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BackgroundMen with persistently elevated and/or rising PSA levels after negative prostate biopsy often undergo multiple repeat biopsies. Prostate cancer antigen 3 (PCA3) has emerged as a predictor of prostate cancer.MethodsWe sought to define the utility of PCA3 in combination with other clinical data in predicting the risk of prostate cancer on repeat biopsy. We retrospectively obtained PCA3, PSA, PSA density (PSAD), digital rectal examination (DRE) and transrectal ultrasound (TRUS) findings from 103 patients at a single institution who had at least one prior negative prostate biopsy. The sensitivity and specificity of PCA3 in detecting prostate cancer was determined. Receiver operating characteristics curves were produced for each variable individually and in multivariable analysis, controlling for PCA3, PSAD, TRUS, PSA and DRE. A nomogram was created, internally validated and compared to another recently published nomogram.ResultsOf the 103 patients, 37 (31%) had prostate cancer on repeat biopsy. The sensitivity and specificity of PCA3 (using a cut point of 25) was 0.67 and 0.64, respectively. In multivariable analyses, PCA3 was independently associated with prostate cancer (odds ratio: 1.02, 95% confidence interval: 1.01-1.04), with area under the curve (AUC) of 0.64. A multivariable model containing PCA3, PSAD, PSA, DRE and TRUS findings showed the most diagnostic accuracy (AUC: 0.82).ConclusionsIn the setting of prior negative biopsies, PCA3 was independently associated with prostate cancer in a multivariable model. In combination with other clinical data, PCA3 is a valuable tool in assessing the risk of prostate cancer on repeat biopsy.

This paper describes pharmacokinetic analyses of the monoamine-oxidase-B (MAO-B) radiotracer [ 18 F]( S )-(2-methylpyrid-5-yl)-6-[(3-fluoro-2-hydroxy)propoxy]quinoline ([ 18 F]SMBT-1) for positron emission tomography (PET) brain imaging. Brain MAO-B expression is widespread, predominantly within astrocytes. Reactive astrogliosis in response to neurodegenerative disease pathology is associated with MAO-B overexpression. Fourteen elderly subjects (8 control, 5 mild cognitive impairment, 1 Alzheimer's disease) with amyloid ([ 11 C]PiB) and tau ([ 18 F]flortaucipir) imaging assessments underwent dynamic [ 18 F]SMBT-1 PET imaging with arterial input function determination. [ 18 F]SMBT-1 showed high brain uptake and a retention pattern consistent with the known MAO-B distribution. A two-tissue compartment (2TC) model where the K 1 /k 2 ratio was fixed to a whole brain value best described [ 18 F]SMBT-1 kinetics. The 2TC total volume of distribution (V T ) was well identified and highly correlated (r 2 ∼0.8) with post-mortem MAO-B indices. Cerebellar grey matter (CGM) showed the lowest mean V T of any region and is considered the optimal pseudo-reference region. Simplified analysis methods including reference tissue models, non-compartmental models, and standard uptake value ratios (SUVR) agreed with 2TC outcomes (r 2  > 0.9) but with varying bias. We found the CGM-normalized 70-90 min SUVR to be highly correlated (r 2  = 0.93) with the 2TC distribution volume ratio (DVR) with acceptable bias (∼10%), representing a practical alternative for [ 18 F]SMBT-1 analyses., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Men reporting same-sex behaviors are disproportionately impacted by sexually transmitted infections (STI). Differences in clinical characteristics and STIs in men who have sex with men only (MSMO), with men and women (MSMW), and with women only (MSW) are not well described., Methods: First visits to two Baltimore City STI clinics 2011-2016 from MSMO and MSMW compared to an age-matched random sample of MSW were analyzed. Acute STI (aSTI) included chlamydia, gonorrhea, nongonococcal urethritis (NGU), and primary or secondary syphilis (PSS). Chi-squared tests and logistic regression examined associations., Results: Among N = 1226 MSMO, N = 491 MSMW and N = 1717 MSW, most identified as Black/African American; mean age (29.8) was similar across groups. 73.5%, 67.2%, and 60.3% of MSMW, MSMO, and MSW reported ≥2 partners in last 6 months. "Always" condom use was reported by 20.4%, 17.4 % and 14.1% of MSMW, MSMO and MSW. Overall HIV prevalence was 13.8%. Among those tested, urogenital chlamydia prevalence was 21.7%, 8.3%, and 3.9% (p ≤ 0.01) in MSW, MSMW, and MSMO. Urogenital gonorrhea prevalence was 11.6%,7.7%, and 8.3% in MSMW, MSW, and MSMO respectively. Extragenital STI (range 2.7-21.9%), NGU (25.2%), and PSS (5.3-5.7%) positivity was similar in MSMW and MSMO. Older age was inversely associated with STI diagnosis in MSW and MSMO only, consistent condom use was protective against aSTI in MSW (aOR:0.60, p < 0.01) and MSMW (aOR:0.54 p = 0.03) only., Conclusion: Differences in behaviors and clinical characteristics associated with aSTI suggest that MSMO, MSMW and MSW have diverse sexual health needs and may require tailored interventions to improve sexual health outcomes., Competing Interests: Conflict of Interest and Disclosure Statement: Dr. Tuddenham reports she has been a consultant for Luca Biologics, Biofire Diagnostics and Roche Molecular Diagnostics and has received a speaker honorarium from Roche Molecular Diagnostics. She receives royalties from UPTODATE. She also participates in research supported by in-kind donation of STI test kits to Johns Hopkins by Hologic. Dr. Hamill has been a consultant for GSK and Chembio. He has received honorarium from UPTODATE and participates in research supported by in-kind donation of STI test kits to Johns Hopkins by Hologic, Chembio, Roche and Cepheid., (Copyright © 2024 American Sexually Transmitted Diseases Association. All rights reserved.)

Numbers of aggressive prostate cancer (aPC) cases are rising, but only a few risk factors have been identified. In this study, we introduce a systematic approach to integrate geospatial data into external exposome research using aPC cases from Pennsylvania. We demonstrate the association between several area-level exposome measures across five Social Determinants of Health domains (SDOH) and geographic areas identified as having elevated odds of aPC. Residential locations of Pennsylvania men diagnosed with aPC from 2005 to 2017 were linked to 37 county-/tract-level SDOH exosome measures. Variable reduction processes adopted from neighborhood-wide association study along with Bayesian geoadditive logistic regression were used to identify areas with elevated odds of aPC and exposome factors that significantly attenuated the odds and reduced the size of identified areas. Areas with significantly higher odds of aPC were explained by various SDOH exposome measures, though the extent of the reduction depended on geographic location. Some areas were associated with race (social context), health insurance (access), or tract-level poverty (economics), while others were associated with either county-level water quality or a combination of factors. Area-level exposome measures can guide future patient-level external exposome research and help design targeted interventions to reduce local cancer burden., (© 2024. The Author(s).)

