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Prediction models are recommended by national guidelines to support clinical decision making in prostate cancer. Existing models to predict pathological outcomes of radical prostatectomy (RP)-the Memorial Sloan Kettering (MSK) models, Partin tables, and the Briganti nomogram-have been developed using data from tertiary care centers and may not generalize well to other settings.Data from a regional cohort (Michigan Urological Surgery Improvement Collaborative [MUSIC]) were used to develop models to predict extraprostatic extension (EPE), seminal vesicle invasion (SVI), lymph node invasion (LNI), and nonorgan-confined disease (NOCD) in patients undergoing RP. The MUSIC models were compared against the MSK models, Partin tables, and Briganti nomogram (for LNI) using data from a national cohort (Surveillance, Epidemiology, and End Results [SEER] registry).We identified 7,491 eligible patients in the SEER registry. The MUSIC model had good discrimination (SEER AUC EPE: 0.77; SVI: 0.80; LNI: 0.83; NOCD: 0.77) and was well calibrated. While the MSK models had similar discrimination to the MUSIC models (SEER AUC EPE: 0.76; SVI: 0.80; LNI: 0.84; NOCD: 0.76), they overestimated the risk of EPE, LNI, and NOCD. The Partin tables had inferior discrimination (SEER AUC EPE: 0.67; SVI: 0.76; LNI: 0.69; NOCD: 0.72) as compared to other models. The Briganti LNI nomogram had an AUC of 0.81 in SEER but overestimated the risk.New models developed using the MUSIC registry outperformed existing models and should be considered as potential replacements for the prediction of pathological outcomes in prostate cancer.

Objectives To evaluate patient, provider, and facility factors associated with variation in opioid prescribing after endoscopic procedures for benign prostatic hyperplasia across a large academic health system to drive improvement efforts. Methods Opioids prescribed at discharge for patients who underwent an endoscopic prostate procedure March 2018-November 2019 were analyzed. Multivariable logistic and linear regression were used to evaluate the relationship between patient, provider, and facility factors and the receipt of any opioid prescription and the quantity prescribed. Results We included 724 patients who had surgery with one of 26 urologists across five facilities. 222 (30.7%) received an opioid prescription, and the average morphine milligram equivalents (MMEs) prescribed was 97.9±33.5. We found wide variation in the proportion of patients who received an opioid prescription across surgeons (range 0%-88.9%) and facilities (range 19.9%-66.7%) and the average MMEs prescribed (range 25-188.5). Outpatient surgery (OR 2.32; 95% confidence interval [CI] 1.22-4.40, P = .010) and preoperative opioid use (OR 15.04; CI 9.65-23.45, P Conclusions Opioid prescribing following endoscopic prostate procedures varied widely. Targeted interventions tailored to younger patients, those taking opioids preoperatively, recipients of outpatient surgery and those undergoing surgery at satellite facilities may be particularly high yield given the association between these factors and increased postoperative prescribing.

Introduction:Understanding best practices in perioperative care is critical for quality of care for our urology patients. We compiled a single, concise resource that provides recommendation...

Introduction:We summarize the 2018 AUA (American Urological Association) Quality Improvement Summit, Opioid Stewardship in Urology, highlighting appropriate urological opioid use as well as...

With anecdotal observations of atypical recurrences following minimally invasive surgery and alongside new concerns following cervical cancer surgery, there is a need to evaluate cancer specific outcomes for minimally invasive kidney cancer surgery using national data. We evaluated cancer specific outcomes following minimally invasive surgery vs open surgery for early stage kidney cancer.We performed a retrospective population based cohort study using data from the SEER (Surveillance, Epidemiology, and End Results) program linked with Medicare claims that included beneficiaries at least 66 years old diagnosed between 2004 and 2013 with early stage, nonurothelial kidney cancer who underwent surgical resection within a year of diagnosis. We compared overall survival, disease specific survival, rate of second kidney cancer surgery and rate of postoperative systemic cancer therapy based on whether surgery was minimally invasive surgery or an open resection. Multivariable regression was used to account for confounders.A total of 5,150 patients were included in analysis and 3,062 (59.5%) underwent minimally invasive surgery. On multivariable analysis minimally invasive surgery was not associated with differences in overall survival (HR 0.94, 95% CI 0.84-1.06) or disease specific survival (HR 0.96, 95% CI 0.83-1.11). Patients treated with minimally invasive surgery were more likely to receive systemic cancer therapy (HR 1.31, 95% CI 1.09-1.59). No difference in the rate of second surgery associated with surgical approach was observed.Use of minimally invasive surgery for early stage kidney cancer was not associated with differences in overall or disease specific survival, or the rate of second kidney cancer surgery. Patients treated with minimally invasive surgery received more postoperative systemic therapy, which could represent a disparate cancer specific outcome associated with minimally invasive surgery.

