LUMBAR Syndrome and Bladder Exstrophy: A Case Report.

LUMBAR syndrome is rare with a multitude of features that requires a high index of suspicion for timely diagnosis and appropriate management. We present on a newborn female whose untreated segmental infantile hemangioma lead to poor healing of her bladder exstrophy closure. The objective of this report is to describe bladder exstrophy as a urogenital anomaly in patients with LUMBAR syndrome and the importance of balancing management of infantile hemangioma and time to surgery.

Robot assisted laparoscopic partial cystectomy for inflammatory myofibroblastic tumor with simultaneous intraoperative flexible cystoscopy for tumor mapping.

Bladder masses are an infrequent occurrence rarely suspected in cases of pediatric hematuria. Inflammatory myofibroblastic tumors represent one differential diagnosis that is difficult to characterize as purely benign and should therefore be given special consideration. Although uncommon, this is an important entity to recognize for potential bladder sparing and minimally invasive surgical approaches.

Bladder management in children with transverse myelitis.

BACKGROUND: Patients with transverse myelitis (TM) often present with urinary retention. While many recover their bladder function, some have persistent voiding dysfunction, and both intermediate and long-term outcomes are variable. OBJECTIVE: In patients who develop urinary retention requiring clean intermittent catheterization (CIC) at onset of TM, we sought to assess factors associated with improved voiding function and the risk of requiring persistent CIC over time. STUDY DESIGN: We reviewed children evaluated at our institution for TM from April 1998 to October 2018. Patients were included if they required CIC at initial presentation of TM. Demographics, initial and follow up neurologic exams were evaluated for their association with a return to baseline volitional voiding after requiring catheterization upon diagnosis of TM, with or without medical therapy. RESULTS: Among the 78 patients who presented with TM during the study period, 43 patients required CIC, with median follow up of 2.7 years. When evaluating for demographic or sensorimotor features associated with improvement to baseline voiding function in patients who initially required CIC, preserved lower extremity reflexes at presentation was the only significant prognostic factor (p < 0.05). Additionally, having complete lower motor neurologic recovery was associated with volitional voiding (p < 0.05). Among the 43 patients who were initially catheterizing, 27/43 (62%) were volitionally voiding at median follow up of 7 months from initial presentation, while the remaining 16/43 remained on CIC for a median follow up of 3.6 years. The cumulative risk of remaining on CIC was 60%, 47%, and 42% at 1, 5, and 10 year follow up, respectively, though there was not a significant difference in the rate of bladder recovery if patients had preserved reflexes. DISCUSSION: In children with TM who initially developed urinary retention, intact reflexes at presentation were associated with urologic recovery. Additionally, complete neurologic recovery was associated with volitional voiding. While 62% were volitionally voiding at most recent follow-up, the cumulative incidence of dependence on CIC within the first year of diagnosis was 60%, with a relatively few patients regaining volitional voiding by 10 years of follow-up. CONCLUSION: Among those initially evaluated for urinary retention in the setting of transverse myelitis, intact lower extremity reflexes on physical exam was associated with improved voiding function at most recent follow-up. However, more than half the patients on CIC at initial presentation required CIC at one year of follow-up. Careful, long-term monitoring of voiding status in patients with TM is recommended, even with improvement of neurological status.

Papers presented at the fall 2020 Pediatric Urologic Oncology Work Group of the Societies of Pediatric Urology meetingNeonatal Serum Electrolyte and Proteinuria Screening on 46,XY Ambiguous Genitalia Patients May Allow Early Diagnosis of Denys-Drash Syndrome: A Case Report.

A term infant with prenatally noted ambiguous genitalia and nonpalpable gonads presented with life-threatening hyponatremia, hypertension, acidosis, and anuric renal failure requiring peritoneal dialysis at age 3 months.Sequencing confirmed 46, XY Denys-Drash syndrome (DDS) due to heterozygous Wilms tumor-1 exon 8 mutation encoding p.His445Arg. Renal US identified bilateral multifocal renal masses at age 8 months. Bilateral retroperitoneal nephrectomies found bilateral nephroblastomatosis without Wilms' tumor avoiding chemotherapy, followed by bilateral laparoscopic orchiopexies. We suggest monthly screening of 46, XY DSD cases for DDS by evaluating for proteinuria and electrolyte disarray starting at diagnosis of DSD to prevent acute life-threatening renal failure presentation.