The apolipoprotein-E4 (APOE*4) and apolipoprotein-E2 (APOE*2) alleles are more common in African American versus non-Hispanic white populations, but relationships of both alleles with Alzheimer's disease (AD) pathology among African American individuals are unclear. We measured APOE allele and β-amyloid (Aβ) and tau using blood samples and positron emission tomography (PET) images, respectively. Individual regression models tested associations of each APOE allele with Aβ or tau PET overall, stratified by racialized group, and with a racialized group interaction. We included 358 older adults (42% African American) with Aβ PET, 134 (29% African American) of whom had tau PET. APOE*4 was associated with higher Aβ in non-Hispanic white (P < 0.0001), but not African American (P = 0.64) participants; racialized group modified the association between APOE*4 and Aβ (P < 0.0001). There were no other racialized group differences. These results suggest that the association of APOE*4 and Aβ differs between African American and non-Hispanic white populations. Other drivers of AD pathology in African American populations should be identified as potential therapeutic targets., Competing Interests: Declaration of Competing Interest None., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: This study aims to determine if there is a difference in prostate cancer nomogram-adjusted risk of biochemical recurrence (BCR) and/or adverse pathology (AP) between African American (AAM) and Caucasian men (CM) undergoing radical prostatectomy (RP)., Methods: A retrospective review was performed of men undergoing RP in the Pennsylvania Urologic Regional Collaborative between 2015 and 2021. Cox proportional hazard regression models were used to compare the rate of BCR after RP, and logistic regression models were used to compare rates of AP after RP between CM and AAM, adjusting for the CAPRA, CAPRA-S, and MSKCC pre- and post-operative nomogram scores., Results: Rates of BCR and AP after RP were analyzed from 3190 and 5029 men meeting inclusion criteria, respectively. The 2-year BCR-free survival was lower in AAM (72.5%) compared to CM (79.0%), with a hazard ratio (HR) of 1.38 (95% CI 1.16-1.63, p < 0.001). The rate of BCR was significantly greater in AAM compared to CM after adjustment for MSKCC pre-op (HR 1.29; 95% CI 1.08-1.53; p = 0.004), and post-op nomograms (HR 1.26; 95% CI 1.05-1.49; p < 0.001). There was a trend toward higher BCR rates among AAM after adjustment for CAPRA (HR 1.13; 95% CI 0.95-1.35; p = 0.17) and CAPRA-S nomograms (HR 1.11; 95% 0.93-1.32; p = 0.25), which did not reach statistical significance. The rate of AP was significantly greater in AAM compared to CM after adjusting for CAPRA (OR 1.28; 95% CI 1.10-1.50; p = 0.001) and MSKCC nomograms (OR 1.23; 95% CI 1.06-1.43; p = 0.007)., Conclusion: This analysis of a large multicenter cohort provides further evidence that AAM may have higher rates of BCR and AP after RP than is predicted by CAPRA and MSKCC nomograms. Accordingly, AAM may benefit with closer post-operative surveillance and may be more likely to require salvage therapies., (© 2023. The Author(s), under exclusive licence to Springer Nature Limited.)

Introduction: White matter hyperintensities (WMH) may promote clinical Alzheimer's disease (AD) disparities between Black American (BA) and non-Hispanic White (nHW) populations. Using a novel measurement, unhealthy white matter connectivity (UWMC), we interrogated racialized group differences in associations between WMH in AD pathology-affected regions and cognition., Methods: UWMC is the proportion of white matter fibers that pass through WMH for every pair of brain regions. Individual regression models tested associations of UWMC in beta-amyloid (Aβ) or tau pathology-affected regions with cognition overall, stratified by racialized group, and with a racialized group interaction., Results: In 201 older adults ranging from cognitively unimpaired to AD, BA participants exhibited greater UWMC and worse cognition than nHW participants. UWMC was negatively associated with cognition in 17 and 5 Aβ- and tau-affected regions, respectively. Racialization did not modify these relationships., Discussion: Differential UWMC burden, not differential UWMC-and-cognition associations, may drive clinical AD disparities between racialized groups., Highlights: Unhealthy white matter connectivity (UWMC) in Alzheimer's disease (AD) pathology-affected brain regions is associated with cognition. Relationships between UWMC and cognition are similar between Black American (BA) and non-Hispanic White (nHW) individuals. More UWMC may partially drive higher clinical AD burden in BA versus nHW populations. UWMC risk factors, particularly social and environmental, should be identified., (© 2023 The Authors. Alzheimer's & Dementia published by Wiley Periodicals LLC on behalf of Alzheimer's Association.)

Background: Elicitation of patients' preferences is an integral part of shared decision-making, the recommended approach for prostate cancer decision-making. Existing decision aids for this population often do not specifically focus on patients' preferences. Healium is a brief interactive web-based decision aid that aims to elicit patients' treatment preferences and is designed for a low health literate population., Objective: This study used a randomized controlled trial to evaluate whether Healium, designed to target preference elicitation, is as efficacious as Healing Choices, a comprehensive education and decision tool, in improving outcomes for decision-making and emotional quality of life., Methods: Patients diagnosed with localized prostate cancer who had not yet made a treatment decision were randomly assigned to the brief Healium intervention or Healing Choices, a decision aid previously developed by our group that serves as a virtual information center on prostate cancer diagnosis and treatment. Assessments were completed at baseline, 6 weeks, and 3 months post baseline, and included decisional outcomes (decisional conflict, satisfaction with decision, and preparation for decision-making), and emotional quality of life (anxiety/tension and depression), along with demographics, comorbidities, and health literacy., Results: A total of 327 individuals consented to participate in the study (171 were randomized to the Healium intervention arm and 156 were randomized to Healing Choices). The majority of the sample was non-Hispanic (272/282, 96%), White (239/314, 76%), married (251/320, 78.4%), and was on average 62.4 (SD 6.9) years old. Within both arms, there was a significant decrease in decisional conflict from baseline to 6 weeks postbaseline (Healium, P≤.001; Healing Choices, P≤.001), and a significant increase in satisfaction with one's decision from 6 weeks to 3 months (Healium, P=.04; Healing Choices, P=.01). Within both arms, anxiety/tension (Healium, P=.23; Healing Choices, P=.27) and depression (Healium, P=.001; Healing Choices, P≤.001) decreased from baseline to 6 weeks, but only in the case of depression was the decrease statistically significant., Conclusions: Healium, our brief decision aid focusing on treatment preference elicitation, is as successful in reducing decisional conflict as our previously tested comprehensive decision aid, Healing Choices, and has the added benefit of brevity, making it the ideal tool for integration into the physician consultation and electronic medical record., Trial Registration: ClinicalTrials.gov NCT05800483; https://clinicaltrials.gov/study/NCT05800483., (©Michael A Diefenbach, Allison Marziliano, Erin K Tagai, Halie Pfister, Emmanuel Lapitan, Simon J Hall, Manish Vira, Said Ibrahim, Kelli Aibel, Alexander Kutikov, Eric M Horwitz, Curtis Miyamoto, Adam C Reese, Suzanne M Miller. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 20.10.2023.)