This study examined the relationship between stimulant medications used for the treatment of attention deficit hyperactivity disorder and semen parameters. We performed a retrospective cohort study at a large, academic institution between 2002 and 2020. We included men with a semen analysis without prior spermatotoxic medication use, empiric medical therapy exposure or confounding medical diagnoses (varicocele, Klinefelter’s syndrome, cryptorchidism, cystic fibrosis, diabetes, cancer or cancer-related treatment, and azoospermia). Men were stratified by stimulant exposure (methylphenidate or amphetamines). A multivariable linear regression was fit to assess the association between individual semen parameters, age, stimulant exposure and non-stimulant medication use. Of 8,861 men identified, 106 men had active prescriptions for stimulants within 90 days prior to semen testing. After controlling for age and exposure to non-stimulant medications, stimulant use was associated with decreased total motile sperm count (β: −18.00 mil/ejaculate and standard error: 8.44, p = 0.033) in the setting of decreased semen volume (β: −0.35 ml, and standard error: 0.16, p = 0.035), but not sperm concentration, motility and morphology. These findings suggest a role for reproductive physicians and mental health providers to consider counselling men on the potential negative impact of stimulants prescribed for attention deficit hyperactivity disorder on semen volume during fertility planning.

INTRODUCTION AND OBJECTIVE:Prior work has shown that detrusor muscle sampling (MS) from transurethral resection of bladder tumor (TURBT) is related to oncologic outcomes. It is unknown if surgeon s...

INTRODUCTION AND OBJECTIVE:Recent work shows that reproductive endocrinologists (REI) are the primary referral base for reproductive urologists; however, many men with infertility do not undergo fe...

INTRODUCTION AND OBJECTIVE:Transperineal (TP) biopsy and adoption of magnetic resonance imaging (MRI) prior to biopsy are both increasingly utilized. Few studies have examined the cost-effectivenes...

TPS286 Background: Most patients (pts) who die of prostate cancer (pca) had potentially curable localized disease when first diagnosed, but their cancer subsequently relapsed to an incurable state. Neoadjuvant intense androgen deprivation therapy (ADT) has led to exceptional pathologic responses in up to 30% of pts with intermediate or high risk localized disease, with evidence of longer term clinical benefit. Prostate cancers with loss of the tumor suppressor gene PTEN, however, are resistant to neoadjuvant therapy that only targets the Androgen Receptor. Ipatasertib has shown efficacy in metastatic castration resistant prostate cancer (mCRPC), especially in pts with tumors that lack PTEN. Methods: This is a single arm study of darolutamide 600 mg BID, ipatasertib, and ADT. The initial phase I portion includes pts with nonmetastatic or mCRPC. Pts start with a lead-in of ipatasertib for 7 days, followed by ipatasertib combined with darolutamide 600 mg BID. The dose limiting toxicity period is the first 4 weeks of combination therapy. The phase I portion will enroll 6-18 pts. The phase II portion is given neoadjuvantly and includes pts with high risk localized pca. Pts receive up to 24 weeks of darolutamide 600 mg BID and ipatasertib at the recommended phase II dose (RP2D), followed by prostatectomy 14-42 days after cycle 6. The phase II portion will enroll up to 20 pts (17 evaluable pts) with high risk pca, with an early evaluation for efficacy after 9 pts are enrolled and with an additional stopping rule for safety. Key eligibility criteria for the phase II portion include 2 or more cores of grade group 4 or higher cancer on prostate needle biopsy or grade group 3 or higher with T3 or T4 disease, no distant metastatic disease, and PTEN loss (defined as 50% or more of tumor tissue being negative for PTEN expression). Exclusion criteria for both portions include small cell carcinoma, bowel inflammation, lung disease, diabetes mellitus requiring insulin, and conditions requiring strong CYP3A inducers or inhibitors. The primary endpoint for the phase I lead-in is to identify the RP2D of ipatasertib. The primary endpoint for the phase II portion is the combined rate of pathologic complete response (defined as absence of pathologic disease on hematoxylin and eosin (H&E) stain (ypT0)), or with presence of minimal residual disease ( < 5 mm linearly). We employ a Simon MiniMax two-stage design with 90.5% power to detect the difference between the null hypothesis (5% or less response rate) and the alternative hypothesis (30% response rate) with one-sided type I error of 0.05. Key secondary endpoints are safety, 2 year biochemical recurrence free survival, and rate of PSA0 (undetectable PSA with testosterone recovery and no additional therapy). Enrollment to the phase 1 portion began in September 2021, and the study is available at select Big Ten institutions. Clinical trial information: NCT04737109.

