Morbidity and Mortality of Total Pelvic Exenteration for Malignancy in the US.

BACKGROUND: Total pelvic exenterations (TPEs) for malignancies are complex operations often performed by multidisciplinary teams. The differences among primary cancer for TPE and multicentered results are not well described. We aimed to describe TPE outcomes for different malignant origins in a national multicentered sample. METHODS: Patients from the National Surgical Quality Improvement Program (NSQIP) database who underwent TPE between 2005 and 2016 for all malignant indications (colorectal, gynecologic, urologic, or other) were included. Chi square and Kruskal-Wallis tests were used to compare patient characteristics by primary malignancy. Multivariate logistic and linear regression models were used to determine factors associated with any 30-day Clavien-Dindo grade 3 or higher complication, length of hospital stay (LOS; days), 30-day wound infection, and 30-day mortality. RESULTS: Overall, 2305 patients underwent TPE. Indications for surgery included 33% (749) colorectal, 15% (335) gynecologic, 9% (196) other, and 45% (1025) urologic malignancies. Median LOS decreased from 10 to 8 days during the study period (p < 0.001), 36% were males, and 50% required blood transfusion. High-grade complications occurred in 15% of patients and were associated with bowel diversion [odds ratio (OR) 1.6, 95% confidence interval (CI) 1.1-2.4], disseminated cancer (OR 1.8, 95% CI 1.4-2.3), and gynecologic cancers (OR 2.9, 95% CI 1.8-4.7). Mortality was 2% and was associated with disseminated cancer (OR 2.2, 95% CI 1.1-4.3) and male sex (OR 2.4, 95% CI 1.3-4.4). CONCLUSIONS: TPE is associated with high rates of complications, however mortality rates remain low. Preoperative and perioperative outcomes differ depending on the origin of the primary malignancy.

Single port robotic radical prostatectomy with the da Vinci SP platform: a step by step approach.

The da Vinci single port (SP) robotic system (Intuitive Surgical, Sunnyvale, CA, USA) is a recently approved robotic platform designed with several modifications to the previously available multi-port robotic systems. This article describes the technique performed utilizing the SP robotic system for radical robotic-assisted laparoscopic prostatectomy (RALP) with or without bilateral pelvic lymph node dissection from a single institution. In this report we describe our step-by-step approach, technical modifications from the multi-port technique and initial results for performing single port robotic-assisted laparoscopic prostatectomy (SP-RALP). We describe our initial experience and technique with the SP robotic system consisting of 23 consecutive patients who underwent SP-RALP between December 2018 and May 2019. The median patient age was 62 years with approximately half of the patients undergoing pelvic lymphadenectomy. The median operative time was 236 minutes, median estimated blood loss was 50 mL and median length of hospital stay was 1 day. No unplanned port placements occurred and no conversions to open surgery occurred. We demonstrate the safety and feasibility of performing a transperitoneal prostatectomy with either a posterior or anterior approach.

Helping Men Find Their Way: Improving Prostate Cancer Clinic Attendance via Patient Navigation.

Navigation programs aim to help patients overcome barriers to cancer diagnosis and treatment. Missed clinic appointments have undesirable effects on the patient, health system, and society, and treatment delays have been shown to result in inferior surgical cure rates for men with prostate cancer (CaP). We sought to measure the impact of patient navigation on CaP clinic adherence. Patient navigators contacted patients prior to their first encounter for known or suspected CaP between 7/1/2016 and 6/30/2017. Encounters from 7/1/2014 to 6/30/2015 were used as a historical control. Patient-variables were analyzed including age, health insurance status, home address, zip code, race, ethnicity, and referring primary care clinic. Encounter-level variables included diagnosis (categorized as known or suspected CaP), date of appointment, type of appointment [new vs. return], and provider. The associations between several factors including navigation contact and these variables with missed appointment were analyzed using generalized linear mixed effects multivariate logistic regression. A total of 2854 scheduled clinic encounters from 986 unique patients were analyzed. Patient navigation resulted in a lower missed appointment rate (8.8% vs. 13.9%, OR = 0.64, IQR 0.44-0.93, p = 0.02 on multivariable analysis). Lack of health insurance (OR = 13.18 [5.13-33.83]), suspected but not confirmed CaP diagnosis (OR = 7.44 [4.85-11.42]), and Black (1.97 [1.06-3.65]) or Hispanic (OR = 3.61 [1.42-9.16]) race, were associated with missed appointment. Implementation of patient navigation reduced missed appointment rates for CaP related ambulatory encounters. Identifying risk factors for missed appointment may aid in targeting navigation services to those most likely to benefit from this intervention.

