Review of Active Surveillance in Underrepresented and High-Risk Populations: Feasibility and Safety.

PURPOSE OF REVIEW: The purpose of this review is to investigate the current use and effectiveness of active surveillance (AS) for clinical low-risk prostate cancer (PCa) in men considered to be "high-risk" based on the factors of race, genetics, healthcare access, and socioeconomic status. RECENT FINDINGS: Advances in molecular biomarkers and imaging have improved the detection, risk stratification, and treatment of PCa. Still, overdiagnosis and overtreatment of indolent disease remain a concern. AS is therefore the preferred option for clinical low-risk disease. Yet, because of the variability in PCa presentation based on the aforementioned environmental and genetic factors, the question remains: Is active surveillance a safe option for everyone? Provider hesitancy should not necessarily exclude high-risk men from participating in AS. Rather, clinicians should employ shared decision-making, sound clinical judgment, and stringent follow-up in order to effectively counsel AS candidates and optimize AS-related outcomes in "high-risk" individuals.

Decision aids for localized prostate cancer in diverse minority men: Primary outcome results from a multicenter cancer care delivery trial (Alliance A191402CD).

BACKGROUND: Decision aids (DAs) can improve knowledge for prostate cancer treatment. However, the relative effects of DAs delivered within the clinical encounter and in more diverse patient populations are unknown. A multicenter cluster randomized controlled trial with a 2×2 factorial design was performed to test the effectiveness of within-visit and previsit DAs for localized prostate cancer, and minority men were oversampled. METHODS: The interventions were delivered in urology practices affiliated with the NCI Community Oncology Research Program Alliance Research Base. The primary outcome was prostate cancer knowledge (percent correct on a 12-item measure) assessed immediately after a urology consultation. RESULTS: Four sites administered the previsit DA (39 patients), 4 sites administered the within-visit DA (44 patients), 3 sites administered both previsit and within-visit DAs (25 patients), and 4 sites provided usual care (50 patients). The median percent correct in prostate cancer knowledge, based on the postvisit knowledge assessment after the intervention delivery, was as follows: 75% for the pre+within-visit DA study arm, 67% for the previsit DA only arm, 58% for the within-visit DA only arm, and 58% for the usual-care arm. Neither the previsit DA nor the within-visit DA had a significant impact on patient knowledge of prostate cancer treatments at the prespecified 2.5% significance level (P = .132 and P = .977, respectively). CONCLUSIONS: DAs for localized prostate cancer treatment provided at 2 different points in the care continuum in a trial that oversampled minority men did not confer measurable gains in prostate cancer knowledge.

The impact of surgical downgrading on prostate cancer recurrence: systematic review and analysis of a multiethnic population.

OBJECTIVE: To perform a systematic review and a retrospective cohort analysis evaluating the rates of surgical downgrading of prostate cancer (PCa) from biopsy (PBx) to radical prostatectomy (RP), and their association with biochemical recurrence (BCR) in a multiethnic population. METHODS: A systematic review of PubMed and other databases was performed. We included retrospective studies evaluating the relationship between surgical downgrading and BCR-free survival. Data regarding Gleason score (GL) downgrading were abstracted from the articles and categorized as follows: GL8-10 to GL7, GL7 to GL6, and GL 7(4 + 3) to GL7(3 + 4). We also performed a retrospective cohort review of patients who underwent RP at our institution from 2005 through 2020. Kaplan-Meier survival analysis and Cox proportional hazards models were used to compare BCR among downgraded versus non-downgraded men. RESULTS: Systematic review yielded 137 abstracts; of these, 36 full-texts were reviewed, 8 of which were included in our systematic review. Despite substantial variability, all showed that GL at RP is one of the most important factors of BCR-free survival. A total of 1,484 men with PCa were analyzed from our institution. On multivariate analysis, GL7 to GL6 downgrading (HR = 0.50, p = 0.022) and GL8-10 to GL7 downgrading (HR = 0.42, p = 0.011) were associated with reduced risk of BCR when compared to men with GL7 and GL8-10 concordance, respectively. However, GL7(4 + 3) to GL7(3 + 4) downgrading was not significantly associated with reduced BCR (HR = 0.56, p = 0.12), when compared to GL7(4 + 3) concordance, although HR was similar. CONCLUSION: Surgical downgrading at RP was associated with a reduced risk of BCR compared to GL concordant disease, and these findings have been validated within our multiethnic population. Pathologic downgrading at the time of RP may be a more useful predictor of subsequent BCR in comparison to that associated with GL concordant pathology.

