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Purpose of review To systematically review the current literature to assess the role of radiomics in the detection and evaluation of prostate cancer (PCa). Recent findings Radiomics involves the high-throughput extraction of radiologic features from clinical imaging, using a panel of sophisticated data-characterization algorithms to make an objective and quantitative determination of diagnoses and clinical characteristics. Radiomics evaluation of existing clinical images would increase their clinical value in many cancer management pathways, including PCa. However, a consensus on the implementation of radiomics has not been established across different sites, delaying its implementation in clinical practice. There are many potential advantages to radiomics. The ability to extract features from existing clinical imaging is one such advantage. A second is the empiric nature of the analysis. The third lies in the application of new technologies, such as machine learning, to be able to evaluate large quantities of data to make clinical conclusions. In this systematic review, we identify publications regarding the role of radiomics in PCa detection and evaluation. Many of these studies noted that radiomics, when incorporated into predictive models, had an advantageous impact on detection of PCa, clinically significant PCa, and extracapsular extension. This may assist in individualized decision making not only for diagnosis of PCa, but also for surveillance and surgical planning. With additional validation in large sample sizes, and randomized, multicenter studies using a consensus driven methodology, radiomics has the potential to alter the landscape of PCa detection and management, necessitating further prospective randomized investigation. Summary Radiomics is a promising new field, allowing for high-throughput analysis of imaging features for PCa detection and evaluation. These features can be extracted from existing data; therefore, the potential for future study is immense.

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.

Simple Summary Prostate cancer is one of the most common cancers in men. Traditionally, prostate cancer is diagnosed via transrectal ultrasound-guided prostate biopsy, using a systematic random template. Using multiparametric magnetic resonance imaging, lesions suspicious for prostate cancer can be identified, and subsequently targeted on biopsy, allowing for increased diagnostic accuracy. This article reviewed the current literature surrounding various types of targeted biopsy, such as transperineal biopsy, allowing for comparison not only between targeted biopsy and systematic biopsy, but also between different varieties of targeted biopsy. Abstract In this review, we evaluated literature regarding different modalities for multiparametric magnetic resonance imaging (mpMRI) and mpMRI-targeted biopsy (TB) for the detection of prostate cancer (PCa). We identified studies evaluating systematic biopsy (SB) and TB in the same patient, thereby allowing each patient to serve as their own control. Although the evidence supports the accuracy of TB, there is still a proportion of clinically significant PCa (csPCa) that is detected only in SB, indicating the importance of maintaining SB in the diagnostic pathway, albeit with additional cost and morbidity. There is a growing subset of data which supports the role of TB alone, which may allow for increased efficiency and decreased complications. We also compared the literature on transrectal (TR) vs. transperineal (TP) TB. Although further high-level evidence is necessary, current evidence supports similar csPCa detection rate for both approaches. We also evaluated various TB techniques such as cognitive fusion biopsy (COG-TB) and in-bore biopsy (IB-TB). COG-TB has comparable detection rates to software fusion, but is operator-dependent and may have reduced accuracy for smaller lesions. IB-TB may allow for greater precision as lesions are directly targeted; however, this is costly and time-consuming, and does not account for MRI-invisible lesions.

PURPOSE OF REVIEW: The goal of this study is to review recent findings and evaluate the utility of MRI transrectal ultrasound fusion biopsy (FBx) techniques and discuss future directions. RECENT FINDINGS: FBx detects significantly higher rates of clinically significant prostate cancer (csPCa) than ultrasound-guided systematic prostate biopsy (SBx), particularly in repeat biopsy settings. FBx has also been shown to detect significantly lower rates of clinically insignificant prostate cancer. In addition, a dedicated prostate MRI can assist in more accurately predicting the Gleason score and provide further information regarding the index cancer location, prostate volume, and clinical stage. The ability to accurately evaluate specific lesions is vital to both focal therapy and active surveillance, for treatment selection, planning, and adequate follow-up. SUMMARY: FBx has been demonstrated in multiple high-quality studies to have improved performance in diagnosis of csPCa compared to SBx. The combination of FBx with novel technologies including radiomics, prostate-specific membrane antigen positron emission tomography (PSMA PET), and high-resolution micro-ultrasound may have the potential to further enhance this performance.