Inflammation on Prostate Needle Biopsy is Associated with Lower Prostate Cancer Risk: A Meta-Analysis.

PURPOSE: We performed a comprehensive literature review and meta-analysis to evaluate the association of inflammation on prostate needle biopsies and prostate cancer risk. MATERIALS AND METHODS: We searched Embase®, PubMed® and Web of Science™ from January 1, 1990 to October 1, 2016 for abstracts containing the key words prostate cancer, inflammation and biopsy. Study inclusion criteria were original research, adult human subjects, cohort or case-control study design, histological inflammation on prostate needle biopsy and prostate cancer on histology. Two independent teams reviewed abstracts and extracted data from the selected manuscripts. Combined ORs and 95% CIs of any, acute and chronic inflammation were calculated using the random effects method. RESULTS: Of the 1,030 retrieved abstracts 46 underwent full text review and 25 were included in the final analysis, comprising a total of 20,585 subjects and 6,641 patients with prostate cancer. There was significant heterogeneity among studies (I2 = 84.4%, p <0.001). The presence of any inflammation was significantly associated with a lower prostate cancer risk in 25 studies (OR 0.455, 95% CI 0.337-0.573). There was no evidence of publication bias (p >0.05). When subanalyzed by inflammation type, acute inflammation in 4 studies and chronic inflammation in 15 were each associated with a lower prostate cancer risk (OR 0.681, 95% CI 0.450-0.913 and OR 0.499, 95% CI 0.334-0.665, respectively). CONCLUSIONS: In a meta-analysis of 25 studies inflammation on prostate needle biopsy was associated with a lower prostate cancer risk. Clinically the presence of inflammation on prostate needle biopsy may lower the risk of a subsequent prostate cancer diagnosis.

The Association of Previous Prostate Biopsy Related Complications and the Type of Complication with Patient Compliance with Rebiopsy Scheme.

PURPOSE: Prostate biopsy complications have important consequences that may affect patient compliance with rebiopsy schemes. However, to our knowledge this has not been studied in earnest. Thus, we evaluated whether previous prostate biopsy related complications and the type of complication were associated with repeat prostate biopsy compliance in a clinical trial with study mandated systematic biopsies. MATERIALS AND METHODS: We retrospectively analyzed the records of 4,939 men 50 to 75 years old who underwent 2-year prostate biopsy and were recommended to undergo 4-year prostate rebiopsy in the REDUCE (Reduction by Dutasteride of Prostate Cancer Events) study. The analyzed biopsy complications were hematuria, urinary tract infection, acute urinary retention and hemospermia. RESULTS: A total of 260 men (5.3%) had a 2-year prostate biopsy related complication, including hematuria in 180 (3.6%), urinary tract infection in 36 (0.7%), acute urinary retention in 26 (0.5%) and hemospermia in 102 (2.1%). A total of 474 men (9.6%) were noncompliant with 4-year rebiopsy. On univariable analysis any previous complication (OR 1.56, 95% CI 1.08-2.24, p = 0.018), urinary tract infection (OR 2.72, 95% CI 1.23-6.00, p = 0.013), acute urinary retention (OR 4.24, 95% CI 1.83-9.81, p = 0.016) and hemospermia (OR 1.78, 95% CI 1.03-3.06, p = 0.037) were associated with rebiopsy noncompliance. Hematuria was not associated with rebiopsy noncompliance (OR 1.19, 95% CI 0.74-1.91, p = 0.483). Results were unchanged on multivariable analysis, including for any complication (OR 1.65, 95% CI 1.08-2.26, p = 0.018), for urinary tract infection (OR 2.62, 95% CI 1.07-3.21, p = 0.029), for acute urinary retention (OR 4.51, 95% CI 1.93-10.54, p = 0.001), for hemospermia (OR 1.85, 95% CI 1.07-3.21, p = 0.029) and for hematuria (OR 1.19, 95% CI 0.74-1.93, p = 0.472). CONCLUSIONS: In men who undergo repeat prostate biopsy a previous biopsy related complication and the type of complication were associated with lower compliance with rebiopsy schemes. Patients who experience biopsy related complications are ideal candidates to receive intervention regarding the importance of prostate rebiopsy to prevent noncompliance.