To assess the impact of confirmatory tests on active surveillance (AS) biopsy disease reclassification and progression to treatment in men with favorable risk prostate cancer (FRPC).We searched the MUSIC registry for men with FRPC managed with AS without or with a confirmatory test. Confirmatory tests included (1) repeat prostate biopsy, (2) genomic tests, (3) prostate magnetic resonance imaging (MRI), or (4) MRI followed by a post-MRI biopsy. Confirmatory test results were deemed reassuring (RA) or nonreassuring (nonRA) according to predefined criteria. Kaplan-Meier curves and multivariable Cox regression models were used to compare surveillance biopsy disease reclassification-free survival and treatment-free survival.Of the 2,514 men with FRPC who were managed on AS, 1211 (48%) men obtained a confirmatory test. We noted differences in the 12-month unadjusted surveillance biopsy disease reclassification-free probability (68%, 83%, and 90%, P.0001) and 24-month unadjusted treatment-free probability (55%, 81%, and 79%, P.0001), for men with nonRA confirmatory tests, no confirmatory test, and RA confirmatory tests, respectively. Excluding patients with genomic confirmatory tests, men with RA confirmatory tests were associated with a lower hazard (hazard ratio [HR] 0.57, 95% confidence interval [CI] 0.38-0.84, P = .005) and men with nonRA confirmatory tests had an increased hazard (HR 1.97, 95% CI 1.22-3.19, P = .006) of surveillance disease reclassification compared with men without confirmatory tests in the multivariable model.These data suggest men with RA confirmatory tests have less surveillance biopsy reclassification and remain on AS longer than men with nonRA test results. Confirmatory tests may help risk stratify men considering active surveillance.

Surgical castration for metastatic prostate cancer is used less frequently than medical castration yet costs less, requires less followup and may be associated with fewer adverse effects. We evaluated temporal trends and factors associated with the use of surgical castration.This retrospective cohort study sampled 24,805 men with newly diagnosed (de novo) metastatic prostate cancer from a national cancer registry in the United States (2004 to 2016). Multivariable logistic regression assessed the association between sociodemographic factors and surgery. Multivariable Cox regression evaluated the association between castration type and overall survival.Overall 5.4% of men underwent surgical castration. This figure decreased from 8.5% in 2004 to 3.5% in 2016 (per year later OR 0.89, 95% CI 0.87-0.91, p0.001). Compared to Medicare, private insurance was associated with less surgery (OR 0.73, 95% CI 0.61-0.87, p0.001) while Medicaid or no insurance was associated with more surgery (OR 1.68, 95% CI 1.34-2.11, p0.001 and OR 2.12, 95% CI 1.58-2.85, p0.001, respectively). Regional median income greater than $63,000 was associated with less surgery (vs income less than $38,000 OR 0.61, 95% CI 0.43-0.85, p=0.004). After a median followup of 30 months castration type was not associated with differences in survival (surgical vs medical HR 1.02, 95% CI 0.95-1.09, p=0.6).In a contemporary, real-world cohort surgical castration use is low and decreasing despite its potential advantages and similar survival rate compared to medical castration. Men with potentially limited health care access undergo more surgery, perhaps reflecting a provider bias toward the perceived benefit of permanent castration.

