"Postulating Penis: What Influences the Interest of Transmasculine Patients in Gender Affirming Penile Reconstruction Techniques?"

BACKGROUND: The limitations of metoidioplasty and phalloplasty have been reported as deterrents for transgender and other gender expansive individuals (T/GE) desiring gender affirming surgery, and thus penile transplantation, epithesis, and composite tissue engineering (CTE) are being explored as alternative interventions. AIM: We aim to understand the acceptability of novel techniques and factors that may influence patient preferences in surgery to best treat this diverse population. METHODS: Descriptions of metoidioplasty, phalloplasty, epithesis, CTE, and penile transplant were delivered via online survey from January 2020 to May 2020. Respondents provided ordinal ranking of interest in each intervention from 1 to 5, with 1 representing greatest personal interest. Demographics found to be significant on univariable analysis underwent multivariable ordinal logistic regression to determine independent predictors of interest. OUTCOMES: Sexual orientation, gender, and age were independent predictors of interest in interventions. RESULTS: There were 965 qualifying respondents. Gay respondents were less likely to be interested in epithesis (OR: 2.282; P = .001) compared to other sexual orientations. Straight individuals were the least likely to be interested in metoidioplasty (OR 3.251; P = .001), and most interested in penile transplantation (OR 0.382; P = .005) and phalloplasty (OR 0.288, P < .001) as potential interventions. Gay and queer respondents showed a significant interest in phalloplasty (Gay: OR 0.472; P = .004; Queer: OR 0.594; P = .017). Those who identify as men were more interested in phalloplasty (OR 0.552; P < .001) than those with differing gender identities. Older age was the only variable associated with a decreased interest in phalloplasty (OR 1.033; P = .001). No demographic analyzed was an independent predictor of interest in CTE. CLINICAL IMPLICATIONS: A thorough understanding of patient gender identity, sexual orientation, and sexual behavior should be obtained during consultation for gender affirming penile reconstruction, as these factors influence patient preferences for surgical interventions. STRENGTHS AND LIMITATIONS: This study used an anonymous online survey that was distributed through community channels and allowed for the collection of a high quantity of responses throughout the T/GE population that would otherwise be impossible through single-center or in-person means. The community-based methodology minimized barriers to honesty, such as courtesy bias. The survey was only available in English and respondents skewed young and White. CONCLUSION: Despite previously reported concerns about the limitations of metoidioplasty, participants ranked it highly, along with CTE, in terms of personal interest, with sexual orientation, gender, and age independently influencing patient preferences, emphasizing their relevance in patient-surgeon consultations. A. Parker, G. Blasdel, C. Kloer et al. "Postulating Penis: What Influences the Interest of Transmasculine Patients in Gender Affirming Penile Reconstruction Techniques?". J Sex Med 2022;19:385-393.

Long-term lower urinary tract sequelae following AUS cuff erosion.

AIMS: To examine the rate of lower urinary tract complications (LUTC) and urinary diversion (UD) after artificial urinary sphincter (AUS) explantation with the acute reconstruction of AUS cuff erosion defects. METHODS: We performed a retrospective study of patients who underwent in-situ urethroplasty (ISU) for AUS cuff erosion from June 2007 to December 2020. Outcomes included LUTC (urethral stricture, diverticulum, fistula), AUS reimplantation, and UD. Defect size was prospectively estimated acutely and a subanalysis was performed to determine the impact of erosion severity (small erosions [<33% circumferential defect] and large erosions [≥33%]) on these outcomes. Kaplan-Meier curves were created to compare survival between the two groups. RESULTS: A total of 40 patients underwent ISU for urethral cuff erosion. The median patient age was 76 years old with a median erosion circumference of 46%. The overall LUTC rate was 30% (12/40) with 35% (14/40) of patients requiring permanent UD. Secondary AUS placement occurred in 24/40 (60%) patients with 11/24 (46%) leading to repeat erosion. On subanalysis, small erosion was associated with improved LUTC-free and UD-free survival but not associated with AUS reimplantation. CONCLUSIONS: Lower urinary tract complications are common after AUS cuff erosion and can lead to the need for permanent UD. Patients with larger erosions are more likely to undergo UD and reach this end-stage condition earlier compared to patients with small erosions.

The emerging role of robotics in upper and lower urinary tract reconstruction.