Determinants of Clinic Absenteeism: A Novel Method of Examining Distance from Clinic and Transportation.

Delayed treatment and non-adherence are associated with inferior prostate cancer (CaP) outcomes. Missed clinic appointments (MA) are one form of non-adherence that may be preventable. We conducted a retrospective cohort study of 1341 scheduled clinic encounters for men referred to an academic urology clinic for evaluation of known or suspected CaP. Driving distance and public transit times were calculated using a Google Distance Matrix API algorithm. Zip code level data regarding socioeconomic status was obtained from the 2013 American Community Survey. Logistic regression multivariate analysis was used to identify MA predictors. Of scheduled clinic encounters, 14% were missed. Public health insurance was associated with MA (Private insurance 10%, Public insurance 19%), (p < 0.01) Calendar month was associated with MA with December showing the highest rate (21.2%) and June the lowest (5.3%) rates. (p = 0.02) Appointments for suspected CaP were more likely to be missed (19.3%) than those for known CaP (10.5%), p < 0.01. Driving distance was inversely associated with rate of MA (CA median 11.8 miles, MA median 10.4 miles, p = 0.04) while public transit times were not (66.7 min for CA, 65.3 min for MA, p = 0.36). Men that missed appointments were from areas with lower household incomes and educational attainment. Patient encounter type, insurance status, and reason for referral remained significantly associated with MA after multivariable adjusted analysis. By computing public transit time to the clinic using a mapping engine, we present a novel way to measure this parameter for studies of urban health care.

The Development of Prostate Adenocarcinoma in a Transgender Male to Female Patient: Could Estrogen Therapy Have Played a Role?

BACKGROUND: Prostate adenocarcinoma (PCa) is a rare diagnosis in the male to female transgender (MtFT) population with only a few case reports published in the current medical literature. Long standing beliefs of androgen suppression conferring a protective effect against prostate cancer development have been challenged by the literature citing adenocarcinoma development in the prostate of rodent models following combined estrogen and testosterone treatment. MATERIALS AND METHODS: We herein present a MtFT patient who presented with high grade PCa following 20 years of exogenous estrogen therapy. RESULTS: Immunohistochemical (IHC) localization of estrogen receptor alpha (ER-α) and progesterone receptor (PR) demonstrated positive staining in stromal cells; while, androgen receptor (AR) demonstrated positive staining in malignant glands and weak scattered staining in adjacent stroma. CONCLUSION: This pattern of staining raises concern for a possible contributing role of exogenous estrogen therapy in tumorigenesis. As awareness of gender dysphoria and acceptance of gender reassignment surgery has seen a recent increase, the unique needs of this population must be recognized. Prostate 77:824-828, 2017. © 2017 Wiley Periodicals, Inc.

Descriptive characteristics of prostate cancer in patients with a history of primary male breast cancer - a SEER analysis.