Introduction: Oncologic implications of variant histology (VH) have been extensively studied in bladder cancer; however, further investigation is needed in upper tract urothelial carcinoma (UTUC). Our study aims to evaluate the impact of VH on oncological outcomes in UTUC patients treated with radical nephroureterectomy (RNU)., Methods: A retrospective analysis was performed on patients who underwent a robotic or laparoscopic RNU for UTUC using the ROBUUST database, a multi-institutional collaborative including 17 centers worldwide. Logistic regression was used to assess the effect of VH on urothelial recurrence (bladder, contralateral upper tract), metastasis, and survival following RNU., Results: A total of 687 patients were included in this study. Median (IQR) age was 71 (64-78) years and 470 (68%) had organ confined disease. VH was present in 70 (10.2%) patients. In a median follow-up of 16 months, the incidence of urothelial recurrence, metastasis, and mortality was 26.8%, 15.3%, and 11.8%, respectively. VH was associated with increased risk of metastasis (HR 4.3, P <.0001) and death (HR 2.0, P =.046). In multivariable analysis, VH was noted to be an independent risk factor for metastasis (HR 1.8, P =.03) but not for urothelial recurrence (HR 0.99, P =.97) or death (HR 1.4, P =.2)., Conclusion: Variant histology can be found in 10% of patients with UTUC and is an independent risk factor for metastasis following RNU. Overall survival rates and the risk of urothelial recurrence in the bladder or contralateral kidney are not affected by the presence of VH., Competing Interests: Disclosure The authors have stated that they have no conflicts of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To evaluate longitudinal trends in surgical case volume among junior urology residents. There is growing perception that urology residents are not prepared for independent practice, which may be linked to decreased exposure to major cases early in residency., Methods: Retrospective review of deidentified case logs from urology residency graduates from 12 academic medical centers in the United States from 2010 to 2017. The primary outcome was the change in major case volume for first-year urology (URO1) residents (after surgery internship), measured using negative binomial regression., Results: A total of 391,399 total cases were logged by 244 residency graduates. Residents performed a median of 509 major cases, 487 minor cases, and 503 endoscopic cases. From 2010 to 2017, the median number of major cases performed by URO1 residents decreased from 64 to 49 (annual incidence rate ratio 0.90, P < .001). This trend was limited to oncology cases, with no change in reconstructive or pediatric cases. The number of major cases decreased more for URO1 residents than for residents at other levels (P-values for interaction <.05). The median number of endoscopic cases performed by URO1 residents increased from 85 to 194 (annual incidence rate ratio 1.09, P < .001), which was also disproportionate to other levels of residency (P-values for interaction <.05)., Conclusion: There has been a shift in case distribution among URO1 residents, with progressively less exposure to major cases and an increased focus on endoscopic surgery. Further investigation is needed to determine if this trend has implications on the surgical proficiency of residency graduates., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Spatial analysis can identify communities where men are at risk for aggressive prostate cancer (PCan) and need intervention. However, there are several definitions for aggressive PCan. In this study, we evaluate geospatial patterns of 3 different aggressive PCan definitions in relation to PCan-specific mortality and provide methodologic and practical insights into how each definition may affect intervention targets., Methods: Using the Pennsylvania State Cancer Registry data (2005-2015), we used 3 definitions to assign "aggressive" status to patients diagnosed with PCan. Definition one (D1, recently recommended as the primary definition, given high correlation with PCan death) was based on staging criteria T4/N1/M1 or Gleason score ≥ 8. Definition two (D2, most frequently-used definition in geospatial studies) included distant SEER summary stage. Definition three (D3) included Gleason score ≥ 7 only. Using Bayesian spatial models, we identified geographic clusters of elevated odds ratios for aggressive PCan (binomial model) for each definition and compared overlap between those clusters to clusters of elevated hazard ratios for PCan-specific mortality (Cox regression)., Results: The number of "aggressive" PCan cases varied by definition, and influenced quantity, location, and extent/size of geographic clusters in binomial models. While spatial patterns overlapped across all three definitions, using D2 in binomial models provided results most akin to PCan-specific mortality clusters as identified through Cox regression. This approach resulted in fewer clusters for targeted intervention and less sensitive to missing data compared to definitions that rely on clinical TNM staging., Conclusions: Using D2, based on distant SEER summary stage, in future research may facilitate consistency and allow for standardized comparison across geospatial studies., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Water is recommended as an alternative for sugar-sweetened beverages (SSBs). Low-income, minority groups in the United States continue to exhibit high SSB and low water consumption, and are more likely to exceed 100% fruit juice recommendations., Objective: To test the effects of a home-based intervention designed to replace SSBs with tap water and reduce excess juice consumption among parents and their infants/toddlers., Design: Randomized controlled trial., Participants: Parents (n = 92) of infants/toddlers who participated in three Early Head Start home-visiting programs that serve predominantly Hispanic, low-income communities during 2019-2021., Intervention: The 12-week intervention (Water Up!@Home) simultaneously addressed physical barriers to tap water consumption (via a water filter) and sociocultural barriers to replacing SSBs and juice with water (via a curriculum). Comparison group received a water filter only. We hypothesized that the intervention would lead to a reduction of 6 fl oz/d in SSB and juice consumption., Main Outcomes: Parent-reported self and infant/toddler SSBs, water (filtered, tap, or bottled), and 100% fruit juice consumption., Statistical Analyses: Analysis of covariance to compare changes in consumption between experimental groups was performed. We also conducted t tests to assess changes within groups., Results: Participants in both groups reported significant reductions in SSBs from baseline (parents: intervention [-11.2 fl oz/d; P < 0.01]; comparison [-8.0 fl oz/d; P < 0.01]; children: intervention [-1.50 fl oz/d; P = 0.03]; comparison [-1.56 fl oz/d; P = 0.02]), increased water consumption (parents in both groups [+5.6 fl oz/d]; children: intervention [+3.61 fl oz/d; P = 0.01], comparison [+2.24 fl oz/d; P = 0.05]), mostly from filtered tap water. Differences between groups were not statistically significant. Intervention participants reported significant reductions in 100% fruit juice vs comparison (parents: -3.6 fl oz/d vs -1.0 fl oz/d; P < 0.01; children: -0.73 fl oz/d vs +0.48 fl oz/d; P = .03)., Conclusions: The intervention effectively reduced 100% fruit juice consumption. Water security should be examined as a contributor to SSB consumption in this population., (Copyright © 2023 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Objective: This study sought to explain results of the Water Up!@Home randomised controlled trial where low-income parents were randomised to receive an educational intervention +a low-cost water filter pitcher or only the filter. Parents in both groups had reported statistically significant reductions in sugar-sweetened beverages (SSB) and increases in water intake post-intervention., Design: Qualitative explanatory in-depth interviews analysed thematically and deductively., Setting: Washington, DC metropolitan area, USA., Participants: Low-income Latino parents of infants/toddlers who had participated in the Water Up! @Home randomised controlled trial., Results: The filter-stimulated water consumption in both groups by (1) increasing parents' perception of water safety; (2) acting as a cue to action to drink water; (3) improving the flavour of water (which was linked to perceptions of safety) and (4) increasing the perception that this option was more economical than purchasing bottled water. Safe and palatable drinking water was more accessible and freely available in their homes; participants felt they did not need to ration their water consumption as before. Only intervention participants were able to describe a reduction in SSB intake and described strategies, skills and knowledge gained to reduce SSB intake. Among the comparison group, there was no thematic consensus about changes in SSB or any strategies or skills to reduce SSB intake., Conclusions: A low-cost water filter facilitated water consumption, which actively (or passively for comparison group) displaced SSB consumption. The findings have implications for understanding and addressing the role of water security on SSB consumption.

Introduction: Perioperative intravesical chemotherapy (IVC) at or around the time of radical nephroureterectomy (RNU) reduces the risk of intravesical recurrence. Guidelines since 2013 have recommended its use. The objective of this study is to examine IVC utilization and determine predictors of its administration within a large international consortium., Methods and Materials: Data was collected from 17 academic centers on patients who underwent robotic/laparoscopic RNU between 2006 and 2020. Patients who underwent concomitant radical cystectomy and cases in which IVC administration details were unknown were excluded. Univariate and multivariate analyses were utilized to determine predictors of IVC administration. A Joinpoint regression was performed to evaluate utilization by year., Results: Six hundred and fifty-nine patients were included. A total of 512 (78%) did not receive IVC while 147 (22%) did. Non-IVC patients were older (P < 0.001), had higher ECOG scores (P = 0.003), and had more multifocal disease (23% vs. 12%, P = 0.005). Those in the IVC group were more likely to have higher clinical T stage disease (P = 0.008), undergone laparoscopic RNU (83% vs. 68%, P < 0.001), undergone endoscopic management of the bladder cuff (20% vs. 4%, P = 0.008). Multivariable regression showed that decreased age (OR 0.940, P < 0.001), laparoscopic approach (OR 2.403, P = 0.008), and endoscopic management of the bladder cuff (OR 7.619, P < 0.001) were significant predictors favoring IVC administration. Treatment at a European center was associated with lower IVC use (OR 0.278, P = 0.018). Overall utilization of IVC after the 2013 European Association of Urology (EAU) guideline was 24% vs. 0% prior to 2013 (P < 0.001). Limitations include limited data regarding IVC timing/agent and inclusion of minimally invasive RNU patients only., Conclusions: While IVC use has increased since being added to the EAU UTUC guidelines, its use remains low at academic centers, particularly within Europe., Competing Interests: Conflict of interest The authors have no conflict of interest., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: To compare the outcomes of robotic radical nephroureterectomy (RRNU) and laparoscopic radical nephroureterectomy (LRNU) within a large multi-institutional worldwide dataset. Materials and Methods: The ROBotic surgery for Upper tract Urothelial cancer STudy (ROBUUST) includes data from 17 centers worldwide regarding 877 RRNU and LRNU performed between 2015 and 2019. Baseline features, perioperative and oncologic outcomes, were included. A 2:1 nearest-neighbor propensity-score matching with a 0.001 caliper was performed. A univariable and a multivariable logistic regression model were built to evaluate the predictors of a composite "tetrafecta" outcome defined as occurrence of bladder cuff excision+LND+no complications+negative surgical margins. Results: After matching, 185 RRNU and 91 LRNU were assessed. Patients in the RRNU group were more likely to undergo bladder cuff excision (81.9% vs 63.7%; p  < 0.001) compared to the LRNU group. A statistically significant difference was found in terms of overall postoperative complications ( p  = 0.003) and length of stay ( p  < 0.001) in favor of RRNU. Multivariable analysis demonstrated that LRNU was an independent predictor negatively associated with achievement of "tetrafecta" (odds ratio: 0.09; p  = 0.003). Conclusions: In general, RRNU and LRNU offer comparable outcomes. While the rate of overall complications is higher for LRNU in this study population, this is mostly related to low-grade complications, and therefore with more limited clinical relevance. RRNU seems to offer shorter hospital stay, but this might also be related to the different geographical location of participating centers. Overall, the implementation of robotics might facilitate achievement of a "tetrafecta" outcome as defined in the present study.