PURPOSE OF REVIEW: Developments in robotic reconstructive urology have introduced novel treatments for complex upper and lower urinary tract disease. Short-term and mid-term data demonstrates excellent outcomes and minimal morbidity, suggesting the advanced instrumentation and visualization of robotics represent a new treatment paradigm in patients that are historically difficult to treat. Here we review recent developments in the robotically assisted surgical management of urethral and ureteral strictures. RECENT FINDINGS: The minimally invasive approach, enhanced precision and reach, and near-infrared fluorescence imaging capabilities of robotic platforms have proven to be valuable additions in reconstructive urology where perfusion is often compromised, or anatomy is distorted. These benefits are leveraged heavily in recent descriptions of robotic-assisted posterior urethroplasty and ureteroplasty. Short-term to mid-term follow-up data for these procedures show excellent patency rates with low morbidity and complication rates when compared with open approaches. Long-term data for these procedures are not yet available. SUMMARY: The role of robotics in reconstructive urology is being actively investigated. Initial findings demonstrate excellent results with low morbidity in the treatment of upper and lower urinary tract disease. Long-term data will ultimately determine the role of robotics in the reconstructive armamentarium.

Multidimensional outcomes of suburethral synthetic midurethral sling removal.

PURPOSE: To report multidimensional outcomes encompassing pain, dyspareunia, and recurrent urinary tract infections (UTIs), following suburethral sling removal (SSR) of synthetic midurethral slings (MUS) placed for female stress urinary incontinence. METHODS: We reviewed a prospectively maintained, IRB-approved database of women undergoing SSR at our institution. Demographic data, type of sling, and symptoms along with Urogenital Distress Inventory-Short Form (UDI-6) scores both before and after SSR were analyzed. Success was defined using several modalities including patient-reported symptoms (ideal outcome) and UDI-6 questionnaire. RESULTS: From 3/2006-2/2017, 443 women underwent SSR of which 230 met study criteria with median overall follow-up of 23 months (mean 30 months). 180/230 (78%) patients reported 3 or more symptoms at presentation. Median most recent post-SSR total UDI-6 score was 38 vs. 50 at baseline (p < 0.0001). By UDI-6, 53% of patients achieved success post-SSR. An ideal outcome was attained in 22/230 (10%) patients. A modified outcome allowing for one minimally invasive anti-incontinence procedure and excluding sexual activity classified 112/230 (49%) patients as successes. CONCLUSIONS: While patients with MUS present with multiple symptoms, following SSR, there is sustained improvement in multiple symptom domains, including pain and urinary incontinence. Allowing for minimally invasive anti-incontinence procedures (not inclusive of subsequent suburethral sling), the rate of success was 49%, which was comparable to that derived from UDI-6 scores (53%).

Erosion rates of 3.5-cm artificial urinary sphincter cuffs are similar to larger cuffs.

OBJECTIVE: To compare long-term outcomes and erosion rates of 3.5-cm artificial urinary sphincter (AUS) cuffs vs larger cuffs amongst men with stress urinary incontinence (SUI), with and without a history of pelvic radiotherapy (RT). PATIENTS AND METHODS: We reviewed the records of all men who underwent AUS placement by a single surgeon between September 2009 and June 2017 at our tertiary urban medical centre. A uniform perineal approach was used to ensure cuff placement around the most proximal corpus spongiosum after precise spongiosal measurement. Patients were stratified by cuff size and RT status, and patient demographics and surgical outcomes were analysed. Cases of AUS revision in which a new cuff was not placed were excluded. Success was defined as patient-reported pad use of ≤1 pad/day. RESULTS: Amongst 410 cases included in the analysis, the 3.5-cm cuff was used in 166 (40.5%), whilst 244 (59.5%) received larger cuffs (≥4.0 cm). Over a median follow-up of 50 months, there was AUS cuff erosion in 44 patients at a rate nearly identical in the 3.5-cm cuff (10.8%, 18/166) and the ≥4-cm cuff groups (10.7%, 26/244, P = 0.7). On multivariate logistic regression, clinical factors associated with AUS cuff erosion included a history of pelvic RT, prior AUS cuff erosion, prior urethroplasty, and a history of inflatable penile prosthesis (IPP) placement. Patient demographics were similar between the cuff-size groups; including age, body mass index, comorbidities, smoking history, RT history, prior AUS, and prior IPP placement. Continence rates were high amongst all AUS patients, with similar success in both groups (82% for 3.5-cm cuff, 90% for ≥4-cm cuff, P = 0.1). CONCLUSIONS: After 8 years of experience and extended follow-up, the outcomes of the 3.5-cm AUS cuff appear to be similar to ≥4-cm cuffs for effectiveness and rates of urethral erosion. RT patients have a higher risk of cuff erosion regardless of cuff size.