A Comparison of Image-Guided Targeted Prostate Biopsy Outcomes by PI-RADS® Score and Ethnicity in a Diverse, Multiethnic Population.

PURPOSE: NonHispanic Black (NHB) and Hispanic/Afro-Caribbean men have the highest risk of prostate cancer (PCa) compared to nonHispanic White (NHW) men. However, ethnicity-specific outcomes of targeted fusion biopsy (FB) for the detection of PCa are poorly characterized. We compared the outcomes of FB by Prostate Imaging Reporting and Data System (PI-RADS®) score and race/ethnicity among a diverse population. MATERIALS AND METHODS: We evaluated all men who underwent image-guided FB for suspicious lesions on prostate magnetic resonance imaging (≥PI-RADS 3) over a 2-year period. We examined associations of race/ethnicity and PI-RADS score with risk of PCa or clinically significant PCa (cs-PCa, Gleason Group ≥2) on FB using mixed-effects logistic regression models. RESULTS: A total of 410 men with 658 lesions were analyzed, with 201 (49.0%) identified as NHB and 125 (30.5%) identified as Hispanic. NHB men had a twofold increase in the odds of detecting cs-PCa (OR=2.7, p=0.045), while Hispanic men had similar odds of detecting cs-PCa compared to NHW men. With regard to all PCa, NHB men had a similar increase in the odds of detecting all PCa (OR=2.4, p=0.050), which was borderline statistically significant compared to NHW men on FB. When we excluded men on active surveillance, NHB men had even stronger associations with detection of cs-PCa (OR=3.10, p=0.047) or all PCa (OR=2.77, p=0.032) compared to NHW men. CONCLUSIONS: NHB men have higher odds for overall PCa and cs-PCa on FB compared to NHW men. Further work may clarify differences per PI-RADS score. Clinicians should interpret prostate magnetic resonance imaging lesions with more caution in NHB men.

Finasteride Use and Risk of Bladder Cancer in a Multiethnic Population.

PURPOSE: Finasteride use has been associated with a reduced incidence of bladder cancer. However, the majority of studies have been conducted primarily in East Asian or White populations. Given differences in the incidence of bladder cancer among racial/ethnic groups, it is important to determine whether the effect of finasteride use on bladder cancer varies by race/ethnicity. MATERIALS AND METHODS: We identified all patients with a diagnosis of benign prostatic hyperplasia between 2000 and 2016 at our academic health center in Bronx, New York via an electronic medical record database. We then identified patients who were prescribed finasteride, and those who developed bladder cancer during followup. We used competing risk analysis to examine associations of finasteride use with risk of bladder cancer, adjusting for age, smoking and race/ethnicity. RESULTS: We identified 42,406 patients with benign prostatic hyperplasia (average±SD age 67±12.9 years), of whom 27.7% were Black and 14.8% were Hispanic. Finasteride was prescribed in 5,698 patients (13.4%). Bladder cancer was diagnosed in 84 of 5,698 finasteride users (1.5%), compared to 762 of 36,708 nonusers (2.1%, log-rank p=0.003). Finasteride was associated with a 36% reduction in risk of bladder cancer (HR: 0.64, 95% CI: 0.51-0.80; p <0.0001) among all patients. When data were stratified by race/ethnicity, finasteride use was associated with a reduction in risk of bladder cancer in White men (HR: 0.61, 95% CI: 0.43-0.86; p=0.005) and Hispanic men (HR: 0.44, 95% CI: 0.21-0.90; p=0.026), but there was no association among Black men (HR: 1.01, 95% CI: 0.67-1.51; p=0.964). CONCLUSIONS: Our study corroborates previous findings that men who are on finasteride have a lower bladder cancer incidence. However, the reduction in risk was seen only in White and Hispanic men, but not among Black men. Therefore, race/ethnicity represents an important stratification factor for future larger studies on finasteride as chemoprevention for bladder cancer.