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: 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.

The Toyota Production System or Lean philosophy has been implemented in many facets of medicine from outpatient areas to critical care units to ancillary services. There has been some doubt about the applicability of this process outside of large private medical centers particularly in relationship to operating room services. We describe the success of the Lean process for the surgical services of a public, inner-city hospital. Lean methodology was applied to operating room (OR) performance measures of utilization, on-time starts, turn over time, and same day cancellations. Secondary measures of OR minutes used, OR cases completed, individual service cancellations for emergencies, and cross service bumping for emergencies were also evaluated. One years worth of data prior to the start of Lean was compared to one year after the completion of Lean. Improved performance was consistently demonstrated in all measures except same day cancellations.

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.

BACKGROUND: Prostate Imaging-Reporting and Data System version 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: 338 patients who underwent mpMRI May 2015–May 2016, with subsequent MRI/transrectal ultrasound fusion-guided biopsy. FIELD STRENGTH: 3T mpMRI [T2W, DWI (ADC map, b-2000 DWI acquisition), and 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. 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 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: We sought to determine whether saturation of the index lesion during magnetic resonance imaging-transrectal ultrasound fusion guided biopsy would decrease the rate of pathological upgrading from biopsy to radical prostatectomy. MATERIALS AND METHODS: We analyzed a prospectively maintained, single institution database for patients who underwent fusion and systematic biopsy followed by radical prostatectomy in 2010 to 2016. Index lesion was defined as the lesion with largest diameter on T2-weighted magnetic resonance imaging. In patients with a saturated index lesion transrectal fusion biopsy targets were obtained at 6 mm intervals along the long axis of the index lesion. In patients with a nonsaturated index lesion only 1 target was obtained from the lesion. Gleason 6, 7 and 8–10 were defined as low, intermediate and high risk, respectively. RESULTS: Included in the study were 208 consecutive patients, including 86 with a saturated and 122 with a nonsaturated lesion. Median patient age was 62.0 years (IQR 10.0) and median prostate specific antigen was 7.1 ng/ml (IQR 8.0). The median number of biopsy cores per index lesion was higher in the saturated lesion group (4 vs 2, p

Background Emergency department thoracotomy (EDT) is a formidable and dramatic last attempt by the trauma surgeon to save the life of a patient in extremis. The aim of this report is to provide a benchmark for comparison with past results by reviewing all available published data since the American College of Surgeons Committee on Trauma review article in 2001, which reviewed literature from 1966 to 1999 regarding indications for and outcomes of EDT. Methods A comprehensive literature search in MEDLINE Library databases was performed for EDT. Data were extracted by three independent reviewers. Results We identified 37 papers with a total of 3466 patients. A total of 85.2% (1720 of the 2018) had penetrating trauma, 58.3% (372 of the 638) had cardiac injuries, 43.0% (251 of the 584) had thoracic injuries and 26.2% (143 of the 546) had abdominal injuries. The overall rate survival in this review was 8% (267 of the 3466, range 0–33.3%). Of 25 papers reporting cases of EDT for penetrating traumas, their survival rate was 9.8% (169 of the 1719, range 0–45.5); similarly, of 14 papers assessing EDT for blunt injuries, the survival rate was 5.2% (24 of the 460, range 0–12.2). Of 15 papers reporting neurological outcomes 84.6% (143 of the 169, range 50–100%) of patients returned to baseline. The survival outcome of EDT in US experience versus non-US experiences was 6.3% (164 of the 2612, range 0–14.9) versus 11.9% (89 of the 745, range 0–33.3) respectively. Conclusion The authors intend this review to serve as a practical and prompt literature search tool for all surgeons who encounter resuscitative thoracotomy in their practice.