Prospective Inclusion of Apparent Diffusion Coefficients in Multiparametric Prostate MRI Structured Reports: Discrimination of Clinically Insignificant and Significant Cancers.

OBJECTIVE: The purpose of this study was to assess the diagnostic performance of prospectively assigned mean apparent diffusion coefficient (ADC) values in multiparametric MRI (mpMRI) structured reports for discriminating clinically insignificant (International Society of Urological Pathology [ISUP] group 1) from clinically significant (ISUP groups 2-5) prostate cancer. MATERIALS AND METHODS: This single-center study included men with abnormal 3-T mpMRI findings (Prostate Imaging Reporting and Data System version 2 score, ≥ 3) who subsequently underwent radical prostatectomy or targeted biopsy with positive results. One of nine radiologists prospectively reported the mean ADC for each lesion during clinical interpretation. Lesions with ADC ≤ 0.700 mm2/s × 10-3 were flagged as concerning for clinically significant prostate cancer. The index lesion at MRI correlated with the site-concordant lesion at targeted biopsy or whole-mount histopathologic analysis. Logistic regression was used to evaluate the utility of mean ADC values for discriminating ISUP grade group 1 from groups 2-5. Diagnostic performance was assessed by ROC AUC. RESULTS: Among the 218 eligible men, those with ISUP group 2-5 lesions had lower mean ADC values than those with ISUP 1 lesions; overall, 0.598 vs 0.803 mm/s2 × 10-3 (p < 0.0001); peripheral zone (PZ), 0.597 vs 0.855 mm/s2 × 10-3 (p < 0.0001); transition zone (TZ), 0.600 vs 0.660 mm/s2 × 10-3 (p = 0.035). The AUC for the PZ was 0.91 and for the TZ was 0.70. The optimal ADC cutoff values were 0.682 mm/s2 × 10-3 for PZ lesions and 0.638 mm2/s × 10-3 for TZ lesions, resulting in sensitivity and specificity of 78% and 94% for the PZ and 72% and 67% for the TZ. CONCLUSION: ADC values estimated prospectively in a clinical setting can help differentiate clinically insignificant from clinically significant prostate cancer, facilitating prebiopsy and pretreatment risk stratification.

Challenges of Multidimensional Outcome Reporting after Suburethral Mid Urethral Sling Removal.

PURPOSE: We sought to determine the types and frequency of presenting symptoms in women undergoing suburethral mid urethral sling removal to improve outcome reporting after removal. MATERIALS AND METHODS: Following institutional review board approval women who underwent suburethral mid urethral sling removal of 1 mid urethral sling were evaluated for their presenting symptoms and correlation with the UDI-6 (Urogenital Distress Inventory-Short Form) questionnaire. Demographic data were recorded. Patient reported presenting symptoms were categorized into 5 domains, including storage symptoms, voiding symptoms, pain, recurrent urinary tract infections or urinary incontinence. The UDI-6 was reviewed preoperatively and 6 to 12 months postoperatively. We also calculated an ideal outcome, defined as resolution of incontinence, pain, resumption of sexual activity and no need for further anti-incontinence procedures. RESULTS: A total of 230 women from 2006 to 2017 met study inclusion criteria, including 116 who completed the UDI-6 postoperatively. Of the women 80% had 3 or more presenting symptoms with pain as the most common symptom. The most common combination of symptoms was all 5 domains, which was noted in 46 of the 230 women (20%). An increasing number of symptoms correlated with the total preoperative UDI-6 score. Symptom domains were associated with the corresponding UDI-6 subdomain questions. Domains not covered by the UDI-6, ie recurrent urinary tract infections and dyspareunia, accounted for 27% of reported symptoms. Due to limited data on sexual activity an ideal outcome was reached in 10% of patients but this rate was 40% after sexual activity information was excluded. CONCLUSIONS: In this series the presenting symptoms were manifold in women undergoing suburethral mid urethral sling removal. The UDI-6 questionnaire correlated with many of these complaints. It may be used in outcome analysis in conjunction with self-reported symptoms.

Delayed Reconstruction of Bulbar Urethral Strictures is Associated with Multiple Interventions, Longer Strictures and More Complex Repairs.