BACKGROUND: Current evidence on risk of prostate cancer following a diagnosis of male breast cancer is limited and guidance for screening in this potentially higher-risk population remainsunclear. Our objective was to quantify prostate cancer risk in men diagnosed with breast cancer. METHODS: We identified men diagnosed with first primary breast cancer between 1988 and 2012 using the Surveillance, Epidemiology and End Results Program registry databases. Men were followed for occurrence of a second primary prostate cancer and secondary outcomes of cancer-specific and overall survival. Stratified analyses were performed by age, breast cancer stage, race, and breast cancer hormone receptor status. Excess risk per 10,000 person-years and standardized incidence ratios (SIR) with 95% confidence intervals (95% CI) were calculated. We used multivaraible Cox proportional hazard models to estimate hazard ratios (HR) and 95% CI for characteristics associated with secondary prostate cancer and survival. RESULTS: From a cohort of 5753 men with breast cancer with median follow up of 4.3 years, we identified 250 cases of second primary prostate cancer. Overall, the incidence of second primary prostate cancer was modestly greater than expected (SIR = 1.12, 95% CI 0.93-1.33), although not statistically significant. Stratified analyses demonstrated associations for men ages 65-74 at the time of breast cancer diagnosis (SIR = 1.34, 95%CI 1.01-1.73), hormone receptor-positive breast cancer (SIR = 1.23, 95%CI 1.11-1.39) or AJCC stage I breast cancer (SIR = 1.36, 95%CI 1.04-1.75) and second primary prostate cancer diagnosis. CONCLUSIONS: The incidence of prostate cancer in men with history of breast cancer is similar to the general population. Men with favorable characteristics of their breast cancer were more likely to develop prostate cancer, possibly due to a lower competing risk of breast cancer mortality.

Assessing clinically significant prostate cancer: Diagnostic properties of multiparametric magnetic resonance imaging compared to three-dimensional transperineal template mapping histopathology.

OBJECTIVE: To evaluate the diagnostic properties of multiparametric magnetic resonance imaging in the detection, localization and characterization of prostate cancer using three-dimensional transperineal template mapping biopsy histopathology as the comparator. METHODS: A retrospective analysis of patients undergoing prostate multiparametric magnetic resonance imaging followed by three-dimensional transperineal template mapping biopsy was carried out. For imaging and pathology data, the prostate was divided in octants with the urethra being the midline. The index test properties were calculated using the biopsy histopathology as the reference test with the following end-points: any cancer, any Gleason ≥7, any Gleason ≥7 or cancer length of ≥4 mm and any Gleason ≥7 or 6 mm in any given core. The latter two definitions correspond to 0.2 and 0.5 mL of cancer volume, respectively. Diagnostic properties including sensitivity, specificity, positive and negative predictive values were calculated. RESULTS: A total of 50 patients were included in the study. A median of 55 (interquartile range 42-63) biopsy cores were obtained per patient. Of 400 prostate octants evaluated, 28.5% had prostate cancer on mapping biopsy, whereas 23% of octants were considered suspicious for cancer on imaging. Multiparametric magnetic resonance imaging negative predictive values for Gleason ≥7 and clinically significant cancers were 84-100%. Similarly, specificity ranged between 79% and 85%. Sensitivity and positive predictive value remained moderate for all the reference test definitions. CONCLUSIONS: Multiparametric magnetic resonance imaging is a useful minimally-invasive tool for detection, localization and characterization of prostate cancer. This imaging modality has high negative predictive value and specificity, and therefore it could be used to reliably rule out clinically significant cancer, obviating the multicore mapping biopsy.

The impact of pathologic staging on the long-term oncologic outcomes of patients with clinically high-risk prostate cancer.