Although prostate cancer is the most common non-cutaneous cancer in men, it is traditionally diagnosed with a non-targeted, systematic transrectal ultrasound prostate biopsy (TRUS-Bx). This technique has been demonstrated to both under-detect clinically significant (CS) cancer and over-detect clinically insignificant cancer, and performs poorly in patients with a prior negative biopsy. With recent advances in MRI technology, most prominently the advent of multiparametric MRI, MRI-targeted prostate biopsy (MRI-TB) has been gaining favor as a more accurate alternative to TRUS-Bx. In this review, we attempt to summarize the current literature on MRI-TB and to determine if there is evidence supporting the use of MRI-TB alone.The literature was reviewed for articles pertaining to MRI-TB and its performance compared to systematic biopsy.Most studies support the increased sensitivity of MRI-TB (0.90, 95% CI 0.85-0.94) compared to TRUS-Bx (0.79, 95% CI 0.68-0.87) for the detection of CS prostate cancer, as MRI-TB can detect up to 30% more high risk and 17% fewer low risk cancers. MRI-TB also tends to perform better than TRUS-Bx in patients with prior negative biopsy, as TRUS-Bx may miss up to half of CS cancers detected by MRI-TB, and in those with lesions at atypical locations. However, as the technology for imaging and image-guided biopsies continues to develop, there is still a role for TRUS-Bx in the management of patients with prostate cancer.Our analysis of the literature suggests that although MRI-TB is superior to TRUS-Bx, there is still a role for traditional systematic biopsy.

The ability to return to work (RTW) postinjury is one of the primary goals of rehabilitation. The modified Rankin Scale (mRS) is a validated simple scale used to assess the functional status of stroke patients during rehabilitation. We sought to determine the applicability of mRS in predicting RTW postinjury in a general trauma population. The trauma registry was queried for patients, aged 18 to 65 years, discharged from 2012 to 2013. A telephone interview for each patient included questions about employment status and physical ability to determine the mRS. Patients who had RTW postinjury were compared with those who had not (nRTW). Two hundred and thirty-four patients met the inclusion criteria. Of these, 171 (72.5%) patients RTW and 63 (26.7%) did nRTW. Patients who did nRTW were significantly older, had longer length of stay and higher rates of in-hospital complications. Multivariate analysis revealed that older patients were less likely to RTW (odds ratio = 0.961, P = 0.011) and patients with a modified Rankin score ≤2 were 15 times more likely to RTW (odds ratio = 14.932, P < 0.001). In conclusion, an mRS ≤2 was independently associated with a high likelihood of returning to work postinjury. This is the first study that shows applicability of the mRS for predicting RTW postinjury in a trauma population.

Emergency department thoracotomy (EDT) is a formidable and dramatic last attempt by the trauma surgeon to save the life of a patient in extremis. The aim of this report is to provide a benchmark for comparison with past results by reviewing all available published data since the American College of Surgeons Committee on Trauma review article in 2001, which reviewed literature from 1966 to 1999 regarding indications for and outcomes of EDT.A comprehensive literature search in MEDLINE Library databases was performed for EDT. Data were extracted by three independent reviewers.We identified 37 papers with a total of 3466 patients. A total of 85.2% (1720 of the 2018) had penetrating trauma, 58.3% (372 of the 638) had cardiac injuries, 43.0% (251 of the 584) had thoracic injuries and 26.2% (143 of the 546) had abdominal injuries. The overall rate survival in this review was 8% (267 of the 3466, range 0-33.3%). Of 25 papers reporting cases of EDT for penetrating traumas, their survival rate was 9.8% (169 of the 1719, range 0-45.5); similarly, of 14 papers assessing EDT for blunt injuries, the survival rate was 5.2% (24 of the 460, range 0-12.2). Of 15 papers reporting neurological outcomes 84.6% (143 of the 169, range 50-100%) of patients returned to baseline. The survival outcome of EDT in US experience versus non-US experiences was 6.3% (164 of the 2612, range 0-14.9) versus 11.9% (89 of the 745, range 0-33.3) respectively.The authors intend this review to serve as a practical and prompt literature search tool for all surgeons who encounter resuscitative thoracotomy in their practice.