PURPOSE: Prior to urethral reconstruction many patients with stricture undergo a variable period during which endoscopic treatments are performed for recurrent obstructive symptoms. We evaluated the association among urethroplasty delay, endoscopic treatments and subsequent reconstructive outcomes. MATERIALS AND METHODS: We reviewed the records of men who underwent primary bulbar urethroplasty from 2007 to 2014. Those with prior urethroplasty, penile and/or membranous strictures and incomplete data were excluded from analysis. Men were stratified by a urethroplasty delay of less than 5, 5 to 10 or greater than 10 years from diagnosis. RESULTS: A total of 278 primary bulbar urethroplasty cases with complete data were evaluated. Median time between stricture diagnosis and reconstruction was 5 years (IQR 2-10). Patients underwent an average ± SD of 0.9 ± 2.4 endoscopic procedures per year of delay. Relative to less than 5 and 5 to 10 years a delay of greater than 10 years was associated with more endoscopic treatments (median 1 vs 2 vs 5), repeat self-dilations (13% vs 14% vs 34%), strictures longer than 2 cm (40% vs 39% vs 56%) and complex reconstructive techniques (17% vs 17% vs 34%). An increasing number of endoscopic treatments was independently associated with strictures longer than 2 cm (OR 1.06, p = 0.003), which had worse 24-month stricture-free survival than shorter strictures (83% vs 96%, p = 0.0003). Each consecutive direct vision internal urethrotomy was independently associated with the risk of urethroplasty failure (HR 1.19, p = 0.02). CONCLUSIONS: Urethroplasty delay is common and often associated with symptomatic events managed by repeat urethral manipulations. Endoscopic treatments appear to lengthen strictures and increase the complexity of repair.

Plication for Severe Peyronie's Deformities Has Similar Long-Term Outcomes to Milder Cases.

INTRODUCTION: Penile plication (PP) for Peyronie's disease (PD) is an established treatment option for mild to moderate curvature, but scant data exist regarding its utility in severe deformities. AIM: To evaluate long-term outcomes among men undergoing PP for PD, comparing severe to mild/moderate penile deformities. METHODS: We performed a retrospective review of patients who underwent PP for PD between 2009 and 2017. All patients underwent multiple parallel tunical plication without degloving. Severe PD was defined as either curvature ≥60 degrees or biplanar curvature ≥35 degrees. Patient demographics and surgical outcomes were analyzed. A modified PD Questionnaire and International Index of Erectile Function (IIEF)-5 were administered by telephone. MAIN OUTCOME MEASURE: Long-term patient-reported outcomes were evaluated from a modified survey incorporating the PD Questionnaire and IIEF-5. RESULTS: Of 327 PP patients, 102 (31%) responded to the telephone survey at a median 59.5 months (interquartile range 28.3-84) since surgery. Patients were equally distributed into severe (n = 51) and mild/moderate (n = 51) groups. Despite a greater mean degree of curvature in severe compared to mild/moderate patients (71.6 degrees vs 37.7 degrees, respectively, P < .001), correction of penile curvature was achieved in 91% of patients, with a mean change of 60.7 degrees in severe cases compared to 31.4 degrees in mild/moderate cases (P < .001). Equal numbers of patients in severe and mild/moderate groups reported improvement of penile curvature (74.5% vs 74.5%, P = 1.0) and sexual function (51.0% vs 49.0%, P = .84). PD Questionnaire metrics were likewise similar between severe and mild/moderate patients (P > .1), as were rates of subjective penile shortening (62.7% vs 62.7%, P = 1.0) and IIEF-5, both pre-operatively (19.5 vs 19.7, P = .9) and post-operatively (19.4 vs 17.6, respectively, P = .15). On multivariate logistic regression, worsening sexual function was significantly associated with increased age (odds ratio 1.07, P = .01) and pre-operative IIEF (odds ratio 1.14, P = .02). CLINICAL IMPLICATIONS: PP should be considered in PD patients with severe deformities, as outcomes are favorable and comparable to those with milder curvature. STRENGTH & LIMITATIONS: This is a novel study evaluating long-term patient-reported outcomes after PP, comparing patients with severe deformity to those with mild/moderate curvature. The study was limited by retrospective design, relatively low survey response rate (31%), and lack of validated post-operative PD questionnaire. CONCLUSION: Long-term patient-reported outcomes of PP for severe PD deformities are comparable to mild/moderate cases, supporting broader application of PP beyond milder deformities. Reddy RS, McKibben MJ, Fuchs JS, et al. Plication for Severe Peyronie's Deformities Has Similar Long-Term Outcomes to Milder Cases. J Sex Med 2018;15:1498-1505.

Penoscrotal Decompression-Promising New Treatment Paradigm for Refractory Ischemic Priapism.