Background: Radical nephroureterectomy (RNU) represents the standard of care for high grade upper tract urothelial carcinoma (UTUC). Open and laparoscopic approaches are well-established treatments, but evidence regarding robotic RNU is growing. The introduction of the Xi ® system facilitates the implementation of this multi-quadrant procedure. The aim of this video-article is to describe the surgical steps and the outcomes of Xi ® robotic RNU., Methods: Single stage Xi ® robotic RNU without patients repositioning and robot re-docking were done between 2015 and 2019 and collected in a large worldwide multi-institutional study, the ROBotic surgery for Upper tract Urothelial cancer STudy (ROBUUST). Institutional review board approval and data share agreement were obtained at each center. Surgical technique is described in detail in the accompanying video. Descriptive statistics of baseline characteristics and surgical, pathological, and oncological outcomes were analyzed., Results: Overall, 148 patients were included in the analysis; 14% had an ECOG >1 and 68.2% ASA ≥3. Median tumor dimension was 3.0 (IQR:2.0-4.2) cm and 34.5% showed hydronephrosis at diagnosis. Forty-eight% were cT1 tumors. Bladder cuff excision and lymph node dissection were performed in 96% and 38.1% of the procedures, respectively. Median operative time and estimated blood loss were 215.5 (IQR:160.5-290.0) minutes and 100.0 (IQR: 50.0-150.0) mL, respectively. Approximately 56% of patients took opioids during hospital stay for a total morphine equivalent dose of 22.9 (IQR:16.0-60.0) milligrams equivalent. Post-operative complications were 26 (17.7%), with 4 major (2.7%). Seven patients underwent adjuvant chemotherapy, with median number of cycles of 4.0 (IQR:3.0-6.0)., Conclusions: Single stage Xi ® RNU is a reproducible and safe minimally invasive procedure for treatment of UTUC. Additional potential advantages of the robot might be a wider implementation of LND with a minimally invasive approach.

Dynamic fibroblast to myofibroblast state transitions underlie the heart's fibrotic response. Because transcriptome maturation by muscleblind-like 1 (MBNL1) promotes differentiated cell states, this study investigated whether tactical control of MBNL1 activity could alter myofibroblast activity and fibrotic outcomes. In healthy mice, cardiac fibroblast-specific overexpression of MBNL1 transitioned the fibroblast transcriptome to that of a myofibroblast and after injury promoted myocyte remodeling and scar maturation. Both fibroblast- and myofibroblast-specific loss of MBNL1 limited scar production and stabilization, which was ascribed to negligible myofibroblast activity. The combination of MBNL1 deletion and injury caused quiescent fibroblasts to expand and adopt features of cardiac mesenchymal stem cells, whereas transgenic MBNL1 expression blocked fibroblast proliferation and drove the population into a mature myofibroblast state. These data suggest MBNL1 is a post-transcriptional switch, controlling fibroblast state plasticity during cardiac wound healing., Competing Interests: Declaration of interests The authors declare no competing interests., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: The COVID-19 pandemic starkly affected all aspects of health care, forcing many to divert resources towards emergent patient needs while decreasing emphasis on routine cancer care. We compared prostate cancer care before and during the pandemic in a multi-institutional cohort., Methods: A prospective regional collaborative was queried to assess practice pattern variations relative to the initial COVID-19 lockdown (March 16 to May 15, 2020). The preceding 10 months were selected for comparison. The impact of the lockdown was evaluated on the basis of 1) weekly trends in biopsy and radical prostatectomy volumes, 2) comparisons between those undergoing prostate biopsy, and 3) clinicopathological characteristics within radical prostatectomy patients. Categorical variables were compared using Fisher's exact and Pearson's chi-square tests, and Wilcoxon rank sum test to evaluate continuous covariates., Results: Overall, there was a 55% and 39% decline in biopsy and prostatectomy volumes, respectively. During the pandemic, biopsy patients were younger with fewer COVID-19 severity risk factors (17.0% vs 9.7% no risk factors, p=0.023) and prostatectomy patients had higher grade group (GG; 45.6% > GG 4 vs 28%, p=0.01). Large variation in the change in procedural volume was noted across practice sites., Conclusion: In a multi-institutional assessment of surgical and diagnostic delay for prostate cancer, we found a non-uniform decline in procedural volume across sites. Future analyses within this cohort are needed to further discern the effects of care delays related to COVID-19.

Importance: Early in the COVID-19 pandemic, racial/ethnic minority communities disproportionately experienced poor outcomes; however, the association of the pandemic with prostate cancer (PCa) care is unknown., Objective: To assess the association between race and PCa care delivery for Black and White patients during the first wave of the COVID-19 pandemic., Design, Setting, and Participants: This multicenter, regional, collaborative, retrospective cohort study compared prostatectomy rates between Black and White patients with untreated nonmetastatic PCa during the COVID-19 pandemic (269 patients from March 16 to May 15, 2020) and prior (378 patients from March 11 to May 10, 2019)., Main Outcomes and Measures: Prostatectomy rates., Results: Of the 647 men with nonmetastatic PCa, 172 (26.6%) were non-Hispanic Black men, and 475 (73.4%) were non-Hispanic White men. Black men were significantly less likely to undergo prostatectomy during the pandemic compared with White patients (1 of 76 [1.3%] vs 50 of 193 [25.9%]; P < .001), despite similar COVID-19 risk factors, biopsy Gleason grade groups, and comparable prostatectomy rates prior to the pandemic (17 of 96 [17.7%] vs 54 of 282 [19.1%]; P = .75). Black men had higher median prostate-specific antigen levels prior to biopsy (8.8 ng/mL [interquartile range, 5.3-15.2 ng/mL] vs 7.2 ng/mL [interquartile range, 5.1-11.1 ng/mL]; P = .04). A linear combination of regression coefficients with an interaction term for year demonstrated an odds ratio for likelihood of surgery of 0.06 (95% CI, 0.01-0.35; P = .002) for Black patients and 1.41 (95% CI, 0.81-2.44; P = .23) for White patients during the pandemic compared with prior to the pandemic. Changes in surgical volume varied by site (from a 33% increase to complete shutdown), with sites that experienced the largest reduction in cancer surgery caring for a greater proportion of Black patients., Conclusions and Relevance: In this large multi-institutional regional collaborative cohort study, the odds of PCa surgery were lower among Black patients compared with White patients during the initial wave of the COVID-19 pandemic. Although localized PCa does not require immediate treatment, the lessons from this study suggest systemic inequities within health care and are likely applicable across medical specialties. Public health efforts are needed to fully recognize the unintended consequence of diversion of cancer resources to the COVID-19 pandemic to develop balanced mitigation strategies as viral rates continue to fluctuate.

