Association between Previous Pelvic Radiation and All-Cause and Cause-Specific Failure of Replacement Artificial Urinary Sphincters.

PURPOSE: In order to accurately characterize how a history of radiation therapy affects the lifespan of replacement artificial urinary sphincters (AUSs), all possible sources of device failure must be considered. We assessed the competing risks of device failure based on radiation history in men with replacement AUSs. MATERIALS AND METHODS: We identified men who had a replacement AUS in a single institutional, retrospective database. To assess survival from all-cause device failure based on radiation history and other factors, we conducted Kaplan-Meier, Cox proportional-hazards and competing risks analyses. RESULTS: Among 247 men who had a first replacement AUS, men with a history of radiation had shorter time to all-cause device failure (median 1.4 vs 3.5 years for men with radiation vs without radiation history, p=0.02). On multivariable Cox-proportional hazards analysis, previous radiation was associated with increased risk of all-cause device failure (HR: 2.12, 95% CI: 1.30-3.43, p=0.002). On multivariable cause-specific hazards analysis, prior radiation was associated with a higher risk of erosion/infection (HR: 7.57, 95% CI: 2.27-25.2, p <0.001), but was not associated with risk of urethral atrophy (p=0.5) or mechanical failure (p=0.15). CONCLUSIONS: Among men with a replacement AUS, a history of pelvic radiation was associated with shorter time to device failure of any cause. Radiation was also specifically associated with a sevenfold increase in the risk of erosion or infection of replacement AUS, but not with urethral atrophy or mechanical failure. Patients with a replacement AUS should be appropriately counseled on how radiation history may impact outcomes of future revisions.

Genomic classifiers for treatment selection in newly diagnosed prostate cancer.

OBJECTIVES: To review systematically the literature on genomic tests for prostate cancer (PCa) and to evaluate the current state of the evidence on their use in patients with newly diagnosed PCa. METHODS: We conducted a systematic review by searching PubMed, Embase, Cochrane Central and conference abstracts from the American Urological Association, published between 2010 and 2018. Studies evaluating Prolaris, Oncotype Dx and Decipher assays were assessed for inclusion by two authors. Studies were excluded if the results were derived from surgical specimens rather than biopsy specimens. A meta-analysis was not performed owing to significant variations in methodologies, definitions and outcome measures. RESULTS: A total of 729 articles were retrieved in our initial search. After removing duplicates (270) and excluding articles deemed not relevant (432), 21 full-text articles were deemed suitable for inclusion in the present analysis. The full-text articles comprised eight studies on Prolaris, eight studies on Oncotype Dx and five studies on Decipher. For each genomic test we extracted data regarding the risks of adverse pathology, biochemical recurrence, metastasis and PCa-specific mortality. CONCLUSION: The results of genomic tests that use biomarkers derived from prostate biopsy can be used in conjunction with clinicopathological variables to improve our ability to risk-stratify patients with newly diagnosed PCa. Additional data are needed on the impact of using these tests on long-term patient outcomes and their cost-effectiveness.

The role of prostate cancer biomarkers in undiagnosed men.

PURPOSE OF REVIEW: This article intends to review biomarkers derived from blood, urine, and tissue that can aid in the diagnosis of prostate cancer (PCa). RECENT FINDINGS: PCa screening requires tools that complement prostate-specific antigen (PSA) with a higher specificity for clinically significant disease. Novel blood biomarkers, such as the Prostate Health Index (phi) and 4Kscore, utilize isoforms of PSA to more accurately predict high-grade PCa than traditional tools such as PSA and the percentage free-to-total PSA. Several gene products associated with PCa can be detected in the urine through commercially available assays. PCa antigen 3 (PCA3), though approved for repeat biopsy decisions, appears inferior to other biomarkers such as phi for identifying aggressive disease. However, combinations of PCA3 with other urine assays have shown promising results. One tissue-based hypermethylation test, named ConfirmMDx, can also be used to determine the need for repeat biopsy in men with a prior negative biopsy. SUMMARY: Several biomarkers have been developed to aid in the screening and diagnosis of PCa. Such tests are often indicated in men with moderately elevated PSA or history of a prior negative biopsy. Their use facilitates reduction of unnecessary biopsies without sacrificing the early diagnosis of clinically significant PCa.

The Relationship of Baseline Prostate Specific Antigen and Risk of Future Prostate Cancer and Its Variance by Race.

