with highest Gleason score on biopsy. Patient demographic, imaging, and histopathologic data were collected. Multivariate logistic regression was conducted to determine independent predictors of having clinically significant (CS) cancer (Gleason ≥ 7) in midline lesions. RESULTS: Out of 1266 patients, we identified 202 suspicious midline lesions in 190 patients [median (IQR) age 63 (10) years; PSA 7.6 (6.6)]. Eighty-eight (46.3 %) patients had cancer detection on FBx of midline lesion. A midline target represented the index lesion of the prostate in 63/190 (33.2 %) patients. Risk category upgrading based on FBx of a midline lesion compared to SBx occurred in 45/190 patients (23.7 %). On multivariate analysis, higher PSA (p = .001), lower MRI-derived prostate volume (p < .001), and moderate–high or high suspicion on mpMRI (p = .014) predicted CS cancer in midline lesions. CONCLUSIONS: MRI-TRUS FBx facilitates sampling of midline lesions. Integration of mpMRI and FBx for targeting of midline lesions improves detection of CS prostate cancer.

To identify the risk factors associated with development of postoperative elevation of creatine kinase (CK) and study its effect on renal function in patients who underwent complex multifocal partial nephrectomy (PN).Patients who underwent PN at National Cancer Institute between January 2007 and December 2012 were included in the study. Elevated serum CK was defined as2000 U/L. Kidney function was assessed using serum creatinine and estimated glomerular filtration rate (eGFR). Changes were reported as percent change from preoperative values and compared using the Wilcoxon test. Regression analysis was performed to identify the predictors of elevation in CK and decline in eGFR.From 407 total cases, 207 had adequate CK data for analysis. Median number of tumors removed was 3 (1-70). Median peak CK was 1458 (82-36,788). Forty-two percent developed CK elevation2000 U/L. Factors associated with postoperative elevation of CK 2000 were young age (p = 0.009), high BMI (p = 0.003) and operating room time (p 0.001). Although CK 2000 was associated with significantly greater decline in eGFR (37.4 vs. 20.3 %, p 0.001) in immediate postoperative period, this change largely resolved to a much less clinically relevant (9.2 vs 3.3 %, p = 0.040) change after 3 months. On multivariate analysis, postoperative elevation in CK was not found to be an independent factor determining renal function at 3 months.In our cohort, a significant proportion of patients developed CK elevations2000 U/L. While patients with elevated CK had more decline in eGFR in immediate postoperative period, postoperative elevations of CK did not appear to impact overall long-term renal function in patients undergoing PN.