Introduction: Active surveillance outcomes in minority patients are poorly characterized, as most surveillance series are comprised primarily of Caucasian men. We aimed to characterize outcomes of African American and Hispanic men undergoing surveillance and to identify factors associated with transition to definitive treatment., Material and Methods: We performed a retrospective analysis of men undergoing active surveillance at our institution. Reasons for transition to definitive treatment were determined. Cessation of active surveillance was recommended for Gleason upgrading on surveillance biopsy. We characterized treatment-free survival for men on surveillance and compared this by race/ethnicity (as self reported by patients). Demographic and clinical variables associated with active surveillance cessation were identified using Cox proportional hazards regression., Results: A total of 141 men were on active surveillance: 84 non-Hispanic Black/African American (59.6%), 32 Hispanic (22.7%), and 25 non-Hispanic White/Caucasian (17.7%). Two-year treatment-free survival for Caucasian, Black and Hispanic patients was 81.2%, 54.4%, and 75.0%, respectively. Pairwise Cox proportional hazards analysis showed significantly decreased treatment-free survival in Black compared to Caucasian men (HR 2.42, 95% CI 1.03-5.68). In African American men, cessation of active surveillance occurred most commonly due to grade reclassification at the time of confirmatory biopsy., Conclusions: Among our active surveillance cohort composed primarily of racial and ethnic minorities, we identified relatively high rates of progression to definitive treatment. African American race was associated with surveillance cessation on univariate analysis. These findings stress the importance of confirmatory biopsy and strict compliance with surveillance protocols in AA men to ensure timely detection of disease reclassification., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Surgical quality improvement collaboratives (QIC) have been established across the nation in numerous specialties. These QICs have shown efficacy in improving the quality, safety and value of care delivered to patients with a wide range of medical conditions. In recent years, urological QICs have emerged, including regional collaboratives such as the Michigan Urological Surgical Improvement Collaborative (MUSIC) and Pennsylvania Urologic Regional Collaborative (PURC), as well as the national American Urological Association Quality Registry Program (AQUA). These urological collaboratives, developed with an initial focus on prostate cancer, have demonstrated an ability to accurately measure prostate cancer outcomes, compare these outcomes among providers and institutions, and enact change among both patients and providers to optimize outcomes for men with prostate cancer. Physician-led regional collaboratives may be uniquely positioned to respond quickly to the rapidly-evolving healthcare landscape and enact practice and provider-level changes when appropriate. This review describes the historical background, current structure and function, and potential future directions of these urologic QICs., Competing Interests: Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/tau.2019.10.18). The series “Controversies in Minimally Invasive Urologic Oncology” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare., (2021 Translational Andrology and Urology. All rights reserved.)

Background: Standard of care for patients with muscle-invasive bladder cancer (MIBC) includes neoadjuvant cisplatin-based chemotherapy (NAC) followed by consolidative therapy with either chemoradiation or radical cystectomy (RC). Some patients experience robust pathologic responses to NAC, and these have been reported to associate with somatic mutations in specific gene pathways including DNA damage response genes., Objective: To evaluate the ability of post-NAC clinical restaging, with or without tumor sequencing, to predict final RC pathologic staging., Design, Setting, and Participants: We reviewed our institutional review board-approved institutional database to identify patients with MIBC who underwent NAC followed by RC from 2003 to 2016. Following NAC prior to RC, cystoscopy was performed routinely, with resection of residual visible tumor and/or tumor base (transurethral resection [TUR]). For patients with pre-NAC tumor tissue available, tumor sequencing was performed. Outcome measurements and statistical analysis: Clinical restaging and tumor sequencing were evaluated for their ability to predict the final pathologic stage accurately at RC using chi-square or Fisher's exact test., Results and Limitations: A total of 114 patients underwent restaging TUR following NAC and prior to RC. The diagnostic accuracy of post-NAC clinical restaging including TUR was poor, with 32% of patients being downstaged falsely when compared with their final RC pathology. Forty-nine patients had sequencing of pre-NAC tumor tissue, of whom 32 showed at least one mutation of interest. However, NAC responses and rates of false downstaging did not differ significantly according to tumor mutation status., Conclusions: This study highlights the inaccuracy of post-NAC clinical restaging TUR with or without adjunctive tumor mutation analysis, to assess pathologic residual disease accurately. Caution must be taken when performing post-NAC restaging, especially when considering conservative management strategies such as active surveillance on this basis. Patient summary: Several groups are evaluating whether certain patients, whose bladder cancer responds well to upfront chemotherapy, may be able to forego cystectomy safely. We demonstrate that currently available staging tools and tumor DNA sequencing cannot identify such patients reliably and accurately., (Copyright © 2020 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Purpose: A minimum number of index procedures is required for graduation. Without thresholds for surgical technique, it is unclear if robotic and open learning is balanced. We assessed the distribution of robotic and open surgeries performed by residents upon graduation., Materials and Methods: Voluntary Accreditation Council for Graduate Medical Education resident case logs from 11 institutions were de-identified and trends in robotic and open major surgeries were compared using Wilcoxon rank sum and 2-sample t-tests., Results: A total of 89,199 major cases were recorded by 209 graduates from 2011 to 2017. The median proportion of robotic cases increased from 2011 to 2017 in reconstruction (4.7% to 15.2%), oncology (27.5% to 54.2%) and pediatrics (0% to 10.9%) (all values p <0.001). Robotic and open cases remained most divergent in reconstruction, with a median of 12 robotic (IQR 9-19) to 70 open cases (IQR 55-106) being performed by residents in 2017. Similar observations occurred in pediatrics. In oncology the number of robotic procedures superseded that of open in 2016 and rose to a median of 148 robotic (IQR 108-214) to 121 open cases (IQR 90-169) in 2017, with the driver being robotic prostatectomy. Substantial differences in surgical technique were observed between institutions and among graduates from the same institution., Conclusions: Although robotic volume is increasing, the balance of surgical technique and the pace of change differ in reconstruction, oncology and pediatrics, as well as among individual institutions and graduates themselves. This raises questions about whether more specific guidelines are needed to ensure equity and standardization in training.

Background: We tested for associations between socioeconomic status (SES) and adverse prostate cancer pathology in a population of African American (AA) men treated with radical prostatectomy (RP)., Patients and Methods: We retrospectively reviewed data from 2 institutions for AA men who underwent RP between 2010 and 2015. Household incomes were estimated using census tract data, and patients were stratified into income groups relative to the study population median. Pathologic outcomes after RP were assessed, including the postsurgical Cancer of the Prostate Risk Assessment (CAPRA-S) score and a definition of adverse pathology (stage ≥ pT3, Gleason score ≥ 4+3, or positive lymph nodes), and compared between income groups., Results: We analyzed data of 347 AA men. Median household income was $37,954. Low-SES men had significantly higher prostate-specific antigen values (mean 10.2 vs. 7.3; P < .01) and CAPRA-S scores (mean 3.4 vs. 2.5; P < .01), more advanced pathologic stage (T3-T4 31.8% vs. 21.5%; P = .03), and higher rates of seminal vesicle invasion (17.3% vs. 8.2%; P < .01), positive surgical margins (35.3% vs. 22.1%; P < .01), and adverse pathology (41.4% vs. 30.1%; P = .03). Linear and logistic regression showed significant inverse associations of SES with CAPRA-S score (P < .01) and adverse pathology (P = .03)., Conclusion: In a population of AA men who underwent RP, we observed an independent association of low SES with advanced stage or aggressive prostate cancer. By including only patients in a single racial demographic group, we eliminated the potential confounding effect of race on the association between SES and prostate cancer risk. These findings suggest that impoverished populations might benefit from more intensive screening and early, aggressive treatment of prostatic malignancies., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: We describe contemporary active surveillance utilization and variation in a regional prostate cancer collaborative. We identified demographic and disease specific factors associated with active surveillance in men with newly diagnosed prostate cancer., Materials and Methods: We analyzed data from the PURC (Pennsylvania Urologic Regional Collaborative), a cooperative effort of urology practices in southeastern Pennsylvania and New Jersey. We determined the rates of active surveillance among men with newly diagnosed NCCN® (National Comprehensive Cancer Network®) very low, low or intermediate prostate cancer and compared the rates among participating practices and providers. Univariate and multivariable analyses were used to identify factors associated with active surveillance utilization., Results: A total of 1,880 men met inclusion criteria. Of the men with NCCN very low or low risk prostate cancer 57.4% underwent active surveillance as the initial management strategy. Increasing age was significantly associated with active surveillance (p <0.001) while adverse clinicopathological variables were associated with decreased active surveillance use. Substantial variation in active surveillance utilization was observed among practices and providers., Conclusions: More than 50% of men with low risk disease in the PURC collaborative were treated with active surveillance. However, substantial variation in active surveillance rates were observed among practices and providers in academic and community settings. Advanced age and favorable clinicopathological factors were strongly associated with active surveillance. Analysis of regional collaboratives such as the PURC may allow for the development of strategies to better standardize treatment in men with prostate cancer and offer active surveillance in a more uniform and systematic fashion.