PURPOSE: Several studies suggest that a baseline prostate specific antigen (PSA) measured in young men predicts future risk of prostate cancer. Considering recent recommendations against PSA screening, high-risk populations (e.g. black men, men with a high baseline PSA) may be particularly vulnerable in the coming years. Thus, we investigated the relationship between baseline PSA and future prostate cancer in a black majority-minority urban population. MATERIALS AND METHODS: A retrospective analysis was performed of the prostate biopsy database (n = 994) at the Brooklyn Veterans Affairs Hospital. These men were referred to urology clinic for elevated PSA and biopsied between 2007 and 2014. Multivariate logistic regression was used to predict positive prostate biopsy from log-transformed baseline PSA, race (black, white, or other), and several other variables. RESULTS: The majority of men identified as black (50.2%). Median age at time of baseline PSA and biopsy was 58.6 and 64.8, respectively. Median baseline PSA was similar among black men and white men (2.70 vs 2.91 for black men vs white men, p = 0.232). Even so, black men were more likely than white men to be diagnosed with prostate cancer (OR 1.62, p < 0.0001). Black men less than age 70 were at particularly greater risk than their white counterparts. Baseline PSA was not a statistically significant predictor of future prostate cancer (p = 0.101). CONCLUSIONS: Black men were more likely to be diagnosed with prostate cancer than were white men, despite comparable baseline PSA. In our pre-screened population at the urology clinic, a retrospective examination of baseline PSA did not predict future prostate cancer.

Patterns of Surgical Management of Male Stress Urinary Incontinence: Data From the AUA Quality Registry.

INTRODUCTION: We examined contemporary patterns in treatment of male stress urinary incontinence and identified predictors of undergoing specific surgical procedures. METHODS: Utilizing the AUA Quality Registry, we identified men with stress urinary incontinence utilizing International Classification of Disease codes and related procedures for stress urinary incontinence performed from 2014 to 2020 utilizing Current Procedural Terminology codes. Characteristics of the patient, surgeon, and practice were included in a multivariate analysis of predictors of management type. RESULTS: We identified 139,034 men with stress urinary incontinence in the AUA Quality Registry, of whom only 3.2% underwent surgical intervention during the study period. Artificial urinary sphincter was the most common procedure with 4,287/7,706 (56%) performed, followed by urethral sling with 2,368/7,706 (31%), and lastly urethral bulking with 1,040/7,706 (13%). There was no significant change by year in volume of each procedure performed during the study period. A large proportion of urethral bulking was performed by a disproportionately small number of practices; 5 high-volume practices performed 54% of the total urethral bulking over the study period. Open surgical procedure was more likely in patients with prior radical prostatectomy, urethroplasty, or care at an academic enter. Urethral bulking was more likely in patients with a history of bladder cancer or care by a surgeon of increasing age or female gender. CONCLUSIONS: Utilization of artificial urinary sphincter and urethral sling now exceeds utilization of urethral bulking for male stress urinary incontinence, though some practices continue to perform a disproportionate volume of bulking. Using data from the AUA Quality Registry, we can identify areas for quality improvement to facilitate guideline-adherent care.

Histopathologic and clinical comparison of recurrent and non-recurrent urethral stricture disease treated by reconstructive surgery.

BACKGROUND: Urethral stricture is a relatively frequent problem often requiring multiple surgical interventions. The objective of this study was to compare the clinicopathologic features of urethral resections from patients who underwent open end-to-end anastomotic urethroplasty and later recurred compared to those who did not. METHODS: A retrospective review of the pathology files identified 36 consecutive patients who underwent urethroplasty. The histopathological analysis included evaluation of the inflammatory infiltrate based on the predominant (>50%) cell type: lymphocyte-rich, neutrophil-rich, plasma cell-rich, and mixed; length and thickness of the fibrous plaque; and the cellularity of the fibrous plaque: cellular (>40 stroma nuclei/HPF) or paucicellular (<40 stroma nuclei/high power field). RESULTS: Ten (28%) patients recurred, and 26 (72%) did not. There was no significant difference between recurrent and non-recurrent cases in age, race, comorbidities, location of the stricture, and etiology. All patients with recurrent strictures showed dense paucicellular fibrotic plaques (10/10; 100%), while this was seen in 14/26 (53.8%) non-recurrent cases (P=0.01). Only one patient with cellular fibrosis showed recurrence during follow-up. The log-rank test shows that time to recurrence is significantly shorter in patients with paucicellular fibrosis compared to those with cellular fibrosis (P=0.036). The inflammation consisted of a mixed population of CD3(+) T-lymphocytes, CD20(+) B-lymphocytes, and CD68(+) histiocytes, and there was no difference in the composition of the inflammation between groups. All cases with plasma cell-rich infiltrate showed normal IgG4:IgG. CONCLUSIONS: Our study supports reporting cellularity of the fibrous plaque as a potential predictor of outcome in patients undergoing reconstructive urethroplasty. Patients with paucicellular fibrosis are at increased risk of recurrence.