BACKGROUND: For prolonged ischemic priapism, outcomes after distal shunt are poor, with only 30% success for priapic episodes lasting longer than 48 hours. AIM: To present a novel, glans-sparing approach of corporal decompression through a penoscrotal approach for cases of refractory ischemic priapism (RIP) after failed distal shunt procedures. METHODS: We describe the technique and present our initial experience with penoscrotal decompression (PSD) for treatment of RIP after failed distal shunt. We compared outcomes of patients with RIP undergoing surgical management using PSD or malleable penile prosthesis (MPP) placement after failed distal penile shunt procedures (2008-2017). OUTCOMES: Our initial experience showed favorable outcomes with PSD compared with early MPP placement in patients with RIP whose distal shunt failed. RESULTS: Of 14 patients with RIP undergoing surgical management after failed distal penile shunt procedures, all patients presented after a prolonged duration of priapism (median = 61 hours) after which the priapism was refractory to multiple prior treatments (median = 3, range = 1-75) including at least 1 distal shunt. MPP was inserted in 8 patients (57.1%), whereas the most recent 6 patients (42.9%) underwent PSD. All patients with PSD (6 of 6, 100%) were successfully treated with corporal decompression without additional intervention and noted immediate relief of pain postoperatively. In contrast, 37.5% of patients (3 of 8) undergoing MPP after failed distal shunt procedures required a total of 8 revision surgeries during a median follow-up of 41.5 months. The most common indications for revision surgery after MPP placement included distal (4 of 8, 50%) and impending lateral (2 of 8, 25%) extrusion. CLINICAL IMPLICATIONS: PSD is a simple, effective technique in the management of RIP after failed distal shunt procedures with fewer complications than MPP placement. STRENGTHS AND LIMITATIONS: Although PSD is effective in the management of RIP after failed distal shunt procedures, long-term assessment of erectile function and ease of future penile prosthetic implantation is needed. CONCLUSION: Corporal decompression resolves RIP through a glans-sparing approach and avoids the high complication rate of prosthetic insertion after failed distal shunt procedures. Fuchs JS, Shakir N, McKibben MJ, et al. Penoscrotal Decompression-Promising New Treatment Paradigm for Refractory Ischemic Priapism. J Sex Med 2018;15:797-802.

Refined nomogram incorporating standing cough test improves prediction of male transobturator sling success.

AIMS: To develop a decision aid in predicting sling success, incorporating the Male Stress Incontinence Grading Scale (MSIGS) into existing treatment algorithms. METHODS: We reviewed men undergoing first-time transobturator sling for stress urinary incontinence (SUI) from 2007 to 2016 at our institution. Patient demographics, reported pads per day (PPD), and Standing Cough Test (SCT) results graded 0-4, according to MSIGS, were assessed. Treatment failure was defined as subsequent need for >1 PPD or further procedures. Parameters associated with failure were included in multivariable logistic models, compared by area under the receiver-operating characteristic curves. A nomogram was generated from the model with greatest AUC and internally validated. RESULTS: Overall 203 men (median age 67 years, IQR 63-72) were evaluated with median follow-up of 45 months (IQR 11-75 months). A total of 185 men (91%) were status-post radical prostatectomy and 29 (14%) had pelvic radiation history. Median PPD and SCT grade were both two. Eighty men (39%) failed treatment (use of ≥1 PPD or subsequent anti-incontinence procedures) at a median of 9 months. History of radiation (P = 0.03), increasing MSIGS (P < 0.0001) and increasing preoperative PPD (P < 0.0001) were associated with failure on univariate analysis. In a multivariable model with AUC 0.81, MSIGS, and PPD remained associated (P = 0.002 and <0.0001 respectively, and radiation history P = 0.06), and was superior to models incorporating PPD and radiation alone (AUC 0.77, P = 0.02), PPD alone (AUC 0.76, P = 0.02), and a cutpoint of >2 PPD alone (AUC 0.71, P = 0.0001). CONCLUSIONS: MSIGS adds prognostic value to PPD in assessing success of transobturator sling for treatment of SUI.

Preoperative Urine Culture Results Correlate Poorly With Bacteriology of Urologic Prosthetic Device Infections.