Open surgical repair of thoracoabdominal aortic aneurysms remains associated with significant morbidity and mortality. We sought to analyse multicentre national data on early outcomes of open surgical thoracoabdominal aortic aneurysm repair. Patients who underwent open repair of thoracoabdominal aortic aneurysm from 2005 to 2010 were identified from the National Surgical Quality Improvement Program database. The primary endpoint was mortality at 30 days. Patient demographics, clinical variables, and intraoperative parameters were analysed by univariate and multivariate logistic regression methods to identify risk factors for mortality. Of the 682 elective repairs, 30-day outcomes of elective repairs were: 10.0% mortality, 21.6% surgical complications, 42.2% pulmonary complications, 17.2% renal complications, 12.9% cardiovascular complications, 19.2% septic complications, and 6.6% wound complications. Multivariate logistic regression analysis showed that age, ASA-class IV, dependent functional status prior to surgery, and operation time are independent risk factors for mortality. Our study found a higher rate of mortality nationwide, as compared to several previous single center studies.

e540 Background: Magnetic resonance imaging (MRI)/transrectal ultrasound (TRUS) fusion-guided prostate biopsy (FBx) has rapidly proliferated in prostate cancer evaluation. FBx success may be dependent on multiple factors, including skills learned with user experience and the type of ultrasound (US) probe used. Our objective of this study was to compare the accuracy of the MRI/TRUS FBx technique utilizing an end fire versus a side fire US probe on an FBx platform. Methods: The participants of the study consisted of three different experience levels (expert ( > 1000 FBx), Urology fellows with none to minimal FBx experience, Urology residents with no FBx experience). Each participant performed three trials of the FBx with the UroNav System in separate phantom models of the prostate. Each trial involved targeting the same set of fiducials through FBx platform and then using US only; first using an end fire US probe, and then using a side fire US probe. Fusion registration error (FRE) was defined as the distance between MR target and transformed core location from the US only biopsy. Results: Six users with 3 different experience levels performed the FBx. Mean FRE with the end fire probe for the residents, fellows, expert was 7.42(±0.11), 5.10(±0.73) & 3.75(±0.75) respectively. Mean FRE with the side fire probe for the residents, fellows, expert was 6.08(±0.09), 4.76(±0.68) & 3.46(±0.08) respectively. There was no significant difference between the FRE averages for end fire vs. side fire. There was an inverse relationship of mean FRE with user experience level (corr. coefficient (r) = -0.79, p = 0.011 for end fire; r = -0.84, p = 0.004 for side-fire). Conclusions: We report the results of a pilot study comparing the efficacy of side fire and end fire US probes in MRI/TRUS FBx. Our preliminary results suggest the type of US probe used does not significantly affect FRE and FBx performance. As expected, FRE decreases with increased user experience. A larger study with more participants will be needed to compare these probes with adequately powered analysis and will dictate the practice in clinical settings as minimization of FRE will improve diagnostic accuracy of this technique in detecting clinically significant cancer.