Effects of pathological upstaging or upgrading on metastasis and cancer-specific mortality in men with clinical low-risk prostate cancer.

OBJECTIVES: To determine if the presence of adverse pathological features in patients eligible for active surveillance (AS) are prognostic of poor oncological outcomes, independent of pretreatment risk. PATIENTS AND METHODS: A retrospective analysis was performed on patients who underwent radical prostatectomy (RP) at two institutions (Cleveland Clinic Foundation and Memorial Sloan Kettering Cancer Center) between 1987 and 2008, and who had subsequent follow-up. Rates of biochemical recurrence, metastasis and death from prostate cancer were compared amongst patients with adverse pathological features (Gleason score ≥7, ≥pT3, or lymph node invasion) based on D'Amico clinical risk (low vs intermediate/high). We also compared survival outcomes between patients with and without pathological upgrading/upstaging amongst D'Amico low-risk patients. Univariate and multivariable Cox regression models were used to assess the association between clinical risk, pathological reclassification, and oncological outcomes. RESULTS: We identified 16 341 patients who underwent RP, of whom 6 371 were clinically low-risk. Adverse outcomes in men with adverse pathological features were significantly lower in those with low clinical risk, with an ~50% and ~70% reduction in the risk of metastasis and death, respectively. Only pathological upgrading/upstaging to Gleason score ≥8, seminal vesicle invasion, and lymph node invasion from clinical low-risk disease, were associated with adverse outcomes. However, these types of reclassification were rare. CONCLUSION: Clinical low-risk patients with pathological upgrading/upstaging have substantially lower rates of important oncological outcomes compared to those with higher pretreatment risk and not substantially different than low-risk patients without pathological upgrading/upstaging. These results call into question the use of this endpoint to counsel patients about the merits and risks of AS.

Outcomes of Active Surveillance after Initial Surveillance Prostate Biopsy.

PURPOSE: We analyzed the rates of disease reclassification at initial and subsequent surveillance prostate biopsy as well as the treatment outcomes of deferred therapy among men on active surveillance for prostate cancer. MATERIALS AND METHODS: From a prospective database we identified 300 men on active surveillance who had undergone initial surveillance prostate biopsy, with or without confirmatory biopsy, within 1 year of diagnosis. Of these men 261 (87%) were classified as having NCCN very low or low risk disease at diagnosis. Disease reclassification on active surveillance was defined as the presence of 50% or more positive cores and/or surveillance prostate biopsy Gleason score upgrading. Patients with type I disease reclassification included those with any surveillance prostate biopsy Gleason score upgrading, while patients with type II reclassification had to have primary Gleason pattern 4-5 disease on surveillance prostate biopsy. Outcomes after initial surveillance prostate biopsy were evaluated using actuarial analyses. RESULTS: At the time of initial surveillance prostate biopsy 49 (16%) and 19 (6%) patients had type I and type II disease reclassification, respectively. Those who underwent confirmatory biopsy had significantly reduced rates of type I (9% vs 23%, p=0.001) and type II (3% vs 9%, p=0.01) reclassification at initial surveillance prostate biopsy. For the 251 patients without disease reclassification at initial surveillance prostate biopsy the 2-year rates of subsequent type I and II reclassification were 17% (95% CI 0-24) and 3% (95% CI 0.1-7), respectively. For the 93 patients who received deferred therapy the 5-year biochemical progression-free probability was 89% (95% CI 79-98), including 95%, 82% and 70% among those without, and those with type I and type II disease reclassification, respectively. CONCLUSIONS: Patients on active surveillance with stable disease at the time of initial surveillance prostate biopsy may be appropriate candidates for less intensive surveillance prostate biopsy schedules.