Purpose: To determine the association of micropapillary urothelial carcinoma (MUC) variant histology with bladder cancer outcomes after radical cystectomy., Materials and Methods: Information on MUC patients treated with radical cystectomy was obtained from five academic centers. Data on 1,497 patients were assembled in a relational database. Tumor histology was categorized as urothelial carcinoma without any histological variants (UC; n = 1,346) or MUC (n = 151). Univariable and multivariable models were used to analyze associations with recurrence-free (RFS) and overall (OS) survival., Results: Median follow-up was 10.0 and 7.8 years for the UC and MUC groups, respectively. No significant differences were noted between UC and MUC groups with regard to age, gender, clinical disease stage, and administration of neoadjuvant and adjuvant chemotherapy (all, P ≥ 0.10). When compared with UC, presence of MUC was associated with higher pathologic stage (organ-confined, 60% vs. 27%; extravesical, 18% vs. 23%; node-positive, 22% vs. 50%; P < 0.01) and lymphovascular invasion (29% vs. 58%; P < 0.01) at cystectomy. In comparison with UC, MUC patients had poorer 5-year RFS (70% vs. 44%; P < 0.01) and OS (61% vs. 38%; P < 0.01). However, on multivariable analysis, tumor histology was not independently associated with the risks of recurrence (P = 0.27) or mortality (P = 0.12)., Conclusions: This multi-institutional analysis demonstrated that the presence of MUC was associated with locally advanced disease at radical cystectomy. However, clinical outcomes were comparable to those with pure UC after controlling for standard clinicopathologic predictors., (Copyright © 2018. Published by Elsevier Inc.)

Introduction: Prior studies suggest that among men with low grade prostate cancer, African Americans (AA) produce less prostate-specific antigen (PSA) than Caucasians. We investigated racial differences in PSA, PSA density (PSAD), and tumor volume among men with prostate cancer, regardless of tumor grade. These racial differences, if present, would suggest that AA men may benefit from different screening, surveillance, and treatment regiments compared to Caucasians., Materials and Methods: We identified men from our institutional prostate cancer database that underwent radical prostatectomy between 2012 and 2015. Clinicopathologic parameters were compared by race. Multivariable linear regression was then performed to identify factors associated with PSA, PSAD, and tumor volume, adjusting for race, age, body mass index, and pathologic parameters., Results: A total of 255 men were included in the analysis, including 182 (71.4%) Caucasian and 73 (28.6%) AA. PSA (10.2 versus 8.1, p = 0.13) and PSAD (0.23 versus 0.22, p = 0.73) did not differ significantly between AA and Caucasian men. In contrast, tumor volume was significantly greater in AA men (13.4 versus 9.6 grams, p = 0.01). In multivariable linear regression analysis, AA race was not associated with PSA (p = 0.80) or PSAD (p = 0.41), but was significantly associated with increased tumor volume (p < 0.01)., Conclusions: AA men who underwent radical prostatectomy in this analysis had larger tumor volume than Caucasian men despite having similar PSA levels. This association suggests that prostate cancers in AA men may produce less PSA than in Caucasian men. These findings have implications for prostate cancer screening and treatment, as PSA may underestimate the presence or extent of cancer in AA men.

Purpose: Racial disparities in complication rates have been demonstrated for a variety of surgical procedures. We hypothesized that African American (AA) patients experience higher postoperative complication rates than whites following urologic oncology procedures., Materials and Methods: Patients in American College of Surgeons National Surgical Quality Improvement Program who underwent radical prostatectomy (RP), radical or partial nephrectomy (RN/PN), and radical cystectomy (RC) between 2005 and 2013 were included. Complications were grouped as minor (Clavien I-II), major (Clavien III-IV), or death (Clavien V). A 30-day complication rates and disparities in preoperative comorbidity burden were compared by race. After adjustment for comorbidity burden, multivariable logistic regression was performed to test the association between race and risk of complication., Results: Of 38,642 patients included in the analysis, 90% were white and 10% were AA. In unadjusted analysis, there were no significant differences in complication rates between AA and white patients for any Clavien grade in the procedures queried (RP: P = 0.07; RN/PN: P = 0.70; RC: P = 0.12). After controlling for a higher comorbidity burden among AA patients, AA race was again not independently associated with 30-day postoperative complications for RP (odds ratio [OR] = 1.08, 95% CI: 0.92-1.29), RN/PN (OR = 0.98, 95% CI: 0.84-1.13), or RC (OR = 1.10, 95% CI: 0.84-1.43)., Conclusion: Despite a higher comorbidity burden, AA patients in American College of Surgeons National Surgical Quality Improvement Program are not at increased risk of 30-day postoperative complications following major urologic cancer surgery. These findings suggest that comorbidity burden, as opposed to race, is most strongly associated with the risk of postoperative complications. To minimize perioperative risk, clinicians should strive to preoperatively optimize medical comorbidities in all patients undergoing urologic cancer surgery., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: To determine rates of spontaneous ureteral stone passage in patients with indwelling ureteral stents, and to identify factors associated with the spontaneous passage of stones while a ureteral stent is in place., Materials and Methods: From our institutional database, we identified patients who underwent ureteroscopic procedures for stone disease between January 1, 2013 and March 1, 2015. We compared the rates of spontaneous stone passage between patients who had previously undergone ureteral stent placement and those who had not. In patients with indwelling stents, multivariate logistic regression was performed to identify factors associated with spontaneous stone passage., Results: A total of 194 patients met inclusion criteria. Spontaneous stone passage rates were similar in the stented (17/119, 14%) and non-stented (15/75, 20%) groups (p = 0.30). In bivariate analysis of stented patients, smaller stone size (p < 0.001) and distal stone location (p = 0.01) were significantly associated with spontaneous stone passage. Multivariate logistic regression analysis of stented patients showed that only small stone size was significantly associated with the likelihood of stone passage (p = 0.01), whereas stent duration, stone location, and stone laterality were not., Conclusions: A small, but clinically significant percentage of ureteral stones pass spontaneously with a ureteral stent in place. Small stone size is associated with an increased likelihood of spontaneous passage in patients with indwelling stents. These findings may help to identify patients who can potentially avoid additional surgical procedures for definitive stone removal after ureteral stent placement.