59 Background: Pathologic progression is identified in > 25% of prostate cancer (CaP) patients on active surveillance (AS). Yet, identifying patients at risk for progression is limited to PSA based biomarkers with variable utility. Multiparametric MRI (mpMRI) with fusion-guided prostate biopsy (FBx) has shown utility in risk stratification for patients considering AS. We compared mpMRI characteristics with PSA kinetics for the prediction of pathologic progression in AS patients. Methods: A review of men on AS with serial mpMRI and 2 or more FBx sessions was performed. FBx sessions consisted of targeted biopsies and a 12 core systematic biopsy. Men who met NIH Expanded AS criteria included those with low and intermediate risk CaP, Gleason score ≤ 3+4 = 7 with no restriction on percent core involvement or number of cores positive. Progression was defined by patients with initial Gleason 3+3 = 6 to any Gleason 4, and Gleason 3+4 = 7 to a primary Gleason 4 or higher. MRI progression was defined as increase in suspicion score, size, or new lesion on follow-up. PSA velocity (PSAV) > 0.75ng/ml/yr, PSA doubling time (PSAdt) < 3 yrs, and imaging characteristics were examined for association with pathologic progression at surveillance biopsy. Results: A total of 164 men, median age of 63 yrs [58-67], were included. Median length of follow up was 19.4 months [IQR 14.3-30.0]. Median PSA, and prostate volume of our cohort were 4.9ng/ml [3.3-7.3] and 47.0ml [36.5-59.8]. The sensitivity and specificity of predicting pathologic progression by mpMRI, PSAV and PSAdt were 45% and 65%, 30% and 76%, and 17% and 86% respectively. A combination of MRI, and PSAV or PSAdt yielded a sensitivity and specificity of 61% and 49% or 54% and 56% respectively. Using a decision curve analysis, mpMRI offers minimal benefit for predicting pathologic progression of CaP. Conclusions: MpMRI alone marginally outperforms PSA kinetics for predicting pathologic progression in men on AS for CaP. The combination of mpMRI along with PSA parameters increase the sensitivity of prostate imaging in identifying progression in AS patients. Research in combinations of imaging with other biomarkers will be needed to more accurately risk stratify AS patients.

15 Background: To determine the effect of learning curves and changes in fusion platform during 9 years of NCI’s experience with multiparametric MRI (mpMRI)/TRUS fusion biopsy. Methods: A review was performed of a prospectively maintained database of patients undergoing mpMRI followed by fusion biopsy (Fbx) and systematic biopsy (Sbx) from 2007−2016. The patients were stratified based on the timing of first biopsy in 3 groups. Cohort 1 included patients biopsied between 7/2007−12/2010, accounting for learning curve at our institution. Cohort 2 included patients biopsied from 1/2011 up to the debut of UroNav (Invivo) platform in 5/2013. Cohort 3 included patients biopsied after 5/2013. Clinically significant (CS) disease was defined as Gleason 7 (3+4) or higher. Cancer detection rates (CDR) between Sbx and Fbx during different time periods were compared using McNemar’s test. Age and PSA standardized CDRs were calculated for comparison between 3 cohorts. Results: 1528 patients were included in the study with 219, 549 and 761 patients included in 3 respective cohorts. Mean age, PSA and race distribution were similar across 3 cohorts. In cohort 1 there was no significant difference between CDR of CS disease by Fbx (24.7%) vs Sbx (21.5%), p = 0.377. Fbx was significantly better than Sbx in detection of CS disease in cohort 2 and cohort 3 (31.5% vs 25.3%, p = 0.001; 36.5% vs 30.2%, p < 0.001, respectively). There was significant decline in detection of low risk disease by Fbx compared to Sbx in the same period (cohort 2: 14.2% vs 20.9%, p < 0.001; cohort 3: 12.5% vs 19.5%, p < 0.001). Age and PSA standardized CDR of CS cancer by Fbx increased significantly between each successive cohort (cohort 1 and 2: 5.2%, 95% CI [2.1-8.5]), 2 and 3 (5.2%, 95% CI [1.8-8.6]). Conclusions: Our results show that after an early learning period using Fbx, CS prostate cancer was detected at significantly higher rates with Fbx than with Sbx, and low risk disease was detected at lower rates. Advances in software allowed for even greater detection of CS disease in the last cohort. This study shows that accuracy of Fbx is dependent on multiple factors; surgeon/radiologist experience and software improvements together produce improved accuracy.

