Limitations of abdominopelvic CT and multiparametric MR imaging for detection of lymph node metastases prior to radical prostatectomy.

PURPOSE: To investigate the performance of pre-surgery CT and multiparametric MRI (mpMRI) to identify lymph node (LN) metastases in the Michigan Urological Surgery Improvement Collaborative (MUSIC). Abdominopelvic CT and mpMRI are commonly used for intermediate- and high-risk prostate cancer (PCa) staging. METHODS: Retrospective analysis of the MUSIC registry identified patients undergoing robot-assisted radical prostatectomy (RP) between 3/2012 and 7/2018. Patients were classified according to pre-surgery imaging modality. Primary outcomes were operating characteristics of CT and mpMRI for detection of pathologic LN involvement (pN1). RESULTS: A total of 10,250 patients underwent RP and 3924 patients (38.3%) underwent CT and/or mpMRI prior to surgery. Suspicion for LN involvement was identified on 2.3% CT and 1.9% mpMRI. Overall, 391 patients were pN1(3.8%), including 0.1% low-, 2.1% intermediate-, and 10.9% high-risk PCa patients. Of 235 pN1 patients that underwent CT prior, far more had negative (91.1%) than positive (8.9%) findings, yielding sensitivity: 8.9%, specificity: 98.3%, negative predictive value (NPV): 92.1%, and positive predictive value (PPV): 32.3% for CT with regard to LN metastases. Similarly, more patients with pN1 disease had negative mpMRI (81.0%) then suspicious or indeterminate MRI (19.0%), yielding sensitivity: 19.0%, specificity: 97.3%, NPV: 95.9%, and PPV: 26.7%. CONCLUSIONS: Abdominopelvic CT and mpMRI have clear limitations in identifying LN metastases. Additional clinicopathologic features should be considered when making management decisions, as 2.1% and 10.9% with intermediate-and high-risk cancer had metastatic LNs. The majority of pN1 patients had a negative CT or a negative/indeterminate mpMRI prior to RP. Pelvic LN dissection should be performed in RP patients with intermediate- or high-risk PCa, independent of preoperative imaging results.

Incidence and clinical relevance of paraneoplastic syndromes in patients with renal cell carcinoma.

BACKGROUND: Paraneoplastic syndromes (PNS) are defined as the signs and symptoms attributed to cytokines or hormones released from a tumor or a patient's immune system. PNS have been reported with many cancers for decades and data supporting their relevance in renal cell carcinoma (RCC) are largely historical. The widespread use of electronic medical record (EMR) systems provides a more robust method to capture data. The objective of this study was to establish contemporary data regarding the incidence and relevance of PNS in patients undergoing nephrectomy for suspected RCC. METHODS: In this retrospective single-institution study, 851 patients undergoing nephrectomy for suspected RCC between 2011 and 2018 were assessed for the presence or absence of PNS as defined by laboratory abnormalities. Factors associated with PNS and with all-cause mortality were examined. RESULTS: The incidence of PNS was 33.1% among 851 patients prior to nephrectomy. The most prevalent PNS were anemia (22.4%), thrombocytosis (7.5%), and elevated C-reactive protein (CRP) (7.4%). PNS were more common in women (39.2% vs. 29.4%, p = 0.0032) and higher stage RCC (31.1% of stage I vs. 54.2% of stage IV, p = 0.0036). Factors associated with the presence of PNS in multivariable analysis included female gender, high comorbidity, and stage IV RCC. Prenephrectomy PNS were associated with poorer survival in multivariable analysis (HR: 2.12, p = 0.0002). Resolution of PNS occurred in 52.1% of patients after nephrectomy, including 55.2% with stage I to III and 38.5% with stage IV RCC (p = 0.10). CONCLUSIONS: Using EMR data, laboratory evidence of PNS was present in one-third of a contemporary cohort of patients undergoing nephrectomy, with >50% of PNS resolving after surgery. Consistent with prior reports, PNS are more common in higher-stage RCC and are associated with poorer survival in RCC patients.

Radical prostatectomy for patients with high-risk, very-high risk, or radiographic suspicion for metastatic prostate cancer: Perioperative and early oncologic results from the MUSIC statewide collaborative.