Perioperative epidural analgesia is not associated with increased survival from renal cell cancer, but overall survival may be improved: a retrospective chart review.

PURPOSE: We investigated the possible association between perioperative epidural and both cancer-specific survival (CSS) and overall survival (OS) in patients undergoing partial or radical nephrectomy for localized renal cell carcinoma (RCC). METHODS: A retrospective chart review was performed on patients who underwent complete surgical resection of localized RCC from 1994-2008 at our institution. Baseline demographics and pathological and survival data were collected. Patients with clinically or pathologically positive lymph nodes or metastatic disease at the time of surgery were excluded. Patients with pathologically positive surgical margins were also excluded. Patients were divided into two groups, systemic analgesia and epidural analgesia. Multivariable Cox regression analysis was used to determine CSS and OS, and survival curves were generated using the Kaplan-Meier method. RESULTS: Four hundred thirty-eight patients were included in the analysis. Baseline characteristics of both groups were similar. Median follow-up was 77 months. On multivariable analysis, patient age (hazard ratio [HR], 1.04; 95% confidence interval [CI], 1.02 to 1.07), epidural status (HR, 0.5; 95% CI, 0.4 to 0.8), year of surgery (HR, 0.9; 95% CI, 0.89 to 0.95), and pathologic T-stage (pT-stage) ≥ 2 (pT-stage2: HR, 2.2; 95% CI, 1.2 to 4.1 and pT-stage3: HR, 3.1; 95% CI, 2.0 to 4.7) were independent predictors of OS. Nevertheless, epidural status did not significantly predict CSS (P = 0.73), while T-stage and year of surgery maintained their respective predictive significance. Tumour grade did not significantly affect OS or CSS. CONCLUSIONS: Our retrospective analysis suggests that epidural at the time of surgical excision of localized RCC does not significantly impact CSS. Nevertheless, use of epidural was associated with significantly improved OS. Future prospective clinical and laboratory studies are warranted in order to characterize these associations further and determine the underlying mechanisms.

Clinical and therapeutic factors associated with adverse pathological outcomes in clinically node-negative patients treated with neoadjuvant cisplatin-based chemotherapy and radical cystectomy.

PURPOSE: Several disease characteristics have been identified as potential predictors for pathological node involvement (pN+) following radical cystectomy (RC). However, these have not been assessed in patients treated with neoadjuvant chemotherapy (NAC). We endeavored to assess factors predicting adverse pathology in clinically node-negative patients treated with NAC and RC. METHODS: Patients from four North American institutions with cT2-4aN0M0 UC who received three or four cycles of NAC followed by RC were selected. Logistic regression was used to predict pN+,

A pretreatment nomogram for prediction of biochemical failure after primary cryoablation of the prostate.

BACKGROUND: To create a predictive nomogram for biochemical failure following primary whole-gland cryoablation of the prostate for localized prostate cancer (LPCa). METHODS: We retrospectively analyzed 2,242 patients from the Cryo On-Line Database (COLD) who were treatment naive and had undergone primary whole gland cryoablation of the prostate for biopsy-confirmed LPCa. Kaplan-Meier (KM) curves estimating 5 year biochemical progression-free survival (bPFS) were generated. Multivariable Cox proportional hazards analysis (CoxPH) was performed in order to construct the nomogram. The nomogram was internally validated using the bootstrap technique. RESULTS: Overall, the KM estimated 5 year bPFS was 72.8%. Stratified by D'Amico risk, The KM estimated 5 year bPFS was 82.6%, 71.1%, and 57.8% for low-, intermediate-, and high-risk groups, respectively. Statistically significant predictors of biochemical outcomes from CoxPH analysis were pre-treatment prostate specific antigen (PTPSA) (P < 0.001), total prostate volume (P = 0.004), clinical stage (P = 0.034), and Gleason score (0.004). A nomogram for predicted 5 year biochemical progression free probability was constructed with a concordance index of 0.652. An online risk calculator was also generated. CONCLUSIONS: To the best of our knowledge, this is the first predictive nomogram for biochemical outcomes after primary whole gland cryoablation of the prostate using socio-demographic, pretreatment, clinical, and prostate biopsy data. Our nomogram and online risk calculator can guide both patients and urologists for shared decision making regarding definitive treatment options.