BACKGROUND: In the prostate-specific antigen (PSA) screening era, approximately 15% of US men still present with clinically high-risk prostate cancer (PC). However, high-risk PC may be downgraded/downstaged at radical prostatectomy (RP), making additional therapy unnecessary. The authors tested the oncologic outcomes in men with clinically high-risk disease stratified on RP pathology. METHODS: A total of 611 men with high-risk PC (PSA level > 20 ng/mL, biopsy Gleason sum [bGS] ≥ 8, or clinical classification of ≥ T3) underwent RP and pelvic lymphadenectomy between 1998 and 2011. Outcomes included biochemical disease recurrence (BCR), receipt of androgen deprivation therapy (ADT), metastases, and PC-specific and overall survival. RP pathology was classified as unfavorable (pathologic Gleason sum ≥ 8, pathologic classification of ≥ T3, or lymph node-positive disease), or favorable (no unfavorable features). Multivariable analyses tested oncologic outcomes stratified by pathologic classification. RESULTS: Overall, 527 men had complete pathologic data and were included in the current analysis. Of the cohort, 206 of 527 men (39%) had favorable pathology. This finding was more common in men with only 1 clinical high-risk feature, and a lower body mass index, PSA level, bGS, and percentage positive biopsy cores. Favorable pathology was associated with decreased BCR (hazards ratio [HR], 0.34), metastases (HR, 0.17), and PC death (HR, 0.17). After a median follow-up of 82 months (range, 49 months-131 months), 193 of the 527 men (37%) received ADT, including only 35 of the 206 men with favorable pathology (17%). Unfavorable pathology was associated with early (≤ 5 years) but not late treatment with ADT. CONCLUSIONS: In a large cohort of men with high-risk PC who were managed with RP, 39% had favorable pathology and superior oncologic outcomes.

Use of nephron sparing surgery and impact on survival in children with Wilms tumor: a SEER analysis.

PURPOSE: Nephron sparing surgery is the standard of care for many adults with renal tumors and has been described in some children with Wilms tumor. However, beyond case series the data concerning nephron sparing surgery application and outcomes in patients with Wilms tumor are scarce. We examined nephron sparing surgery outcomes and factors associated with its application in children with Wilms tumor. MATERIALS AND METHODS: We retrospectively reviewed the 1998 to 2010 SEER database. We identified patients 18 years old or younger with Wilms tumor. Clinical, demographic and socioeconomic data were abstracted, and statistical analysis was performed using multivariate logistic regression (predicting use of nephron sparing surgery limited to unilateral tumors smaller than 15 cm) and Cox regression (predicting overall survival) models. RESULTS: We identified 876 boys and 956 girls with Wilms tumor (mean ± SD age 3.3 ± 2.9 years). Of these patients 114 (6.2%) underwent nephron sparing surgery (unilateral Wilms tumor in 74 and bilateral in 37). Median followup was 7.1 years. Regarding procedure choice, nephron sparing surgery was associated with unknown lymph node status (Nx vs N0, p <0.001) and smaller tumor size (p <0.001). Regarding survival, only age (HR 1.09, p = 0.002), race (HR 2.48, p = 0.002), stage (HR 2.99, p <0.001) and lymph node status (HR 2.17, p = 0.001) predicted decreased overall survival. Survival was not significantly different between children undergoing nephron sparing surgery and radical nephrectomy (HR 0.79, p = 0.58). CONCLUSIONS: In children with Wilms tumor included in the SEER database nephron sparing surgery has been infrequently performed. Nephron sparing surgery application is associated with smaller, bilateral tumors and with omission of lymphadenectomy. However, there are no evident differences in application of nephron sparing surgery based on demographic or socioeconomic factors. Despite lymph node under staging, overall survival is similar between patients undergoing nephron sparing surgery and radical nephrectomy.

Robotic single-port multiquadrant surgery to treat renal tumors and benign abdominal conditions.