Immediate Artificial Urinary Sphincter (AUS) Reactivation at the Time of Urethral Cuff Exchange is Not Associated with Increased Erosion Rate.

OBJECTIVE: To retrospectively evaluate the outcomes of immediate artificial urinary sphincter (AUS) reactivation in patients after urethral cuff replacement. It is common practice to delay reactivation of an AUS for four to six weeks following surgery to replace a failed urethral cuff. This is due to concerns about local tissue edema risking obstruction and concerns for urethral erosion. Despite these concerns, there are no published data to support this practice. METHODS: Retrospective chart review of single surgeon procedures performed from 2005-2020. Patients with urethral cuff replacement for recurrent stress incontinence due to compression or mechanical failure were included. RESULTS: Thirty-four patients were identified who had immediate reactivation of the AUS following urethral cuff exchange. Thirty of these patients (88.2%) had radical prostatectomy and five patients also underwent further radiation therapy (14.7%). At 6 months follow-up, there was no reported events of erosion. Likewise, 32/34 (94%) of patients had no complications and reported expected urinary function of the AUS. Urinary retention was not observed. One patient required further re-exploration for a complication within his AUS system (2.9%), and another was ultimately unsatisfied with their unchanged baseline continence despite a fully functioning AUS (2.9%). CONCLUSION: In this series, we observe that immediate reactivation of the AUS after urethral cuff exchange is a safe and reasonable management approach. Limitations of this analysis include a single institution, retrospective study. However, early AUS reactivation after device revision has not been reported in the literature and warrants further investigation given the impact on patient quality of life.

Whom to Biopsy: Prediagnostic Risk Stratification with Biomarkers, Nomograms, and Risk Calculators.

This article describes markers used for prostate biopsy decisions, including prostrate-specific antigen (PSA), free PSA, the prostate health index, 4Kscore, PCA3, and ConfirmMDx. It also summarizes the use of nomograms combining multiple variables for prostate cancer detection.

The role of whole-lesion apparent diffusion coefficient analysis for predicting outcomes of prostate cancer patients on active surveillance.

PURPOSE: To explore the role of whole-lesion apparent diffusion coefficient (ADC) analysis for predicting outcomes in prostate cancer patients on active surveillance. METHODS: This study included 72 prostate cancer patients who underwent MRI-ultrasound fusion-targeted biopsy at the initiation of active surveillance, had a visible MRI lesion in the region of tumor on biopsy, and underwent 3T baseline and follow-up MRI examinations separated by at least one year. Thirty of the patients also underwent an additional MRI-ultrasound fusion-targeted biopsy after the follow-up MRI. Whole-lesion ADC metrics and lesion volumes were computed from 3D whole-lesion volumes-of-interest placed on lesions on the baseline and follow-up ADC maps. The percent change in lesion volume on the ADC map between the serial examinations was computed. Statistical analysis included unpaired t tests, ROC analysis, and Fisher's exact test. RESULTS: Baseline mean ADC, ADC0-10th-percentile, ADC10-25th-percentile, and ADC25-50th-percentile were all significantly lower in lesions exhibiting ≥50% growth on the ADC map compared with remaining lesions (all P ≤ 0.007), with strongest difference between lesions with and without ≥50% growth observed for ADC0-10th-percentile (585 ± 308 vs. 911 ± 336; P = 0.001). ADC0-10th-percentile achieved highest performance for predicting ≥50% growth (AUC = 0.754). Mean percent change in tumor volume on the ADC map was 62.3% ± 26.9% in patients with GS ≥ 3 + 4 on follow-up biopsy compared with 3.6% ± 64.6% in remaining patients (P = 0.050). CONCLUSION: Our preliminary results suggest a role for 3D whole-lesion ADC analysis in prostate cancer active surveillance.

Nocturia: aetiology and treatment in adults.

Nocturia is an extremely common condition that has major sequelae for affected patients. Through disruption of sleep, nocturia impairs quality of life and worsens health outcomes, and is associated with a variety of morbidities including diabetes, coronary artery disease, obstructive sleep apnoea, obesity, metabolic syndrome, and depression. Unsurprisingly, several studies have also linked nocturia with reduced survival. Nocturia is not simply a consequence of lower urinary tract disease; rather, it is a multifactorial disorder that is often a manifestation of an underlying renal or systemic disease. Through the use of the frequency volume chart, clinicians can accurately quantify nocturia and determine its aetiology. Evaluation of quality of life and sleep using simple measures is essential in order to assess the impact of nocturia on a patient. Numerous treatment options for nocturia exist, but most are associated with minor benefit or lack sufficient evidence supporting their use. By systematically analysing an individual's causes of nocturia, clinicians can design appropriate treatment strategies to most effectively treat this condition.