The New York Section EMPIRE Collaborative: Piloting a Multi-Institutional, Simulation-Based Surgical Skills Boot Camp for Junior Urology Residents.

INTRODUCTION: Since the integration of the intern year into urology residencies, programs are mandated to introduce fundamental skills to junior residents. Our goal was to assess the impact of one such program: the 2023 New York Section of the AUA (NYS-AUA) EMPIRE (Educational Multi-institutional Program for Instructing REsidents) Boot Camp. METHODS: Junior urology residents from all 10 NYS-AUA institutions attended a free EMPIRE Boot Camp on June 9, 2023. The seminar covered procedural skills including urethral catheterization, cystoscopy, renal and bladder ultrasound, transrectal prostate ultrasound with biopsy, and an introduction to robotics/laparoscopy. Sessions focused on urologic emergencies and postoperative scenarios. Participants completed questionnaires before, immediately after, and 6 months post course, assessing comfort with procedures and overall program quality using a 5-point Likert scale and free text responses. t Tests compared pre and immediate/6-month post scores. RESULTS: Forty junior residents, along with faculty and resident instructors from all 10 NYS-AUA programs, participated. Of the 40 trainees, 35 (87.5%) completed pre- and immediate post-boot camp surveys, while 23 (57.5%) responded to the 6-month follow-up survey. Ratings showed significant improvement in comfort with basic urologic technical skills for 13 out of 14 domains (93%) immediately after the course and at the 6-month mark. Attendees reported notably higher comfort levels in managing obstructive pyelonephritis (P = .003) and postoperative complications (P = .001) following didactic sessions. CONCLUSIONS: A skills-based, free collaborative urology boot camp for junior residents is feasible and can be effective. Trainees reported improved comfort performing certain technical skills and managing urologic emergencies both immediately after the course and at 6 months of follow-up.

Low risk is low risk, regardless of race or ethnicity: Outcomes of prostate cancer active surveillance and factors associated with reclassification in a racially diverse cohort.

INTRODUCTION: Active surveillance (AS) is the standard for very low- and low-risk prostate cancer. Although risk factors for pathologic reclassification while on AS have been identified, results are mixed for non-Hispanic Black (NHB) and Hispanic ethnicity. We aim to further explore how race and ethnicity may be affecting AS participation and outcomes in a primarily urban, diverse, and vulnerable population. MATERIALS AND METHODS: Patients eligible for AS from 2005-2020 were reviewed. Demographics, race/ethnicity, prostate specific antigen (PSA), prostate volume, and pathologic characteristics were analyzed between patients enrolled in AS and those that underwent immediate therapy. Kaplan-Meier survival analysis was used to compare biochemical recurrence (BCR) rates. Cox proportional hazards models were used to develop prediction models for clinical reclassification. RESULTS: A total of 471 men were eligible for AS. Of those, 188 (39.9%) enrolled in AS while 283 (60.1%) underwent immediate radical therapy. No significant differences were found in racial/ethnic composition between the AS and immediate treatment groups. In our AS cohort, 79 (42.0%) experienced clinical reclassification and underwent deferred treatment. BCR rates were similar between treatment groups. Race/ethnicity were not found to be predictors of clinical reclassification, while metrics at diagnostic biopsy such as elevated PSA, higher PSA density, and lower prostate volume increased reclassification odds. CONCLUSIONS: In our diverse population, NHB race and Hispanic ethnicity were not significant predictors of adverse reclassification while on AS. Our findings support utilizing other metrics taken at initial biopsy to identify high-risk patients such as PSA, prostate volume, and PSA density.