BACKGROUND: Multiquadrant procedures are technically more demanding than sequential operations. The new single port (SP) system allows to work in every abdominal quadrant maintaining an adequate triangulation without the need for changes in the port positioning. METHODS: In February 2020, two patients underwent a robotic SP partial nephrectomy for malignancy combined with a cholecystectomy and a left inguinal hernia repair respectively. RESULTS: Both procedures were successfully completed with one robotic docking and without the need for conversion. The operative time was 213 minutes for the right partial nephrectomy (126 min) with cholecystectomy (18 min), and 257 minutes for the left partial nephrectomy (161 min) with inguinal hernia repair (35 min). Estimated blood loss was 200 (150-250) mL, while the total warm ischemia time was 15 minutes for the right partial nephrectomy and 53 minutes for the left partial nephrectomy. There were no intraoperative complications or perioperative transfusions. The postoperative course was uneventful, and the postoperative hospital stay was 1 and 2 days. Both resections had free margins and the median tumor size was 2.5 (1.5-3.5) cm. Histopathology analysis revealed chronic cholecystitis and renal cell carcinomas with free margins and a median tumor size of 2.5 (1.5-3.5) cm. After a mean follow-up of 24 months, no surgical-related complications or recurrence were detected. CONCLUSIONS: The robotic SP approach facilitates the completion of combined surgical procedures in multiple abdominal quadrants through a single 25mm incision.

Delayed radical prostatectomy for intermediate-risk prostate cancer is associated with biochemical recurrence: possible implications for active surveillance from the SEARCH database.

INTRODUCTION: Active surveillance (AS) is increasingly accepted as appropriate management for low-risk prostate cancer (PC) patients. It is unknown whether delaying radical prostatectomy (RP) is associated with increased risk of biochemical recurrence (BCR) for men with intermediate-risk PC. METHODS: We performed a retrospective analysis of 1,561 low and intermediate-risk men from the Shared Equal Access Regional Cancer Hospital (SEARCH) database treated with RP between 1988 and 2011. Patients were stratified by interval between diagnosis and RP (≤ 3, 3-6, 6-9, or >9 months) and by risk using the D'Amico classification. Cox proportional hazard models were used to analyze BCR. Logistic regression was used to analyze positive surgical margins (PSM), extracapsular extension (ECE), and pathologic upgrading. RESULTS: Overall, 813 (52%) men were low-risk, and 748 (48%) intermediate-risk. Median follow-up among men without recurrence was 52.9 months, during which 437 men (38.9%) recurred. For low-risk men, RP delays were unrelated to BCR, ECE, PSM, or upgrading (all P > 0.05). For intermediate-risk men, however, delays >9 months were significantly related to BCR (HR: 2.10, P = 0.01) and PSM (OR: 4.08, P < 0.01). Delays >9 months were associated with BCR in subsets of intermediate-risk men with biopsy Gleason score ≤ 3 + 4 (HR: 2.51, P < 0.01), PSA ≤ 6 (HR: 2.82, P = 0.06), and low tumor volume (HR: 2.59, P = 0.06). CONCLUSIONS: For low-risk men, delayed RP did not significantly affect outcome. For men with intermediate-risk disease, delays >9 months predicted greater BCR and PSM risk. If confirmed in future studies, this suggests delayed RP for intermediate-risk PC may compromise outcomes.

Characteristics of patients diagnosed with both melanoma and renal cell cancer.