To evaluate the integration of 3T nonendorectal coil multiparametric prostate magnetic resonance imaging (mpMRI) at 2 high-volume practices that routinely use mpMRI in the setting of active surveillance.This was an institutional review board-approved, Health Insurance Portability and Accountability Act-compliant, and dual-institution retrospective cohort study. Subjects undergoing 3T mpMRI without endorectal coil at either study institution over a 13-month period (August 1, 2015-August 31, 2016) were selected based on predefined criteria: clinical T1/T2 Gleason 6 prostate cancer, prostate-specific antigen15 ng/mL, ≥40 years old, mpMRI within 2 years of prostate biopsy, and Prostate Imaging Reporting and Data System (PI-RADS) v2 score assigned. Subjects surveilled for Gleason ≥3 + 4 prostate cancer were excluded. The primary outcome was detection of Gleason ≥3 + 4 prostate cancer on magnetic resonance-ultrasound fusion biopsy, standard biopsy, or prostatectomy within 6 months following mpMRI. Positive predictive values (PPVs) were calculated.A total of 286 subjects (N = 193 from institution 1, N = 93 from institution 2) met the criteria. Most (87% [90 of 104]) with maximum PI-RADS v2 scores of 1-2 did not receive immediate biopsy or treatment and remained on active surveillance. Incidence and PPVs for PI-RADS v2 scores of ≥3 were the following: PI-RADS 3 (n = 57 [20%], PPV 21% [6 of 29]), PI-RADS 4 (n = 96 [34%], PPV 51% [39 of 77]), and PI-RADS 5 (n = 29 [13%], PPV 71% [20 of 28]). No Gleason ≥4 + 3 prostate cancer was identified for PI-RADS v2 scores of 1-3 (0 of 43 with histology). Following mpMRI and subsequent biopsy, 21% (61 of 286) of subjects were removed from active surveillance and underwent definitive therapy.The 3T nonendorectal coil mpMRI has been integrated into the care of patients on active surveillance and effectively stratifies risk of Gleason ≥3 + 4 prostate cancer in this population.

Objectives To determine whether a needle disinfectant step during transrectal ultrasonography (TRUS)-guided prostate biopsy is associated with lower rates of infection-related hospitalisation. Patients and methods We conducted a retrospective analysis of all TRUS-guided prostate biopsies taken across the Michigan Urological Surgery Improvement Collaborative (MUSIC) from January 2012 to March 2015. Natural variation in technique allowed us to evaluate for differences in infection-related hospitalisations based on whether or not a needle disinfectant technique was used. The disinfectant technique was an intra-procedural step to cleanse the biopsy needle with antibacterial solution after each core was sampled (i.e., 10% formalin or 70% isopropyl alcohol). After grouping biopsies according to whether or not the procedure included a needle disinfectant step, we compared the rate of infection-related hospitalisations within 30 days of biopsy. Generalised estimating equation models were fit to adjust for potential confounders. Results During the evaluated period, 17 954 TRUS-guided prostate biopsies were taken with 5 321 (29.6%) including a disinfectant step. The observed rate of infection-related hospitalisation was lower when a disinfectant technique was used during biopsy (0.60% vs 0.90%; P = 0.04). After accounting for differences between groups the adjusted hospitalisation rate in the disinfectant group was 0.85% vs 1.12% in the no disinfectant group (adjusted odds ratio 0.76, 95% confidence interval 0.50-1.15; P = 0.19). Conclusions In this observational analysis, hospitalisations for infectious complications were less common when the TRUS-guided prostate biopsy included a needle disinfection step. However, after adjusting for potential confounders the effect of needle disinfection was not statistically significant. Prospective evaluation is warranted to determine if this step provides a scalable and effective method to minimise infectious complications.

BACKGROUND AND OBJECTIVES: Recent studies demonstrating decreased survival following minimally invasive surgery (MIS) for cervical cancer have generated concern regarding oncologic efficacy of MIS. Our objective was to evaluate the association between surgical approach and 5-year survival following resection of abdominopelvic malignancies. METHODS: Patients with stage I or II adenocarcinoma of the prostate, colon, rectum, and stage IA2 or IB1 cervical cancer from 2010-2015 were identified from the National Cancer Data Base. The association between surgical approach and 5-year survival was assessed using propensity-score-matched cohorts. Distributions were compared using logistic regression. Hazard ratio for death was estimated using Cox proportional-hazard models. RESULTS: The rate of deaths at 5 years was 3.4% following radical prostatectomy, 22.9% following colectomy, 18.6% following proctectomy, and 6.8% following radical hysterectomy. Open surgery was associated with worse survival following radical prostatectomy (HR, 1.18; 95% CI, 1.05-1.33; P = .005), colectomy (HR, 1.45; 95% CI, 1.39-1.51; P < .001), and proctectomy (HR, 1.28; 95% CI, 1.10-1.50; P = .002); however, open surgery was associated with improved survival following radical hysterectomy (HR, 0.61; 95% CI, 0.44-0.82; P = .003). CONCLUSIONS: These results suggest that MIS is an acceptable approach in selected patients with prostate, colon, and rectal cancers, while concerns regarding MIS resection of cervical cancer appear warranted.