A 28-year-old pregnant woman at 19 weeks gestation presented with dysuria as well as lower abdominal and left flank pain. Imaging revealed left-sided hydronephrosis and a mass invading the posterior bladder wall. Management included placement of a left nephrostomy tube and transurethral resection of ~25% of the mass. Microscopy showed an ectopic decidual reaction within the muscularis propria. The patient improved symptomatically and continued prenatal care. Complete resolution of her ureteral obstruction was demonstrated during the postpartum period. Ectopic decidual reactions involving the urinary bladder are extremely rare, and ureteral obstruction secondary to this phenomenon has not yet been reported., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To assess life expectancy and biopsy outcomes in men undergoing prostate biopsy at an academic medical center., Methods: We analyzed men who underwent prostate biopsy at our medical center between July 2012 and June 2014. Long-term other-cause mortality risk was determined using survival tables. Indications for biopsy and biopsy outcomes were assessed, and compared among men with varying mortality risks., Results: A total of 417 men underwent prostate biopsy, in whom 14-year other-cause mortality risk ranged from 9% to 74%. One hundred ninety-three men (46.3%) were considered low-mortality risk (<40% risk of 14-year mortality), 131 (31.4%) intermediate risk (41%-55% 14-year mortality), and 93 (22.3%) high risk (>55% 14-year mortality). Of the 417 patients who underwent biopsy, 149 (35.7%) were found to have prostate cancer. There was no significant difference in the rate of positive biopsies (P = .72), distribution of Gleason scores (P = .60), or percentage of positive biopsy cores (P = .74) between mortality risk groups. However, by UCSF Cancer of the Prostate Risk Assessment score, there was significant trend toward higher-risk prostate cancer in men with intermediate and high-mortality risk (P = .04)., Conclusion: In this analysis, a large number of men with limited life expectancies underwent prostate biopsy. The majority of these men had negative biopsies or low-risk cancers, suggesting that they were unlikely to benefit from biopsy. To avoid potentially unnecessary prostate biopsies, the practitioner must give serious consideration to a patient's age and medical comorbidities before making a recommendation as to whether biopsy should be performed., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: The widespread adoption of prostate-specific antigen-based prostate cancer screening caused a stage migration toward earlier stage disease at diagnosis. We investigated whether this stage migration has persisted in a contemporary analysis of a population-based statewide cancer registry., Materials and Methods: We analyzed the Pennsylvania Cancer Registry, a statewide registry of all newly diagnosed cancers. Data were collected on prostate cancers diagnosed between 1992 and 2012. We determined age-adjusted prostate cancer incidence and mortality rates, as well as the distribution of tumor stage (localized, regional, or metastatic) at diagnosis, and assessed for changes in these variables over time using joinpoint analysis., Results: Between 1992 and 2012, 210,831 new cases of prostate cancer were diagnosed in Pennsylvania, and 33,948 men died of disease. Age-adjusted prostate cancer incidence rates, and specifically the incidence of localized disease, have decreased dramatically since 2007 to 2008. Due to the decreased diagnosis of localized disease, regional and metastatic tumors have made up a greater percentage of all prostate cancer diagnoses in recent years, despite a relatively stable incidence of these advanced stage tumors., Conclusions: Over the past 2 decades, age-adjusted prostate cancer incidence rates in Pennsylvania have decreased, primarily because of the decreased detection of early-stage disease. There has been a corresponding shift toward more advanced disease at diagnosis. These findings may be explained by the decreased use of prostate-specific antigen-based screening, among other factors. The 2012 United States Preventative Services Task Force recommendations against prostate cancer screening may exacerbate this concerning trend, potentially resulting in an increase in prostate cancer-specific mortality., (Copyright © 2016 Elsevier Inc. All rights reserved.)

We report a case of multiple fungal renal abscesses in a 36-year-old woman with a history of diabetes and intravenous substance use disorder. The patient presented with fever and hematuria, and was found to be bacteremic and fungemic. She was initially managed with broad-spectrum antibiotics and antifungals. She remained febrile and imaging on treatment day 14 showed no improvement of the renal abscesses. Thus, a nephrectomy was performed, after which the patient defervesced and follow-up blood cultures were negative. There is a paucity of literature regarding management of multifocal fungal renal abscesses that fail to respond to medical management., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Minimally invasive surgery, including both traditional laparoscopic and robot-assisted laparoscopic approaches, has increasingly become the standard of care for urologic abdominal and pelvic surgery. This is a comprehensive review of the contemporary literature regarding complications of laparoscopic and robotic urologic surgery. The review highlights pertinent studies with the goal of providing the minimally invasive urologic surgeon with an up-to-date overview of general and procedure-specific complications and their management.

Purpose: In this study we evaluate an ultrasensitive prostate specific antigen assay in patients with prostate cancer after radical prostatectomy to predict long-term biochemical recurrence-free survival., Materials and Methods: A total of 754 men who underwent radical prostatectomy and had an undetectable prostate specific antigen after surgery (less than 0.1 ng/ml) were studied. Prostate specific antigen was measured in banked serum specimens with an ultrasensitive assay (Hybritech® PSA, Beckman Coulter Access® 2) using a cutoff of 0.01 ng/ml. Prostate specific antigen was also measured in 44 men after cystoprostatectomy who had no pathological evidence of prostate cancer with the Hybritech assay and with the Quanterix AccuPSA™ assay., Results: Of the 754 men 17% (131) experienced biochemical recurrence (median 4.0 years). Those men without biochemical recurrence (83%, 623) had a minimum of 5 years of followup (median 11). Prostate specific antigen was less than 0.01 ng/ml in 93.4% of men with no biochemical recurrence, whereas 30.5% of men with biochemical recurrence had a prostate specific antigen of 0.01 ng/ml or greater. On multivariate analysis postoperative prostate specific antigen at a 0.01 ng/ml cutoff, pathological stage and Gleason score, and surgical margins were significant independent predictors of biochemical recurrence risk. Kaplan-Meier estimates for mean biochemical recurrence-free survival were 15.2 years (95% CI 14.9-15.6) for prostate specific antigen less than 0.01 ng/ml and 10.0 years (95% CI 8.4-11.5) for prostate specific antigen 0.01 ng/ml or greater (p <0.0001). Biochemical recurrence-free rates 11 years after surgery were 86.1% (95% CI 83.2-89.0) for prostate specific antigen less than 0.01 ng/ml and 48.9% (95% CI 37.5-60.3) for prostate specific antigen 0.01 ng/ml or greater (p <0.0001). Prostate specific antigen concentrations in 44 men after cystoprostatectomy were all less than 0.03 ng/ml, with 95.4% less than 0.01 ng/ml., Conclusions: In men with a serum prostate specific antigen less than 0.1 ng/ml after radical prostatectomy a tenfold lower cutoff (0.01 ng/ml) stratified biochemical recurrence-free survival and was a significant independent predictor of biochemical recurrence, as were pathological features. Prostate specific antigen concentrations in men without pathological evidence of prostate cancer suggest that a higher prostate specific antigen concentration (0.03 ng/ml) in the ultrasensitive range may be needed to define the detection threshold., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To report pathologic outcomes and predictors of adverse pathology in men undergoing radical prostatectomy (RP) after an initial period of active surveillance (AS)., Methods: We studied pathologic outcomes in men who underwent RP after some time on AS. Pathologic outcomes were compared between men with and without evidence of disease reclassification on AS. Rates of adverse pathology (defined as pathologic stage ≥ pT3a, RP Gleason ≥ 4+3, or lymph node involvement) were determined and were compared depending on the variable that defined disease reclassification., Results: Of 1086 men enrolled in AS, 130 (12.0%) underwent RP after a median time of 1.96 years (range, 0.55-12.26 years) on AS. Ninety-seven (74.6%) of these men had evidence of disease reclassification on AS. Rates of adverse pathology were greater in men with evidence of reclassification compared to those without (P = .05). Among men with disease reclassification, rates of adverse pathology ranged from 23.8% to 44.7% depending on the variable used to define reclassification. Longer time on AS was not associated with adverse pathology (P = .68)., Conclusion: Adverse pathology after RP is more common in men with evidence of disease reclassification on AS compared to those undergoing RP for other reasons. However, we identified varying outcomes among these patients depending on the criterion that defined reclassification. These data may enable identification of men who can safely continue on AS despite evidence of disease reclassification., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: The objective of this study was to evaluate the use of neoadjuvant chemoradiation in patients with prostate sarcoma treated at our institution and report oncological outcomes., Materials and Methods: The records of patients with intermediate- or high-grade prostate sarcoma treated with curative intent at our institution from 1993 to 2013 were reviewed. Patient demographic information, tumor characteristics, and treatment modalities used were assessed. Overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS) were calculated., Results: Eight patients met inclusion criteria. The mean age at presentation was 64 years, and urinary obstruction was the most common presenting symptom. All patients underwent surgical resection and neoadjuvant radiation and 6 had concurrent chemotherapy. Four patients received intraoperative radiation. With a median follow-up of 36 months, there were no local recurrences, 6 metastases, 4 deaths from disease, and no deaths from other causes. The median OS and CSS was 67.8 months, with actuarial OS and CSS rates of 100% at 1 year, 75% at 2 years, 62.5% at 3 years, and 62.5% at 5 years. Median RFS was 14.2 months, with actuarial RFS rate of 75% at 1 year, 37.5% at 2 years, and 25% at 3 years., Conclusion: Prostate sarcomas are rarely cured using surgical resection alone. Our cohort treated with a multimodality approach had favorable CSS and RFS compared with historic and contemporary series of surgery alone and no local recurrences. Most patients developed metastatic recurrence, highlighting the aggressive nature of this disease., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: Despite the widespread use of minimally invasive radical prostatectomy (MIRP), there remain concerns regarding its safety in patients with a history of prior abdominopelvic or inguinal surgery., Methods: A prospective database of 1165 MIRP procedures performed by a single surgeon at a high-volume tertiary care center from 2001 to 2013 was analyzed. After an initial period of transperitoneal MIRP (TP), an extraperitoneal (EP) approach was used preferentially beginning in 2005 (for both laparoscopic and robotic cases), and robotics were used preferentially beginning in 2010. Overall perioperative complications, major complications (Clavien-Dindo III or IV), and abdominal complications (e.g., ileus, bowel/organ injury, or vascular injury) were compared for patients with and without a prior surgical history. Uni- and multivariate logistic regression were used to control the impact of robotics, approach, operative time, estimated blood loss, case number, prostate weight, and primary Gleason on complications., Results: Three hundred patients undergoing MIRP had prior abdominopelvic or inguinal surgery (25.8%). Of these, 102 (34%) underwent TP and 198 (66%) EP MIRP. Robotics was used in 286 cases (24.6%) and pure laparoscopy in 879 (75.4%). Complications occurred in 111 patients (9.5%) from the total cohort, with major complications in 32 (2.75%) and abdominal complications in 19 (1.63%). Prior surgery was not associated with overall, major, or abdominal complications. Of the controlling factors, only increasing operative time was associated with postoperative abdominal complications (most of which were ileus) on multivariate analysis., Conclusions: In this large single-surgeon series where both EP and TP approaches to MIRP are utilized, prior abdominopelvic or inguinal surgery was not associated with an increased risk of perioperative complications.