BACKGROUND: Patients with renal cell carcinoma (RCC) and malignant melanoma (MM) have an increased risk of additional malignancies. We identified characteristics of MM and RCC associated with a patient developing both cancers. METHODS: A total of 147,656 cases of RCC and 225,548 of MM submitted to the Surveillance, Epidemiology, and End Results database between 1973 and 2008 were analyzed. Standardized incidence ratios (SIR) with 95 % confidence intervals (CI) were calculated for MM after RCC and vice versa. Clinical and pathological characteristics were compared between patients with RCC or MM only and with both cancers using multivariable proportional hazards and competing risks regression models. RESULTS: Overall 1,241 patients developed both cancers. The crude incidence rates of RCC in patients with a prior MM diagnosis and vice versa were 5.2 and 9.4 per 10,000 person-years, respectively. There was an excess of MM in RCC patients (SIR 1.45, CI 1.34-1.57) and of RCC in MM patients (SIR 1.34, CI 1.25-1.43). Median years from RCC to MM diagnosis was 4.3 (2.0-7.8) and from MM to RCC 4.7(2.3-9.9). Patients with a history of MM had more papillary RCC (10.2 vs. 4.8 %, p = 0.01) and were more likely to be female (25.9 vs. 20.5 %, p < 0.001). On multivariable analyses, ocular MM was independently associated with subsequent RCC (HR 1.76 CI 1.24-2.49), as were increasing age, and male sex. CONCLUSIONS: We confirmed a bidirectional association between RCC and MM. A history of MM was found to be associated with papillary RCC and advanced RCC. Ocular MM predicted an increased risk of RCC diagnosis. Further research is warranted into the mechanisms responsible for the association between RCC and MM.

The effect of dietary sodium and fructose intake on urine and serum parameters of stone formation in a pediatric mouse model: a pilot study.

PURPOSE: Dietary factors have a role in stone disease in adults but little is known about the relationship in children. We tested whether diet could alter urine and serum parameters in a pediatric mouse model. MATERIALS AND METHODS: We randomized 30 female BALB/c mice at age 3 weeks to mouse chow, a complex carbohydrate Western diet or a high fructose, high sodium Western diet. Body weight was measured twice weekly. Urine was periodically collected and mice were sacrificed on day 30. Samples were pooled to analyze serum and urine electrolyte factors. RESULTS: There was no significant difference in body weights among the groups at any time or in kidney weight at sacrifice (each p >0.15). There was no observable increase in urine stone forming analytes across the arms except uric acid, which tended to be higher in the Western diet and high fructose, high sodium Western diet groups. There was a substantial decrease in urinary stone inhibitors (magnesium and citrate), a decrease in urinary potassium and an increase in serum calcium in the 2 Western diet groups. CONCLUSIONS: This pilot study suggests that consuming a Western diet, especially one composed of high fructose and sodium, may alter parameters that predispose to stone formation in children by decreasing stone inhibitors. Results require validation in larger studies and ultimately in humans.

Perioperative intravesical chemotherapy in non-muscle-invasive bladder cancer: a systematic review and meta-analysis.

The role for a single dose of intravesical chemotherapy (IVC) after transurethral resection (TUR) remains unclear in patients with non-muscle-invasive bladder cancer (NMIBC). Several recent randomized clinical trials (RCTs) have evaluated its effect on recurrence, prompting this systematic review of RCTs comparing a single immediate postoperative dose of IVC versus placebo within 24 hours of TUR of NMIBC, and this meta-analysis using a random-effects model to predict the pooled relative risk (RR) of tumor recurrence. Subanalyses pooled studies by drug type and a meta-regression was performed to determine the effect of underlying patient risk factors on the efficacy of a single dose of IVC. A total of 3103 patients were randomized in the 18 RCTs that met inclusion criteria. The recurrence rate in patients receiving perioperative IVC and TUR was 37% versus 50% in the TUR-alone group. The pooled RR of recurrence for IVC and TUR was 0.67 (95% CI, 0.56-0.79), corresponding to a 13% absolute reduction and a number needed to treat of 7.2 patients to avoid 1 recurrence. The proportions of patients with tumor risk factors (T1, high-grade, multifocal, or recurrent) were not associated with IVC efficacy. A single dose of IVC administered within 24 hours of TUR of NMIBC was found to result in a reduction in tumor recurrence (RR, 0.67; 95% CI, 0.56-0.79). Patients with higher-risk tumor features seem to benefit at a similar rate.

Does a positive response to spermatic cord block predict response to microdenervation of the spermatic cord for chronic scrotal content pain?