OBJECTIVE: High-risk (HR) prostate cancer (CaP) patients are at greatest risk for occult metastases and disease progression. Radical prostatectomy (RP) provides benefit, but remains of unknown oncologic value compared with other options. We investigated outcomes of RP for HR, very-high-risk (VHR), or metastatic CaP. METHODS: Included are 1,635 patients undergoing RP between January 2012 and December 2018 (prior to widespread availability of CaP-specific PET imaging). VHR CaP was defined as having ≥2HR features, >4cores of biopsy Gleason ≥4+4, or primary Gleason pattern 5. Metastatic CaP was defined by radiographic evidence of N1 and/or M1 CaP and grouped as cN1Many and cN0M1. Pre-treatment, perioperative, and early oncologic data were compared. Patient/tumor characteristics were compared according to risk groups using Chi-squared and Wilcoxon rank-sum tests. Kaplan-Meier analysis of cancer progression and multivariable analyses were performed. RESULTS: Length of stay >2days and readmission following RP was 10.8% and 5.5% for patients with HR or higher CaP. Median time to progression was 3.9 months (IQR:1.6-13.9), and 2-year progression-free probability was 67% for HR, 53% for VHR, 51% for cN1Many, and 58% for cN0M1. In multivariable analysis, VHR (hazard ratio:1.70; P < 0.0001) and cN1Many (1.96, P < 0.0001) were highly significant predictors of progression, while cN0M1 was not (P = 0.54), compared with non-metastatic HR CaP. Limitations include selection biases and imprecision of imaging methodologies. CONCLUSIONS: Most patients with HR or higher CaP remain progression-free 2 years after RP, with acceptable perioperative outcomes. Progression-free survival was similar in cN1 and VHR patients, better with non-metastatic HR CaP, and between these for cN0M1 patients indicating the imprecise clinical staging occurring with conventional imaging modalities alone.

Management of prostate cancer after holmium laser enucleation of the prostate.

INTRODUCTION: Holmium laser enucleation of the prostate (HoLEP) is effective in treating lower urinary tract symptoms from prostatic disease. We investigate the role of HoLEP in the management of patients with benign prostatic hypertrophy (BPH) and prostate cancer (CaP). METHODS: Retrospective review of data regarding all patients undergoing HoLEP at a single institution was performed. Pre- and postoperative PSA, multiparametric MRI, and pathology results were analyzed for those with CaP identified prior to or incidentally at HoLEP. RESULTS: From February 2016 to February 2020, 201 patients underwent HoLEP. Twelve patients had CaP diagnosed before HoLEP: 6 patients with GG1 are on active surveillance (AS), 3 of 4 intermediate-risk patients are on AS and 1 received treatment for disease progression, and both high-risk CaP patients achieved symptomatic benefit from HoLEP and are receiving systemic therapy for CaP. Twenty-one patients (11.1%) with incidentally detected CaP at HoLEP remain on AS or watchful waiting based on clinical scenario. CONCLUSION: Screening for CaP in HoLEP candidates with PSA and MRI is recommended given that >10% will have incidental CaP. After HoLEP for BPH/LUTS, patients with CaP can be surveilled with PSA and/or MRI. Further investigation is warranted to determine the durability of success of these approaches.

Patient Preferences and Treatment Decisions for Prostate Cancer: Results From A Statewide Urological Quality Improvement Collaborative.

OBJECTIVES: To examine the relationship between influential factors and treatment decisions among men with newly diagnosed prostate cancer (PCa). METHODS: We identified men in the Michigan Urological Surgery Improvement Collaborative registry diagnosed with localized PCa between 2018-2020 who completed Personal Patient Profile-Prostate. We analyzed the proportion of active surveillance (AS) between men who stated future bladder, bowel, and sexual problems (termed influential factors) had "a lot of influence" on their treatment decisions versus other responses. We also assessed the relationship between influential factors, confirmatory testing results and choice of AS. RESULTS: A total of 509 men completed Personal Patient Profile-Prostate. Treatment decisions aligned with influential factors for 88% of men with favorable risk and 49% with unfavorable risk PCa. A higher proportion of men who identified bladder, bowel and sexual concerns as having "a lot of influence" on their treatment decision chose AS, compared with men with other influential factors, although not statistically significant (44% vs 35%, P = .11). Similar results were also found when men were stratified based on PCa risk groups (favorable risk: 78% vs 67%; unfavorable risk: 17% vs 9%, respectively). Despite a small sample size, a higher proportion of men with non-reassuring confirmatory testing selected AS if influential factors had "a lot of influence" compared to "no influence" on their treatment decisions. CONCLUSION: Men's concerns for future bladder, bowel, and sexual function problems, as elicited by a decision aid, may help explain treatment selection that differs from traditional clinical recommendation.

Comparison of Side Effects and Tolerability Between Intravesical Bacillus Calmette-Guerin, Reduced-Dose BCG and Gemcitabine for Non-Muscle Invasive Bladder Cancer.

OBJECTIVES: To compare patient-reported side effects and tolerability of full-dose Bacillus Calmette-Guérin (BCG), reduced-dose BCG, and gemcitabine one week after administration. METHODS: All patients from July 2019 to November 2020 receiving intravesical therapy (IVT) for non-muscle invasive bladder cancer (NMIBC) at our institution were surveyed before repeat instillation. Survey questions recorded IVT retention times and the duration and severity of the following side effects: bladder symptoms, fatigue, body aches, hematuria, fever, chills, and other. All responses were collected and quantified in a de-identified, password-protected database. Statistical analysis was performed using SAS JMP 13. RESULTS: Of 592 surveys completed, symptoms of any kind were reported on 463 surveys (78%) with the most common symptoms including bladder symptoms (59%), fatigue (52%), body aches (26%), and hematuria (18%). Patients were able to hold full-dose BCG, reduced-dose BCG, and gemcitabine for the protocol-specified duration 87%, 95%, and 71% of the time (P <0.05). The prevalence, severity, and duration of body aches were highest with gemcitabine (P <0.05) while the prevalence and duration of hematuria were higher with BCG (P <0.05). Reduced-dose BCG had the lowest prevalence, severity, and duration of fatigue (P <0.05). CONCLUSION: Significant differences in the side effects and tolerability of full-dose BCG, reduced-dose BCG, and gemcitabine were demonstrated using this novel survey, and these differences are of value for informing IVT selection. Evaluation of IVTs other than gemcitabine and BCG will further inform selection of therapies for NMIBC.