Urine Cytology Rarely Escalates Clinical Management in the Surveillance of Non-muscle-Invasive Bladder Cancer.

INTRODUCTION: The use of urine cytology in the surveillance of non-muscle invasive bladder cancer (NMIBC) is widely variable in clinical practice. We studied the impact of surveillance urine cytology on clinical decision making during NMIBC surveillance. METHODS: A retrospective chart review was conducted on patients surveilled for clinical NMIBC from 2013 to 2020 with at least one follow-up cytology result after diagnosis. Patients were classified into risk categories according to American Urological Association (AUA) NMIBC guidelines. Data were obtained regarding tumor recurrence pathology and the frequency and findings of surveillance cystoscopies and urine cytologies. Positive (suspicious, malignant) and negative (atypical or negative for malignant cells) cytology results were correlated with cystoscopy and pathology findings when obtained within 3 months of the cytology specimen to determine if cytology impacted plan of care. RESULTS: Two hundred fourteen patients with NMIBC were followed for a median of 34 months, with 1045 urine cytologies collectively obtained over the surveillance period. There were no positive urine cytologies among patients with low-risk NMIBC; therefore, cytology did not change management in this cohort. The potential for cytology to escalate management for patients of any risk group (ie, positive cytology in the absence of positive cystoscopy or pathology findings) occurred in 30 (2.9%) cases. However, clinical decision making was only altered in 4 cases (0.4% of all cytologies). CONCLUSIONS: Less than 1% of urine cytology specimens collected during NMIBC surveillance impacted clinical management, none of whom had low-risk disease. The use of urine cytology for surveillance of low-risk NMIBC should continue to be strongly discouraged, as it did not change management in any such cases.

Radical cystectomy for clinically muscle invasive bladder cancer: does prior non-invasive disease affect clinical outcomes?

PURPOSE: To compare clinical and pathologic outcomes of radical cystectomy for muscle invasive bladder cancer in relation to prior history of non-invasive urothelial carcinoma. MATERIALS AND METHODS: Retrospective data collected from 1,150 patients managed by radical cystectomy for urothelial carcinoma of the bladder from the Canadian Bladder Cancer Network were analysed. Patients with clinical stage T2 or more were included and divided into two groups: (Group 1) patients with prior history of non-invasive urothelial carcinoma (N = 365) and (Group 2) patients with clinical muscle invasive cancer de novo (N = 785). Variables analysed included patient age, gender, pathologic stage, adjuvant chemotherapy, recurrence and mortality. RESULTS: Both groups were nearly equal in mean age and gender distribution, with mean ages of 67.2 and 66.7 years, and 79.7 and 79.5%, respectively (P = 0.4 and 0.9, respectively). The presence of preoperative hydronephrosis was 20.8 and 32.6% (P = 0.0007) for groups 1 and 2, respectively. The rate of higher pathological stage (T3 or T4) was 36.3 and 58% (P < 0.0001), positive lymph nodes were 20.1 and 28.8% (P = 0.002), and lymphovascular invasion was 31.7 and 46.2% (P = 0.0001) for groups 1 and 2, respectively. The rate of adjuvant chemotherapy was 15.5 and 23.3% (P = 0.002) for groups 1 and 2, respectively. None of the sampled patients received neoadjuvant chemotherapy. The overall survival (OS) and disease-specific survival (DSS) rates at 5 years were 62 and 70% for group 1 and 51 and 60% for group 2, respectively, while at 10 years, OS and DSS were 46 and 66% for group 1 and 35 and 49% for group 2, respectively (P = 0.0001 and 0.0002, respectively). Using multivariate analysis examining factors affecting recurrence and survival, we found that previous non-invasive bladder tumour history was associated with a significantly reduced risk of mortality and recurrence (Hazard ratio of 0.7 for all risks, P = 0.0002). CONCLUSION: Our retrospective study suggests that patients with non-invasive urothelial carcinoma of the bladder that progress to muscle invasion and require radical cystectomy appear to have better pathologic and clinical outcome than patients presenting with clinical muscle invasive disease de novo.