INTRODUCTION: Microdenervation of the spermatic cord (MDSC) has been demonstrated to be an effective treatment for men with intractable scrotal content pain. AIM: This study evaluates the correlation between a positive response to a spermatic cord block with local anesthetic and the subsequent surgical outcome following MDSC. MAIN OUTCOME MEASURES: Pre- and post-cord block pain and pre- and post-MDSC pain. METHODS: A retrospective review of 74 patients (77 testicular units) who underwent MDSC from 2006 to 2010 was performed. Pre- and post-spermatic cord block pain scores based on a 0-10 visual analog scale (VAS) were compared with pre- and post-MDSC pain scores. A positive response to the block was defined as greater than or equal to 50% temporary reduction of pain based on VAS. RESULTS: The average patient age was 42 years with a mean follow-up of 10 months. The mean duration of symptoms before surgery was 69 months. Mean pre-cord block pain score was 8 with an 89% average decrease in pain following the block. Mean post-MDSC pain score was 2 with an average decrease of 73%. The level of temporary improvement from the cord block appeared to be a useful predictor of sustained improvement with MDSC (P = 0.05). Positive response to spermatic cord block was an independent predictor of MDSC response (P = 0.03). CONCLUSIONS: Men with chronic orchialgia who have a positive response to a spermatic cord block are likely to have durable and complete resolution of symptoms after undergoing MDSC. The amount of pain relief obtained after the cord block correlates with pain relief after undergoing a MDSC. Men with chronic orchialgia who desire surgical correction should undergo a preoperative spermatic cord block as part of their complete evaluation. The result of the cord block can help guide the practitioner and the patient toward definitive surgical management via MDSC.

Evolution of the concept of focal therapy for prostate cancer.

The landscape of prostate cancer has been rapidly evolving, and technological advances in imaging and biopsy tools offer novel approaches to focal therapy. In this dynamic environment, the role of focal therapy for prostate cancer is being shaped both by advances in technology and by reconsidering the epidemiological and outcomes data for available treatments. Here we focus on the evolution of the concept of focal therapy and its potential roles in the management of prostate cancer.

Biparametric Quantitative MRI for Prostate Cancer Detection.

OBJECTIVES: This study sought to prospectively investigate a novel quantitative biparametric prostate magnetic resonance imaging (MRI) protocol to detect prostate cancer (PCa) in biopsy-naïve men. Secondarily, this study reports the accuracy of fractional order calculus (FROC) diffusion and quantitative T2 compared with the Prostate Imaging Reporting & Data System (PI-RADS). METHODS: This prospective pilot study (NCT04175730) enrolled 50 prostate biopsy-naïve men who met eligibility criteria. All men received 3T MRI with T2 and diffusion-weighted imaging (DWI) (b-values: 50-4,000 s/mm2). Men with PI-RADS lesions ≥3 underwent targeted and systematic prostate biopsy, omitting systematic biopsy cores in peripheral zone lesions. DWI series images were fit to signal decay to calculate ADC (mm2/s) and the FROC model for coefficient DF (mm2/s). The primary end point was detection of Gleason grade group ≥2 (GG≥2) PCa. Receiver operating characteristic regression and area under the curve (AUC) were reported. RESULTS: Forty-eight men underwent MRI and biopsy. Mean age was 61.5 years (56-68), 29% were White, 52% were African American, mean PSA was 6.0 ng/mL (4.9-8.0), and mean PSA density was 0.14 ng/mL2. In total, 61 PI-RADS ≥3 lesions were targeted for biopsy. GG≥2 PC was found in 7% (1/14) of PI-RADS 3 lesions, 28% (10/36) of PI-RADS 4 lesions, and 36% (4/11) of PI-RADS 5 lesions. The AUC for detection of GG≥2 PC was 0.63 (0.5-0.76) for PI-RADS, 0.82 (0.68-0.96) for ADC, and 0.87 (0.77-0.97) for the FROC model. CONCLUSION: This small prospective pilot study demonstrates the feasibility of a novel quantitative biparametic MRI protocol to detect prostate cancer in biopsy-naïve men.