Renal artery angiography in pediatric trauma using a national data set.

INTRODUCTION: With limited pediatric renal trauma management literature, treatment pathways for children have been extrapolated from the adult population. A shift to non-operative management has led to higher renal preservation rates; however, characterization of endovascular intervention in the pediatric trauma population is lacking. OBJECTIVE: This study uses the National Trauma Data Bank (NTDB), to evaluate renal outcomes after use of renal artery angiography. We hypothesized that patients undergoing renal artery angiography for renal trauma are unlikely to require additional surgical interventions. STUDY DESIGN: All children ≤18 years old treated for traumatic renal injuries from 2012 to 2015 were identified by the Abbreviated Injury Scaled Score (AISS) codes in the NTDB. AISS codes were converted to American Association for Surgery of Trauma (AAST) grades. ICD-9 codes were used to identify patients that had renal artery angiography, and additional renal interventions such as nephrectomy, partial nephrectomy, percutaneous nephrostomy tube or ureteral stent placement. RESULTS: 536,379 pediatric trauma cases were in the NTDB from 2012 to 2015, with 4506 renal injury cases identified. A total of 88 patients had renal artery angiography (ICD-9 88.45). Only 10% (n = 9) of patients who received renal artery angiography underwent an additional urological intervention. Of those nine, two patients were excluded due to renal angiography taking place after nephrectomy was performed. The remaining seven patients had high grade laceration (AAST grade 4-5). Overall, two patients underwent post angiography nephrectomies, two patients had partial nephrectomies, one percutaneous nephrostomy tube was placed (prior to partial nephrectomy), one aspiration of a kidney (prior to ureteral stent placement), and three had ureteral stent placements. DISCUSSION: The limitations of this study include: the NTDB is a national dataset that is not population based, inclusion is limited to the first hospitalization, inaccuracies exist in encounter coding, and the database is lacking laterality of the renal injury. Based on nonspecific nature of ICD-9 coding for angioembolization, we are unable to discern the number of cases that subsequently had angioembolization after or at the time of angiography. CONCLUSION: Renal artery angiography in children remains a rare procedure, 88/4,506, in children with renal trauma. In pediatric trauma cases that undergo renal artery angiography additional procedures are more common with higher grade injuries. Further studies are needed to create pediatric specific trauma management algorithms.

Robotic Ureteral Reimplantation.

Minimally invasive techniques have gained popularity in pediatric surgery. Among these, is the robotic approach for ureteral reimplantation in children with vesico-ureteral reflux. We describe main indications of this surgery, our surgical technique as well as trouble shooting of anatomical variants and the post-operative management. We also provide a description of other techniques described in the literature and a brief review of outcomes of published series.

Initial experience with extraperitoneal robotic-assisted simple prostatectomy using the da Vinci SP surgical system.

Robotic-assisted simple prostatectomy (RASP) has emerged as a safe and effective treatment option for symptomatic patients with lower urinary tract symptoms related to significant benign prostatic enlargement (BPE) above 80 g. The recent release of the da Vinci SP robotic system (Intuitive, Sunnyvale, CA, USA) continues to advance the minimally invasive nature of robotic surgical technology. We now report our institution's initial experience performing RASP using the da Vinci SP robotic system. An IRB-approved, retrospective chart review was performed of all patients undergoing robotic-assisted simple prostatectomy using the da Vinci SP surgical system in the treatment of benign prostatic enlargement by a single surgeon from March to June 2019. Pre-operative, intraoperative, and post-operative data were collected for descriptive analysis. A total of 10 men, mean age of 69 ± 4 years, with mean prostate volume of 104 ± 11 g underwent surgery. The robotic cannula and a single assistant port were utilized in all cases. No cases required conversion to a multi-port robotic platform or open approach, nor required the placement of additional assistant ports. No intraoperative or immediate post-operative complications were noted. Mean estimated blood loss was 141 ± 98 mL and operative time was 172 ± 19 min. Mean catheter time was 1.9 ± 1.8 days. One patient reported transient de novo stress urinary incontinence. Single-port RASP is a safe and effective intervention for BPE. The smaller surgical footprint from the device appears to make earlier catheter removal possible. Comparative evaluation with multi-port RASP and other modalities is warranted.