Importance Understanding variation in patient-reported outcomes following radical prostatectomy may inform efforts to reduce morbidity after this procedure. Objective To describe patient-reported urinary outcomes following radical prostatectomy in the diverse practice settings of a statewide quality improvement program and to explore whether surgeon-specific variations in observed outcomes persist after accounting for patient-level factors. Design, Setting, and Participants This prospective population-based cohort study included 4582 men in the Michigan Urological Surgery Improvement Collaborative who underwent radical prostatectomy as primary management of localized prostate cancer between April 2014 and July 2018 and who agreed to complete validated questionnaires prior to surgery and at 3, 6, and 12 months after surgery. Data were analyzed from 2019 to June 2019. Exposures Radical prostatectomy. Main Outcomes and Measures Patient- and surgeon-level analyses of patient-reported urinary function 3 months after radical prostatectomy. Outcomes were measured using validated questionnaires with results standardized using previously published methods. Urinary function survey scores are reported on a scale from 0 to 100 with good function established as a score of 74 or higher. Results For the 4582 men undergoing radical prostatectomy within the Michigan Urological Surgery Improvement Collaborative who agreed to complete surveys, mean (SD) age was 63.3 (7.1) years. Survey response rates varied: 3791 of 4582 (83%) responded at baseline, 3282 of 4137 (79%) at 3 months, 2975 of 3770 (79%) at 6 months, and 2213 of 2882 (77%) at 12 months. Mean (SD) urinary function scores were 88.5 (14.3) at baseline, 53.6 (27.5) at 3 months, 68.0 (25.1) at 6 months, and 73.7 (23.0) at 12 months. Regression analysis demonstrated that older age, lower baseline urinary function score, body mass index (calculated as weight in kilograms divided by height in meters squared) of 30 or higher, clinical stage T2 or higher, and lack of bilateral nerve-sparing surgery were associated with a lower probability of reporting good urinary function 3 months after surgery. When evaluating patients with good baseline function, the rate at which individual surgeons’ patients reported good urinary function 3 months after surgery varied broadly (0% to 54.5%;P Conclusions and Relevance In this study, patient- and surgeon-level urinary outcomes following prostatectomy varied substantially. Documenting surgeon-specific variations after accounting for patient factors may facilitate identification of surgical factors associated with superior outcomes.

Importance After radical prostatectomy, adverse pathologic features and postoperative prostate-specific antigen (PSA) levels can herald disease recurrence or progression. Postoperative radiotherapy (RT) remains beneficial in this setting. Objective To examine the evidence supporting the use of postoperative RT as well as recent advances that help determine timing, scope, and use in combination with androgen deprivation therapy (ADT) with or without lymphatic irradiation. Evidence Review A search was conducted of Medline (Ovid), Embase (Elsevier), and the Cochrane Library (Wiley) databases, in addition to clinical trial registries. The reference list of included studies was reviewed for relevant articles. The search was limited to studies published between January 1, 2014, and December 31, 2019. Findings After 548 citations were screened, 27 articles were selected for inclusion. In addition to conventional imaging, positron-emission tomographic (PET)–based radiotracers can aid in disease localization. While PET imaging may influence management with RT, studies are underway examining this issue, and several limitations must be considered, such as limited detectability at lower PSA levels and regional sensitivity. Available genomic classifiers can risk stratify patients or assess potential added benefit of RT. Prospective validation is underway with cooperative group trials. Adjuvant RT, on the basis of adverse pathologic features (such as extraprostatic extension or positive margins) is beneficial in terms of disease control, but it is unclear whether this therapy translates into more meaningful clinical benefit (eg, improved overall survival and a reduction in metastasis), which has been demonstrated by only 1 older, prospective randomized study. Preliminary data suggest that for a relatively favorable-risk population (low Gleason score but with positive margins), PSA monitoring may be a reasonable alternative in some men. Use of androgen deprivation therapy and lymphatic irradiation should be considered in higher-risk cohorts (those with high PSA, high Gleason score, seminal vesicle invasion or node positivity) in conjunction with postoperative RT. Conclusions and Relevance The findings of this review suggest that postprostatectomy RT should be considered for men with prostate cancer in the setting of adverse pathologic features; in carefully selected patients with favorable characteristics, close PSA monitoring is an option. Androgen deprivation therapy and pelvic lymphatic irradiation should be considered for higher risk cohorts (eg, higher PSA values, higher Gleason score). PET imaging and molecular studies remain unproven as decision tools.