INTRODUCTION: Although preoperative negative urine culture results and treatment of urinary tract infections are generally advised before artificial urinary sphincter (AUS) and penile prosthesis (PP) surgery to prevent device infection, limited evidence exists to support this practice. AIM: To evaluate the relation between preoperative urine culture results and the bacteriology of prosthetic device infections. METHODS: Men undergoing AUS and/or PP placement at a tertiary referral center from 2007 through 2015 were analyzed. A total of 713 devices were implanted in 681 patients (337 AUSs in 314 patients and 376 PPs in 367 patients), of whom 259 (36%) did not have preoperative urine culture and were excluded. The remaining 454 patients received standard broad-spectrum perioperative antibiotics. Two patient groups were identified based on preoperative urine cultures: group 1 had negative urine culture results and group 2 had untreated asymptomatic positive urine culture results identified postoperatively. MAIN OUTCOME MEASURES: Device infection was diagnosed clinically and cultures obtained from the explanted device and tissue spaces were compared with preoperative urine culture results. RESULTS: Although multivariate analysis showed that patients undergoing AUS placement had a 4.5-fold greater risk of positive urine culture results (114 of 250, 45%) compared with those undergoing PP placement (36 of 204, 18%; P < .001), infection rates between device types were similar (8 of 250 for AUSs [3%] and 7 of 204 for PPs [3%]; P = .89). At a median follow-up of 15 months, device infection occurred in 15 of 454 devices (3%) implanted and no differences in infection rates were noted between urine culture groups (10 of 337 in group 1 [3.3%] and 5 of 117 in group 2 [4.3%]; P = .28). Remarkably, only 1 of 15 device infections (7%) had the same organism present at preoperative urine culture. CONCLUSIONS: Despite the finding that patients with AUS placement had a 4.5 times higher rate of positive urine culture results than patients with PP placement, preoperative urine culture results appeared to show little correlation with the bacteriology of prosthetic device infections.

Equivocal ureteropelvic junction obstruction on diuretic renogram--should minimally invasive pyeloplasty be offered to symptomatic patients?

PURPOSE: Equivocal ureteropelvic junction obstruction refers to clinical symptoms and/or other radiological suggestions of possible ureteropelvic junction obstruction but with inconclusive results of obstruction on diuretic renogram. We evaluated long-term outcomes in patients with equivocal ureteropelvic junction obstruction treated with minimally invasive pyeloplasty. MATERIALS AND METHODS: We retrospectively analyzed the records of 125 consecutive patients who underwent minimally invasive pyeloplasty as performed by a single surgeon from May 2004 to July 2013. Of 98 patients with followup those with more than 6-month followup were included in analysis. Equivocal ureteropelvic junction obstruction, defined as half-life less than 20 minutes on diuretic renogram, was identified in 23 patients. All patients underwent transperitoneal minimally invasive pyeloplasty. We evaluated patient demographics, preoperative and postoperative symptoms and renal function. RESULTS: The 16 female and 7 male patients with equivocal ureteropelvic junction obstruction had flank pain and associated hydronephrosis on imaging. At a median followup of 20.2 months (range 7 to 75) 95.7% of patients with equivocal obstruction achieved complete symptom resolution. Mean ± SD preoperative and postoperative half-life was 14.1 ± 3.7 and 7.4 ± 4.2 minutes, respectively, for an improvement of 6.7 minutes (p < 0.001). In 1 patient (4.3%) with equivocal obstruction of a complicated iatrogenic etiology treatment ultimately failed postoperatively and endopyelotomy was required. There was no statistically significant difference in clinical or radiological success between the equivocal obstruction group and the 75 patients treated with minimally invasive pyeloplasty for definitive ureteropelvic junction obstruction (p = 0.44 and 0.07, respectively). CONCLUSIONS: In patients with radiographic equivocal ureteropelvic junction obstruction and flank pain minimally invasive pyeloplasty efficaciously provides symptomatic relief and functional preservation. Results are comparable to those in patients with high grade obstruction.

The role of image guided biopsy targeting in patients with atypical small acinar proliferation.

PURPOSE: Men diagnosed with atypical small acinar proliferation are counseled to undergo early rebiopsy because the risk of prostate cancer is high. However, random rebiopsies may not resample areas of concern. Magnetic resonance imaging/transrectal ultrasound fusion guided biopsy offers an opportunity to accurately target and later retarget specific areas in the prostate. We describe the ability of magnetic resonance imaging/transrectal ultrasound fusion guided prostate biopsy to detect prostate cancer in areas with an initial diagnosis of atypical small acinar proliferation. MATERIALS AND METHODS: Multiparametric magnetic resonance imaging of the prostate and magnetic resonance imaging/transrectal ultrasound fusion guided biopsy were performed in 1,028 patients from March 2007 to February 2014. Of the men 20 met the stringent study inclusion criteria, which were no prostate cancer history, index biopsy showing at least 1 core of atypical small acinar proliferation with benign glands in all remaining cores and fusion targeted rebiopsy with at least 1 targeted core directly resampling an area of the prostate that previously contained atypical small acinar proliferation. RESULTS: At index biopsy median age of the 20 patients was 60 years (IQR 57-64) and median prostate specific antigen was 5.92 ng/ml (IQR 3.34-7.48). At fusion targeted rebiopsy at a median of 11.6 months 5 of 20 patients (25%, 95% CI 6.02-43.98) were diagnosed with primary Gleason grade 3, low volume prostate cancer. On fusion rebiopsy cores that directly retargeted areas of previous atypical small acinar proliferation detected the highest tumor burden. CONCLUSIONS: When magnetic resonance imaging/transrectal ultrasound fusion guided biopsy detects isolated atypical small acinar proliferation on index biopsy, early rebiopsy is unlikely to detect clinically significant prostate cancer. Cores that retarget areas of previous atypical small acinar proliferation are more effective than random rebiopsy cores.