Regular vs. selective use of closed suction drains following robot-assisted radical prostatectomy: results from a regional quality improvement collaborative.

BACKGROUND: Closed suction drain (CSD) placement is common in robot-assisted radical prostatectomy (RARP). Our goal is to quantify outcomes of RARP for patients undergoing RARP by surgeons who regularly or selectively use CSDs. METHODS: Patients undergoing RARP (4/2014-7/2017) were prospectively entered into the Michigan Urological Surgery Improvement Collaborative (MUSIC) registry. Outcomes included length of stay (LOS) >2 days, >16-day catheterization, 30-day readmission, and clinically significant urine leak or ileus. Retrospective analysis of each adverse event was performed comparing groups using chi-square tests. RESULTS: In all, 6746 RARPs were performed by 115 MUSIC surgeons. CSDs were used in 4451 RARP (66.0%), with wide variation in surgeon CSD use (median: 94.7%, range: 0-100%, IQR: 45-100%). The cohorts of patients treated by surgeons with regular vs. selective CSD usage were similar. CSD use pattern was not associated with rates of prolonged catheterization (4.6% vs. 3.9%, p = 0.17) or readmission (4.5% vs. 4.0%, p = 0.35) and multivariable analysis confirmed these findings (each p > 0.10). Regular CSD use was associated with LOS >2 days (8.4% vs. 6.3%, p = 0.001) and multivariable analyses indicated an odds ratio (OR) of 1.42 (95% CI: 1.12-1.79; p = 0.017) and increased likelihood of clinically significant ileus (OR: 1.64; CI: 1.14-2.35; p = 0.008). CONCLUSIONS: Although there are specific situations in which CSDs are beneficial, e.g. anastomotic leak or observed lymphatic drainage, regular CSD use during RARP was associated with a greater likelihood of LOS >2 days and clinically significant ileus. Our data suggest that CSD should be placed selectively rather than routinely after RARP.

"My bladder is hanging out of my anus": Successful Management of First Reported Case of Male Transanal Bladder Prolapse.

We present a case of an 81-year-old man who presented with a large recto-urethral fistula resulting in prolapsing bladder through the anus. A multi-disciplinary approach with urology, colorectal surgery and plastic surgery was utilized for management of the prolapse with excellent postoperative result. This unique scenario enabled a transanal cystoprostatectomy; the procedure was completed using a natural orifice without transabdominal surgery.

Variable correlation of grid coordinates to core location in template prostate biopsy.

PURPOSE: Transperineal template prostate biopsy has been proposed to facilitate systematic biopsy in patients undergoing repeat biopsy who are at high risk for cancer. Advocates tout the reliability of the grid to define biopsy location compared to hand-held transrectal ultrasound guided biopsy. However, accuracy of the biopsy needle depends on bevel position, tissue deformity, and technique. Due to this potential for error, we sought to determine whether the use of transperineal template biopsy would assure reproducibly accurate needle placement. MATERIALS AND METHODS: A standard 0.5 cm brachytherapy grid was utilized for transperineal biopsy. A single grid hole was used to obtain biopsies. The bevel of the needle was rotated to a different position with each biopsy, and the angle of the needle was varied to test the ability of the grid to "map" the prostate. RESULTS: We observed wide variation of needle location through a single brachytherapy grid hole. We are able to show that at 5 cm depth, an area of 2.47 mm(2) is possible to biopsy and at a depth of 25 cm; approximately 7.56 mm(2) is possible to biopsy. This gives a precision of biopsy of at the most shallow depth 22% and at the deepest 7%. CONCLUSION: There is potential for technical and equipment associated error with transperineal template guided prostate biopsy. The grid alone can account for substantial sources of error, so technique remains critical if the grid coordinates are to be used to predict presence or extent of cancer.

The etiology and management of acute prostatitis.

Acute bacterial prostatitis is a common and clinically important genitourinary disorder. Patient populations who are at especially high risk of acute prostatitis include those with diabetes, cirrhosis, and suppressed immune systems. The cause is usually an ascending infection, but bacteria can also be introduced during transrectal prostate biopsy. Clinical presentation ranges from mild lower urinary tract symptoms to full sepsis. The causative organisms are usually similar to those that cause other common genitourinary infections, and include Escherichia coli and Enterococcus spp. Oral or intravenous antibiotics are usually effective for curing the infection and progression to chronic bacterial prostatitis is, therefore, uncommon. Immunosuppressed patients require special consideration, as bacterial prostatitis in these patients can be caused by atypical infecting organisms and might, therefore, require additional therapies. A lack of response to standard therapy can lead to complications such as a prostatic abscess or fistula.