Background Clinical registries provide physicians with a means for making data-driven decisions but few opportunities exist for patients to interact with registry data to help make decisions. Objective We sought to develop a web-based system that uses a prostate cancer (CaP) registry to provide newly diagnosed men with a platform to view predicted treatment decisions based on patients with similar characteristics. Design, setting, and participants The Michigan Urological Surgery Improvement Collaborative (MUSIC) is a quality improvement consortium of urology practices that maintains a prospective registry of men with CaP. We used registry data from 45 MUSIC urology practices from 2015 to 2017 to develop and validate a random forest machine learning model. After fitting the random forest model to a derivation cohort consisting of a random two-thirds sample of patients after stratifying by practice location, we evaluated the model performance in a validation cohort consisting of the remaining one-third of patients using a multiclass area under the curve (AUC) measure and calibration plots. Results and limitations We identified 7543 men diagnosed with CaP, of whom 45% underwent radical prostatectomy, 30% surveillance, 17% radiation therapy, 5.6% androgen deprivation, and 1.8% watchful waiting. The personalized prediction for patients in the validation cohort was highly accurate (AUC 0.81). Conclusions Using clinical registry data and machine learning methods, we created a web-based platform for patients that generates accurate predictions for most CaP treatments. Patient summary We have developed and tested a tool to help men newly diagnosed with prostate cancer to view predicted treatment decisions based on similar patients from our registry. We have made this tool available online for patients to use.

We retrospectively evaluated urologist adherence to the AUA guidelines on the management of new patients with benign prostatic hyperplasia related lower urinary tract symptoms in a large university urology group.All first time benign prostatic hyperplasia/lower urinary tract symptom visits to the urology clinic at the Northwestern Medical Faculty Foundation between January 1, 2008 and December 31, 2012 were evaluated using an institutionally managed electronic medical record data repository. Clinical documentation and orders from each encounter were assessed to determine the rate of performance of guideline measures. Approximately 1% of all results were manually reviewed in a validation process designed to determine the reliability of the electronic medical record based system.A total of 3,494 eligible encounters were evaluated in the final analysis. Provider adherence rates with the 9 measures recommended in the guidelines varied by measure from 53.0% to 92.8%. The rate of performance of 5 not routinely recommended measures was 10.2% or less. Post-void residual and urinary flow measurement were optional measures, and were performed on 68.1% and 4.6% of new encounters respectively. Manual validation revealed the electronic medical record data extraction was concordant with manual review in 96.7% of cases (95% CI 94.8-98.5).Using electronic medical record based data extraction techniques, we reliably document a baseline adherence rate with AUA guidelines on the management of benign prostatic hyperplasia. Establishing this benchmark will be important for future investigation into patient outcomes related to guideline adherence and into methods for improving provider adherence.

BACKGROUND Active surveillance (AS) for prostate cancer includes follow-up with serial prostate biopsies. The optimal biopsy frequency during follow-up has not been determined. The goal of this investigation was to use longitudinal AS biopsy data to assess whether the frequency of biopsy could be reduced without substantially prolonging the time to the detection of disease with a Gleason score ≥ 7. METHODS With data from 1375 men with low-risk prostate cancer enrolled in AS at Johns Hopkins, a hidden Markov model was developed to estimate the probability of undersampling at diagnosis, the annual probability of grade progression, and the 10-year cumulative probability of reclassification or progression to Gleason score ≥ 7. It simulated 1024 potential AS biopsy strategies for the 10 years after diagnosis. For each of these strategies, the model predicted the mean delay in the detection of disease with a Gleason score ≥ 7. RESULTS The model estimated the 10-year cumulative probability of reclassification from a Gleason score of 6 to a Gleason score ≥ 7 to be 40.0%. The probability of undersampling at diagnosis was 9.8%, and the annual progression probability for men with a Gleason score of 6 was 4.0%. On the basis of these estimates, a simulation of an annual biopsy strategy estimated the mean time to the detection of disease with a Gleason score ≥ 7 to be 14.1 months; however, several strategies eliminated biopsies with only small delays (