The Role of Magnetic Resonance Image Guided Prostate Biopsy in Stratifying Men for Risk of Extracapsular Extension at Radical Prostatectomy.

PURPOSE: Magnetic resonance imaging detects extracapsular extension by prostate cancer with excellent specificity but low sensitivity. This limits surgical planning, which could be modified to account for focal extracapsular extension with image directed guidance for wider excision. In this study we evaluate the performance of multiparametric magnetic resonance imaging in extracapsular extension detection and determine which preoperative variables predict extracapsular extension on final pathology when multiparametric magnetic resonance imaging predicts organ confined disease. MATERIALS AND METHODS: From May 2007 to March 2014, 169 patients underwent pre-biopsy multiparametric magnetic resonance imaging, magnetic resonance imaging/transrectal ultrasound fusion guided biopsy, extended sextant 12-core biopsy and radical prostatectomy at our institution. A subset of 116 men had multiparametric magnetic resonance imaging negative for extracapsular extension and were included in the final analysis. RESULTS: The 116 men with multiparametric magnetic resonance imaging negative for extracapsular extension had a median age of 61 years (IQR 57-66) and a median prostate specific antigen of 5.51 ng/ml (IQR 3.91-9.07). The prevalence of extracapsular extension was 23.1% in the overall population. Sensitivity, specificity, and positive and negative predictive values of multiparametric magnetic resonance imaging for extracapsular extension were 48.7%, 73.9%, 35.9% and 82.8%, respectively. On multivariate regression analysis only patient age (p=0.002) and magnetic resonance imaging/transrectal ultrasound fusion guided biopsy Gleason score (p=0.032) were independent predictors of extracapsular extension on final radical prostatectomy pathology. CONCLUSIONS: Because of the low sensitivity of multiparametric magnetic resonance imaging for extracapsular extension, further tools are necessary to stratify men at risk for occult extracapsular extension that would otherwise only become apparent on final pathology. Magnetic resonance imaging/transrectal ultrasound fusion guided biopsy Gleason score can help identify which men with prostate cancer have extracapsular extension that may not be detectable by imaging.

Comparison of magnetic resonance imaging and ultrasound (MRI-US) fusion-guided prostate biopsies obtained from axial and sagittal approaches.

OBJECTIVE: To compare cancer detection rates and concordance between magnetic resonance imaging and ultrasound (MRI-US) fusion-guided prostate biopsy cores obtained from axial and sagittal approaches. PATIENTS AND METHODS: Institutional records of MRI-US fusion-guided biopsy were reviewed. Detection rates for all cancers, Gleason ≥3 + 4 cancers, and Gleason ≥4 + 3 cancers were computed. Agreement between axial and sagittal cores for cancer detection, and frequency where one was upgraded the other was computed on a per-target and per-patient basis. RESULTS: In all, 893 encounters from 791 patients that underwent MRI-US fusion-guided biopsy in 2007-2013 were reviewed, yielding 4688 biopsy cores from 2344 targets for analysis. The mean age and PSA level at each encounter was 61.8 years and 9.7 ng/mL (median 6.45 ng/mL). Detection rates for all cancers, ≥3 + 4 cancers, and ≥4 + 3 cancers were 25.9%, 17.2%, and 8.1% for axial cores, and 26.1%, 17.6%, and 8.6% for sagittal cores. Per-target agreement was 88.6%, 93.0%, and 96.5%, respectively. On a per-target basis, the rates at which one core upgraded or detected a cancer missed on the other were 8.3% and 8.6% for axial and sagittal cores, respectively. Even with the inclusion of systematic biopsies, omission of axial or sagittal cores would have resulted in missed detection or under-characterisation of cancer in 4.7% or 5.2% of patients, respectively. CONCLUSION: Cancer detection rates, Gleason scores, and core involvement from axial and sagittal cores are similar, but significant cancer may be missed if only one core is obtained for each target. Discordance between axial and sagittal cores is greatest in intermediate-risk scenarios, where obtaining multiple cores may improve tissue characterisation.