Objectives: To characterize pathological and cancer-specific outcomes of surgically resected cystic renal tumors and to identify clinical or radiographic features associated with these outcomes., Methods and Materials: All patients at our institution who underwent radical or partial nephrectomy for complex renal cystic masses between 2004 and 2011 with available computed tomographic imaging were included. The Bosniak score was determined, as were 10 specific radiographic characteristics of renal cysts in patients with preoperative imaging available for review. These characteristics were correlated with cystic mass histopathology. Recurrence-free survival after surgery was determined., Results: Overall, 133 patients underwent renal surgery for complex cystic lesions, 89 (67%) of whom had malignant lesions. Malignancy risk increased with Bosniak score (P≤0.01) and presence of mural nodules (P = 0.01). Most (63%) malignancies demonstrated clear cell histology. The papillary renal cell carcinomas (25%) exhibited lower enhancement levels (P = 0.04) and were less often septated (P<0.01). Of the malignancies, 79% were low stage (pT1), and 73% were Fuhrman grade 1 or 2. Large cyst size was associated with advanced tumor stage (P = 0.05). Neither Bosniak score nor any other radiographic parameter was associated with Fuhrman grade. In 70 patients with a median follow-up of 43 months, only 1 (1.4%) developed disease recurrence., Conclusions: Most cystic renal malignancies are low-stage, low-grade lesions. Papillary renal cell carcinomas account for nearly a quarter of cystic renal malignancies and have unique radiographic characteristics. Disease recurrence after surgical resection is rare. These findings suggest an indolent behavior for cystic renal tumors, and these lesions may be amenable to active surveillance., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: To assess the utility of an extensive restaging examination performed after the completion of neoadjuvant chemotherapy (NAC) but before radical cystectomy (RC) in the management of patients with advanced bladder cancer., Methods: We studied 62 patients who underwent NAC with the intent of proceeding to consolidative RC. A restaging examination, including endoscopic and bimanual examination, as well as cross-sectional imaging of the abdomen and pelvis, was performed after chemotherapy. The impact of restaging on clinical management was determined. In patients proceeding to RC, the degree of correlation between clinical stage (at diagnosis vs on restaging) and pathologic stage was determined., Results: Restaging altered the treatment course in 6 patients (9.7%) in whom RC was not performed because of restaging findings. An additional 56 patients (90.3%) proceeded to RC. In these patients, compared with clinical stage at diagnosis, the postchemotherapy clinical stage correlated more strongly with pathologic stage (κ = 0.02 vs 0.17). On multivariate analysis, diagnostic clinical stage was not associated with pathologic stage (P = .85), whereas postchemotherapy clinical stage was strongly predictive of pathologic stage (P <.01)., Conclusion: An extensive restaging examination altered treatment strategy in a small, but clinically significant subset of patients treated with NAC for bladder cancer. Furthermore, restaging allowed for more accurate prediction of pathologic stage after RC, thereby improving assessment of patient prognosis. Consideration should be given to incorporating a restaging evaluation into the standard management paradigm for bladder cancer., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objectives: To determine how high-resolution transrectal ultrasound (HiTRUS) compares with conventional TRUS (LoTRUS) for the visualization of prostate cancer., Methods and Materials: Twenty-five men with known prostate cancer scheduled for radical prostatectomy were preoperatively imaged with both LoTRUS (5MHz) and HiTRUS (21MHz). Dynamic cine loops and still images for each modality were saved and subjected to blinded review by a radiologist looking for hypoechoic foci ≥ 5 mm in each sextant of the prostate. Following prostatectomy, areas of prostate cancer ≥ 5 mm on pathologic review were anatomically correlated to LoTRUS and HiTRUS findings. The accuracy of LoTRUS and HiTRUS to visualize prostate cancer in each sextant of the prostate and to identify high-grade and locally advanced disease was assessed. The McNemar test was used to compare sensitivity and specificity and paired dichotomous outcomes between imaging modalities., Results: Among 69 sextants with pathologically identified cancerous foci at radical prostatecomy, HiTRUS visualized 45 and missed 24, whereas LoTRUS visualized 26 and missed 43. Compared with LoTRUS, HiTRUS demonstrated improved sensitivity (65.2% vs. 37.7%) and specificity (71.6% vs. 65.4%). HiTRUS's agreement with pathologic findings was twice as high as LoTRUS (P = 0.006). HiTRUS provided a nonsignificant increase in visualization of high-grade lesions (84% vs. 60%, P = 0.11)., Conclusions: HiTRUS appears promising for prostate cancer imaging. Our initial experience suggests superiority to LoTRUS for the visualization of cancerous foci, and supports proceeding with a clinical trial in the biopsy setting., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Purpose: At our institution the eligibility criteria used to enroll patients in active surveillance are clinical stage T1, prostate specific antigen density less than 0.15 ng/ml, biopsy Gleason score 6 or less, 2 or fewer positive biopsy cores and 50% or less involvement of any biopsy core. We hypothesized that these criteria may be excessively strict, precluding many men from active surveillance., Materials and Methods: We studied pathological outcomes in men treated with radical prostatectomy between 1995 and 2012 who met 4 or more of the 5 active surveillance criteria. Outcomes included a definition of significant tumor (pathological Gleason 7 or greater, or nonorgan confined). We compared adverse pathology rates between men who met all 5 vs 4 of 5 active surveillance criteria., Results: Of 8,261 men 1,890 (22.9%) met all active surveillance eligibility criteria and 2,133 (25.8%) met 4. Men with values exceeding prostate specific antigen density and biopsy Gleason criteria were at increased risk for adverse pathological outcomes. Clinical stage greater than T1 was not associated with adverse pathological findings. The risk of significant tumors in men with clinical stage T2 lesions, 3 or fewer positive biopsy cores and less than 60% core involvement was comparable to that of men who met all active surveillance criteria., Conclusions: Prostate specific antigen density greater than 0.15 ng/ml and biopsy Gleason score 7 or greater are strongly associated with adverse pathological findings at radical prostatectomy. Our findings suggest that active surveillance criteria should be expanded to include men with clinical stage T2 lesions and a greater number of positive biopsy cores of low grade. Based on these preliminary findings, we are in the process of reassessing active surveillance eligibility criteria using more detailed pathological analysis., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)