INTRODUCTION AND OBJECTIVES: Little is known about longitudinal follow-up patterns for men on active surveillance (AS) for prostate cancer (CaP) or how this compares with guideline recommendations. In this context, we examined the rates of conversion to secondary therapy, and the frequency of follow-up PSA tests and prostate biopsy among men managed with AS in the diverse academic and community urology practices comprising the Michigan Urological Surgery Improvement Collaborative (MUSIC). METHODS: MUSIC is a consortium of 42 urology practices that maintains a prospective clinical registry with detailed and validated clinical data for all patients diagnosed with CaP. For this analysis, we identified all patients that entered AS and had at least two years of follow-up in the same practice. We first determined the percentage of patients who transitioned to secondary therapies. Next, we calculated the proportion of AS patients who received the minimum suggested 2year follow-up based on NCCN recommendations: at least 3 PSA tests and one repeat biopsy. We then compared the proportion of patients receiving recommendation concordant AS follow-up at the participating sites. RESULTS: We identified 513 patients that entered AS in MUSIC practices from 1/2012 to 9/2013. The median age of the cohort was 66, median PSA was 5.3 ng/mL (IQR 4.1-7.5 ng/mL), 75% of patients had Gleason 6 disease. Across the entire cohort, 15.6% transitioned to a secondary-treatment before reaching 2 years of follow-up (median time to treatment 1⁄4 13.4 months), with 63% of these patients undergoing prostatectomy. At a practice level, rates of treatment varied widely ranging from 0 to 33% (p1⁄40.002). Overall, 20.2% of patients entering AS received guideline-concordant PSA and biopsy surveillance over 2 years of follow-up; however, this proportion varied widely across MUSIC practices, ranging from 9.1% to 55.1% (p

The human penis is composed of the paired dorsal corpora cavernosa and the ventral corpus spongiosum each of which is encased within a fibrous sheath, the tunica albuginea, and then all of which are enclosed within Buck’s fascia, Colles’ fascia, and the skin. The spongiosum contains the urethra and is contiguous with the glans distally. The arterial supply to the penis is from the four terminal branches of the paired penile arteries, which are themselves branches of the internal pudendal arteries. The external iliac, obturator, vesical, and femoral arteries provide accessory arterial supply to the penile artery in some cases. Venous outflow originates from postcavernous venules that coalesce to form emissary veins. These veins empty into the cavernous vein, the deep dorsal vein, and the superficial dorsal vein depending on their origin within the penis. Efferent innervation is from parasympathetic, sympathetic, and somatic sources. Somatosensory afferents course from the penis to central sites.

The American Urological Association (AUA) published new prostate cancer (CaP) screening guidelines in 2013. We apply the guidelines to a retrospective cohort to compare tumor characteristics of those no longer recommended for screening with those who remain screening candidates. We identified cases of screening detected CaP (stage cT1c) in the Surveillance Epidemiology and End Results database from October 2005 to December 2010. The 2013 AUA Guidelines were retrospectively applied to the cohort. Men were categorized into three groups for comparison based on whether or not they would now be recommended for CaP screening (Unscreened, Young Unscreened, and Screened). We compared clinical and pathological characteristics of CaP across study groups. A total of 142,382 men were identified. Screening would no longer be recommended for 40,160. Those no longer recommended for screening had higher median PSA (6.4 vs. 5.8 ng/mL, p

INTRODUCTION AND OBJECTIVES: The validated Interstitial Cystitis Symptom and Problem Index (ICSI-PI) reliably measures symptoms and associated bother in patients with interstitial cystitis. We evaluated whether the ICSI-PI reliably measures overactive bladder (OAB) symptoms in patients with OAB with/without incontinence (OAB wet/dry). METHODS: Adults in our prospective observational neuromodulation study were evaluated. Inclusion criteria were OAB wet/dry and staged lead and generator implant. Subjects completed the ICSI-PI and Overactive Bladder Questionnaire-short form (OAB-q) at baseline and 3, 6, and 12 months post implant. The ICSI-PI is comprised of a symptom index (IC-SI) and bother index (IC-PI) which assess voiding symptoms and pain. The OAB-q contains symptom severity (SS) and health related quality of life (HRQOL) scales. Descriptive statistics were performed for sample characteristics. At each time point, IC-SI and OAB-q SS responses, and IC-PI and OAB-q HRQOL responses were compared with Spearman’s Correlations in patients that completed both measures. RESULTS: Of 215 patients (mean age 65.1 14.2 years), 80% were female, 94% were caucasian, 67.4% had attended at least some college, 24.5% had an income >$70,000/year, and 84% had OAB wet. As shown in the table below, at each time point there was a strong correlation between IC-SI and OAB-q SS scores. Additionally, IC-PI and OAB-q QOL scores were strongly negatively correlated indicating that higher symptom bother negatively impacted HRQOL. CONCLUSIONS: Even though pain is not a component of the OAB syndrome, the ICSI-PI appears to reliably measure voiding symptoms and bother in patients with OAB.