32 Background: Several studies have demonstrated an association in prostate cancer patients between the tumor volume of the index lesion calculated from whole mount pathology after radical prostatectomy and biochemical recurrence (BCR). We aimed to evaluate whether the index lesion tumor volume (ILTV) measured on MRI would have similar predictive ability. Methods: Clinical and pathologic data from a prospectively maintained, single-institution database was analyzed for 501 patients who underwent RARP (without prior therapy) between 2007 and 2016. Patients were excluded if they were found to have metastatic disease on pathology or if postoperative PSA ≥ 0.2ng/ml after RARP. ILTV was calculated from T2W MRI by multiplying length by width by depth by 0.52. Tumor volume was stratified into two categories based on the cutoff of 2cm3. BCR was defined as 2 PSA values ≥ 0.2 ng/ml, 1 PSA value ≥ 0.4 ng/ml, or receipt of radiation therapy/hormonal therapy after RARP. Cox proportional hazard regression was used to assess associations of clinical, imaging, and histopathological variables with BCR. Results: The median age of our cohort was 60 years (IQR 10) and median PSA was 6.20 ng/ml (IQR 6). Of the 493 patients who met our inclusion criteria, 55 (11.2%) experienced BCR. Patients with ILTV > 2cc had a higher incidence of BCR compared to those with ILTV < 2cc (18.0% vs 8.8%, p = 0.008). On univariate analysis, age (HR 0.96, p = 0.026), PSA (HR 1.04, p < 0.001), black race (HR 1.816, p = 0.047), Gleason 8-10 on biopsy (HR 3.725, p < 0.001), and ILTV (HR 2.496, p = 0.002) were significant for prediction of BCR. Although age (HR 0.955, p = 0.021), PSA (HR 1.029, p = 0.013), and Gleason 8-10 on biopsy (HR3.367, p < 0.001) were found to be independent predictors of BCR, tumor volume was not found to be an independent predictor (HR 0.960, p = 0.642). Conclusions: Although ILTV alone was predictive of BCR, ILTV was not found to be an independent predictor of BCR, indicating that at this time, MRI cannot yet measure ILTV with enough accuracy to predict oncologic outcomes. As imaging technology improves, ILVT may provide additional prognostic information.

e541 Background: Focal therapy (FT) for localized prostate cancer (PCa) 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 upcoming treatment strategy. Methods: An anonymous online questionnaire was designed to collect information on urologists’ views and use of focal therapy. The survey was sent to members of the Endourological Society (ES) and American Urological Association (AUA). Multivariate logistic regression analysis was done to determine predictors for utilization of FT for localized prostate cancer. Results: A total of 383 responses were received [AUA: 342, ES: 41]. Mean age of respondents was 43(±11.2) years. Although about half of the respondents (51.4%) believed FT to be moderate to extremely beneficial in the treatment of PCa, only 23% (89) of the respondents currently utilize FT in their practice. While the most common setting for utilization of FT was in patients with unilateral intermediate risk (75.2%) PCa, a small percentage of respondents also used FT for patients with bilateral intermediate risk and unilateral high risk PCa (9% and 7% respectively). The most common FT modality was Cryoablation in 62% followed by High Intensity Focused Ultrasound in 44%. Most common reasons for not using focal therapy were the lack of belief in ‘index lesion theory’ (186) (63.2%) followed by the lack of experience (121) (41.1%). About 58.2% respondents would use FT often in an office or outpatient setting if they had access to reliable and cost effective options. Surgeon’s experience (practice for more than 15 years) (p = 0.035) was the only independent predictor for utilizing FT in localized PCa. Conclusions: Only a quarter of our respondents utilize FT in their practice with surgeon’s experience being the only independent predictor for utilizing FT. Majority of respondents though consider FT to be beneficial in prostate cancer management would use it more often if they provided more reliable and cost effective options. Over time experience and accessibility to reliable methods to perform FT may lead to further use of this novel treatment.