Single- versus dual-console robot-assisted radical prostatectomy: impact on intraoperative and postoperative outcomes in a teaching institution.

OBJECTIVE: To compare the outcomes of robotic-assisted laparoscopic prostatectomy (RALP) using a dual versus single-console system in a resident training program using intraoperative, perioperative and postoperative measures. METHODS: Patients with PCa who underwent RALP prior to and after implementing a dual-console system at an academic institution were reviewed from 2006-2012. All surgeries were performed by a single-faculty surgeon well after the learning curve was established. In all cases, chief residents participated in the surgery and performed progressively more portions. Demographic, intraoperative and pathologic parameters were obtained. Continence and erectile function were assessed at 6 and 12 months. Postoperative complications were graded using the Clavien-Dindo classification. Predictors of outcomes on univariate analysis were included in multivariate logistic or linear models. RESULTS: Of 381 patients, 185 and 196 underwent single- or dual-console RALP, respectively. There was a significant decrease in mean operative time using the dual-console system (222 vs. 171 min, p < 0.0001) as well as in the incidence of intraoperative complications (8.65 vs. 1.53%, p < 0.0001) and postoperative complications (14.1 vs. 6.63%, p = 0.03.) Complications of Clavien grade ≥3a occurred more frequently with a single-console system (7 vs. 1%, p = 0.003.) Differences persisted when controlling for potential confounders by multivariate regression. Postoperative measures of continence, erectile function and the rate of biochemical recurrence were similar between cohorts. CONCLUSIONS: When training resident surgeons to perform RALP, a dual-console system may improve intraoperative and perioperative outcomes. The dual-console may represent a safer, more efficient modality for robotic surgical education as compared to a single-console system.

Comparison of MR/ultrasound fusion-guided biopsy with ultrasound-guided biopsy for the diagnosis of prostate cancer.

IMPORTANCE: Targeted magnetic resonance (MR)/ultrasound fusion prostate biopsy has been shown to detect prostate cancer. The implications of targeted biopsy alone vs standard extended-sextant biopsy or the 2 modalities combined are not well understood. OBJECTIVE: To assess targeted vs standard biopsy and the 2 approaches combined for the diagnosis of intermediate- to high-risk prostate cancer. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study of 1003 men undergoing both targeted and standard biopsy concurrently from 2007 through 2014 at the National Cancer Institute in the United States. Patients were referred for elevated level of prostate-specific antigen (PSA) or abnormal digital rectal examination results, often with prior negative biopsy results. Risk categorization was compared among targeted and standard biopsy and, when available, whole-gland pathology after prostatectomy as the "gold standard." INTERVENTIONS: Patients underwent multiparametric prostate magnetic resonance imaging to identify regions of prostate cancer suspicion followed by targeted MR/ultrasound fusion biopsy and concurrent standard biopsy. MAIN OUTCOMES AND MEASURES: The primary objective was to compare targeted and standard biopsy approaches for detection of high-risk prostate cancer (Gleason score ≥ 4 + 3); secondary end points focused on detection of low-risk prostate cancer (Gleason score 3 + 3 or low-volume 3 + 4) and the biopsy ability to predict whole-gland pathology at prostatectomy. RESULTS: Targeted MR/ultrasound fusion biopsy diagnosed 461 prostate cancer cases, and standard biopsy diagnosed 469 cases. There was exact agreement between targeted and standard biopsy in 690 men (69%) undergoing biopsy. Targeted biopsy diagnosed 30% more high-risk cancers vs standard biopsy (173 vs 122 cases, P < .001) and 17% fewer low-risk cancers (213 vs 258 cases, P < .001). When standard biopsy cores were combined with the targeted approach, an additional 103 cases (22%) of mostly low-risk prostate cancer were diagnosed (83% low risk, 12% intermediate risk, and 5% high risk). The predictive ability of targeted biopsy for differentiating low-risk from intermediate- and high-risk disease in 170 men with whole-gland pathology after prostatectomy was greater than that of standard biopsy or the 2 approaches combined (area under the curve, 0.73, 0.59, and 0.67, respectively; P < .05 for all comparisons). CONCLUSIONS AND RELEVANCE: Among men undergoing biopsy for suspected prostate cancer, targeted MR/ultrasound fusion biopsy, compared with standard extended-sextant ultrasound-guided biopsy, was associated with increased detection of high-risk prostate cancer and decreased detection of low-risk prostate cancer. Future studies will be needed to assess the ultimate clinical implications of targeted biopsy. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00102544.