INTRODUCTION AND OBJECTIVES: Prostate Specific Antigen (PSA) is a well-documented marker for prostate cancer (CaP). PSA velocity (PSAV) is a derivative that has been used to increase PSA performance characteristics for CaP detection. Elevated PSAV may be an early sign of underlying CaP, but has somewhat limited sensitivity and specificity. Explanations for false-positive PSAV include missed CaP on biopsy; prostatitis; or assay standardization bias. Reasons for false-negative PSAV include very low volume CaP or high grade CaP (severely de-differentiated cells produce less PSA); prior, resolved prostatitis; or assay standardization bias. METHODS: We assessed patients who underwent prostate biopsy after prior screening with 3 PSA blood tests. PSAV was calculated using linear regression. Elevated PSAV was defined as change in PSA 0.35 ng/mL/yr. After stratifying based on PSAV, we specifically examined: 1) patients with an elevated PSAV but no CaP on biopsy and 2) patients with low PSAV but CaP on biopsy. RESULTS: Between 2003 and 2010, 1358 patients underwent prostate biopsy after previous screening with 3 PSA tests. 106 had PSAV 0.35 ng/mL/yr and negative biopsy. Of these, 62 (58%) had CaP on biopsy at a later date, suggesting negative biopsy at the time of elevated PSAV may have been due to missed early, low volume CaP. 10 (9.4%) biopsies revealed prostatic intraepithelial neoplasia (PIN), also suggesting a possibly missed small CaP. 12 biopsies (11.3%) had signs of prostatitis. In the remaining 22 (20.7%), cause for elevated PSAV was not readily apparent; transient inflammation, prostatic trauma, or assay standardization bias may have played a role. 480 patients with PSAV 0.35 had CaP on biopsy. Of these, 22 (4.6%) had a Gleason 8–10 tumor. 464 were treated with radical prostatectomy. Surgical pathology for 266 (55.4%) revealed total CaP volume 5% of submitted tissue. Of the remaining patients, 30% had possibly slow growing Gleason 6 tumors involving 6–20% of submitted tissue, and 54% had Gleason 7 tumors. In some cases, assay standardization bias or prior resolved prostatitis may have caused the spuriously low PSAV. CONCLUSIONS: Nearly 80% of patients with false-positive PSAV had an easily explained confounder-missed CaP or prostatitis. Nearly 60% of patients with false-positive PSAV were eventually found to have CaP, underscoring the need to closely follow a patient’s PSA despite initial negative biopsy. False-negative tests can often be explained by low volume or high Gleason grade disease, prior resolved prostatitis, or possible PSA assay standardization bias.

Benign prostatic hyperplasia is characterized by smooth muscle and epithelial proliferation primarily within the prostatic transition zone that can cause a variety of problems for a patient, the most frequent being bothersome lower urinary tract symptoms. In most cases, medical therapy has become the first-line treatment modality of choice, with a variety of pharmacologic mechanisms proving to be beneficial. Several large trials have shown the efficacy of alpha-receptor blocking and 5-alpha reductase inhibiting medications when used alone and in combination. Newer data has shown the benefit of anti-muscarinic medications in specific populations who suffer from bladder outlet obstruction causing storage urinary symptoms. Phytotherapeutic supplements are numerous and used frequently; however, data supporting safety and efficacy is limited, making treatment recommendations difficult. The available clinical trial data for all of these types of therapy is discussed in this article.

Minimally invasive techniques have been described recently for liver resections. We have developed a surgical approach to liver resection that combines the benefits of minimally invasive surgery with the safety of open liver resection. We have applied this hybrid approach to selected cases, and we feel that it can be adopted by most hepatobiliary surgeons, even those with minimal or no laparoscopic experience. Briefly, this technique consists of laparoscopic mobilization of the target liver lobe, followed by standard open liver resection through the extraction site. The required incisions parallel those needed for hand-assisted laparoscopic liver resections. We have compared these hybrid procedures with contemporaneous laparoscopic, hand-assisted, and open liver resections at our institution and have found that they compare favorably with minimally invasive procedures. A wider utilization of this approach by both general and hepatobiliary surgeons will result in a more generalized acceptance of minimally invasive liver resection that ultimately will advance the field and benefit patients in need of liver surgery.