Clinical Risk Factors Associated With Small Renal Mass Malignant Histology in a Multi-Ethnic Population Undergoing Partial Nephrectomy.

INTRODUCTION: Small renal masses (SRMs) are often incidentally diagnosed, and a large proportion are malignant. However, there is a paucity of data describing predictors of malignancy in minority patients with SRMs. Thus, our goal was to examine clinical risk factors associated with SRM malignant histology in patients undergoing partial nephrectomy (PN) a diverse, urban academic center. MATERIALS AND METHODS: Patients with a SRM undergoing PN at a single institution between 2010 to 2018 were reviewed. Demographic, clinical, and imaging characteristics were compared to pathology results. Logistic regression was used to examine associations between demographic/clinical variables for malignant and high-grade histology. RESULTS: In total, 331 patients who underwent PN for SRM were included. Of those, 264 (79.8%) had malignant histology while 67 (20.2%) had benign histology. The proportions of men and of current smokers were significantly higher among patients with malignant histology. In multivariate models, non-Hispanic Black (NHB) patients had increased odds of having malignant histology (OR 2.46, 95% CI: 1.01-5.99, P = .048) and current smokers (OR = 4.02; 95% CI 1.14-14.18, P = .031). Hispanic patients had a 3-fold increased risk of high-grade RCC (OR 3.06, 95% CI: 1.19-7.87, P = 0.02) compared to Non-Hispanic White patients. CONCLUSION: In our population, male sex, smoking, and NHB race/ethnicity was associated with an increased risk of malignancy in patients undergoing partial nephrectomy for SRM. Older age and Hispanic race/ethnicity were associated with high grade RCC. Our results suggest that urologists should exercise a higher level of vigilance in managing and treating SRM among NHB and Hispanic patients.

Randomized controlled trial of virtual reality and hybrid simulation for robotic surgical training.

OBJECTIVE: To evaluate if two commonly used laparoscopic simulators could be adapted and used successfully for the robotics platform in a laparoscopic and robotic naïve medical student population. MATERIALS AND METHODS: We identified two widely validated laparoscopic simulation programs, LapSim(®) (Surgical Science Sweden AB), and ProMIS(®) (Haptica, Ireland)for inclusion in the study. The McGill Inanimate System for Training and Evaluation of Laparoscopic Skills(®) task set was used for ProMIS, and adapted for the DaVinci(®) console (Intuitive Surgical, Inc., Sunnyvale, CA, USA) robotic platform. We then randomized 20 naïve medical students to receive training on either LapSim or ProMIS, both or neither, and evaluated them before and after training. RESULTS: When the groups were compared at baseline, there were no statistical differences in mean scores amongst the groups in univariate analysis (α= 0.05). When comparing mean scores within groups before and after training sessions, statistically significant performance enhancement in all four robotic tasks were identified in the groups receiving dual training. CONCLUSION: We have shown that the use of ProMIS hybrid and LapSim virtual reality (VR) simulators in conjunction with each other can considerable improve robotic console performance in novice medical students compared with hybrid and VR simulation alone.

Ureteral metastasis in colorectal cancer: A case report and review of literature.

Colorectal cancer (CRC) is a common clinical entity. A significant proportion of patients experience metastatic disease, typically in the form of lung and liver spread. We present the case of a CRC cancer patient with distant metastasis to the ureter, causing hydronephrosis. Ureteroscopy and biopsy confirmed the diagnosis and the patient was subsequently treated with percutaneous nephrostomy tube placement. Distant spread of CRC to the ureter represents an exceedingly rare phenomenon. This case highlights the importance of heightened index of suspicion for ureteral involvement in CRC when hydronephrosis is identified on staging or surveillance cross sectional imaging.