31 Background: To determine the accuracy of multiparametric MRI (mpMRI) and fusion biopsy in predicting focal therapy candidates by correlating agreement between patients’ pre-prostatectomy MRI and biopsy findings with whole mount pathology. Methods: Patients who underwent mpMRI and biopsy followed by prostatectomy between 2010-2015 were included in the study. Patients were considered good candidates for focal therapy if they had intermediate risk cancer (max Gleason 3+4 or 4+3 on biopsy) in only one hemisphere of the prostate, and if they had an mpMRI visible lesion(s) on one hemisphere that did not cross midline. Patients were considered poor candidates for focal therapy if they had either low risk cancer (Gleason 6), high risk cancer (Gleason 8, 9 and 10), intermediate risk cancer bilaterally, MRI visible lesions that cross the midline, or contained extracapsular extension or seminal vesicle invasion. Whole mounts of patients considered good candidates were then examined histologically for maximum tumor involvement. Results: 501 patients who underwent prostatectomy between 2010 and 2015 were included in the study, with mean age 60.0 (±10.0) and PSA 6.21 (±6.0). 395 patients were considered poor focal candidates, and 106 were considered good focal candidates. Of these 106, 66 patients had whole mounts available for analysis (14 random biopsy, 52 fusion biopsy). 42/66 (63.6%) patients were confirmed as candidates (6/14 (42.9%) who had random biopsy and 36/52 (68.0%) who had fusion). Candidates failed prediction due to Gleason upgrade in final histopathology in 20/24 (83.3%), and for significant Gleason detection bilaterally in 4/24 (16.7%). Conclusions: Our results suggest that application of mpMRI and biopsy criteria to predict focal therapy candidates may result in undertreatment of a large portion of patients with significant cancer. Results from mpMRI guided targeted biopsy were shown to be a more accurate tool for predicting candidates for focal therapy than results from random biopsy alone. More accurate predictive capability is needed before focal therapy can be widely accepted.

43 Background: Tumor volume measured on postoperative pathology has been shown to be associated with adverse pathologic and oncologic outcomes. Advances in imaging technology may facilitate the prediction of these outcomes prior to surgery. In this study, we evaluated the predictive value of tumor volume of the index lesion (ILTV) calculated from prostate MRI in analyzing adverse pathologic outcomes following radical prostatectomy (RARP). Methods: Clinical and pathologic data from a prospectively maintained, single-institution database was analyzed for patients who underwent 3T MRI prior to RARP (without prior therapy) between 2007 and 2016. ILTV was calculated from T2W MRI by multiplying length by width by depth by 0.52. Adverse pathologic outcomes were determined on whole mount prostatectomy specimens, and defined as positive margins (PM), extracapsular extension (ECE), positive lymph nodes (LNI), and seminal vesicle invasion (SVI). Logistic regression was used to assess associations of clinical, imaging, and histopathological variables with adverse pathologic features. Results: From the 501 patients who underwent RARP, 490 received MRI prior to surgery. The median age of our cohort of was 60 years (IQR 10), and median PSA was 6.21 ng/ml (IQR 6). There were 74/480 patients (15.4%) with PM, 112/474 (23.6%) with ECE, 30/478 (6.4%) with LNI, and 32/482 (6.7%) with SVI. Patients with adverse outcomes had larger ILTV compared to those without (PM: 1.038cc vs 0.807cc, p=0.041; ECE: 1.388cc vs 0.765cc, p

Background Toxic colitis (TC) is a potentially lethal complication of inflammatory bowel disease and infectious colitis. Methods The National Surgical Quality Improvement Project dataset was queried to identify emergent colectomy for a primary diagnosis of TC using International Classification of Diseases, Ninth Revision codes. The study endpoints were 30-day mortality and 30-day morbidity. We performed multivariate logistic regression analyses to study factors associated with 30-day mortality. Results Of the 189 TC patients, mortality for colectomy was 26.5%, 42.3% experienced pulmonary complications, 20.6% experienced sepsis complications, 17.5% experienced cardiovascular complications, 12.7% experienced renal complications, and 14.8% experienced wound complications. On multivariate analysis, independent factors associated with mortality were age 70 to 80 years (odds ratio [OR] 3.5), age greater than 80 (OR 22.2), female sex (OR 4.1), uremia blood urea nitrogen greater than 40 (OR 4.1), coagulopathy international normalized ratio greater than 2 (OR 7.7), preoperative respiratory failure (OR 2.73), and preoperative steroid use (OR 3.9). Conclusions Patients with TC are very ill. Poor outcome is associated with older age, female sex, preoperative azotemia, preoperative respiratory failure, and chronic steroid use. These factors will help acute care surgeons in preoperative risk assessment and could be an important addition to decision-making strategies.