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.

Optimal sampling scheme in men with abnormal multiparametric MRI undergoing MRI-TRUS fusion prostate biopsy.

OBJECTIVES: To determine the implications of different prostate sampling schemes on the diagnosis of clinically significant prostate cancer (csPCA, ISUP group 2-5) and clinically insignificant prostate cancer (ciPCA, ISUP group 1) in men with abnormal multiparametric magnetic resonance imaging (mpMRI) undergoing MRI-transrectal ulrasound fusion targeted biopsies. MATERIALS AND METHODS: This is a retrospective analysis of a cohort including all men who had a single lesion on mpMRI of the prostate performed between January 2016 and June 2017. All men underwent an MRI-transrectal ulrasound fusion biopsy and systematic (SBx) sampling of the prostate, which combined and were considered the standard of reference. The hypothetical 3 biopsy sampling schemes were defined as follows: Targeted biopsy only (TBx), TBx + ipsilateral SBx (ipsi-SBx) and TBx + contralateral SBx (contra-SBx) and were evaluated for the detection of csPCA and ciPCA. Sensitivity and 95% intervals were calculated, McNemar test was used to compare sensitivities between the various sampling schemes. RESULTS: TBx + SBx detected csPCa in 47% (55 of 116) of the 116 men who met eligibility criteria. Sensitivity and 95% confidence intervals for csPCa detection was 85.5% (73.3%-93.5%), 96.4% (87.5%-99.6%), and 92.7 (82.4%-98%) for TBx alone, TBx + ipsi-SBx and TBx + contra-SBx, respectively. csPCa detection rates were higher for both TBx + ipsi-SBx and TBx + contra-SBx compared to TBx alone. Clinically insignificant cancers alone were detected in 7.7% (9 of 116), 10.3% (12 of 116), and 14.6% (17 of 116) of the cohort by TBx only and TBx + ipsi-SBx, and TBx + contra-SBx, respectively. CONCLUSIONS: TBx + ipsi-SBx may increase the detection of csPCa while limiting overdiagnosis of indolent cancers.

Diagnostic Utility of a Likert Scale Versus Qualitative Descriptors and Length of Capsular Contact for Determining Extraprostatic Tumor Extension at Multiparametric Prostate MRI.

OBJECTIVE: The purpose of this study is to determine the reproducibility and diagnostic performance of a Likert scale in comparison with the European Society of Urogenital Radiology (ESUR) criteria and tumor-pseudocapsule contact length (TCL) for the detection of extraprostatic extension (EPE) at multiparametric MRI. MATERIALS AND METHODS: This was a retrospective review of all men who underwent multiparametric MRI followed by prostatectomy between November 2015 and July 2016. Multiparametric 3-T MRI studies with an endorectal coil were independently reviewed by five readers who assigned the likelihood of EPE using a 1-5 Likert score, ESUR criteria, and TCL (> 10 mm). EPE outcome (absent or present) for the index lesion at whole-mount histopathologic analysis was the standard of reference. Odds ratios (ORs) and areas under the ROC curve (Az) were used for diagnostic accuracy. The interreader agreement was determined using a weighted kappa coefficient. A p < 0.05 was considered significant. RESULTS: Eighty men met the eligibility criteria. At univariate analysis, the Likert score showed the strongest association (OR, 1.8) with EPE, followed by prostate-specific antigen level (OR, 1.7), ESUR score (OR, 1.6), and index lesion size (OR, 1.2). At multivariable analysis, higher Likert score (OR, 1.8) and prostate-specific antigen level (OR, 1.6-1.7) were independent predictors of EPE. The Az value for Likert scores was statistically significantly higher (0.79) than that for TCL (0.74; p < 0.01), but not statistically significantly higher than the value for ESUR scores (0.77; p = 0.17). Interreader agreement with Likert (κ = 0.52) and ESUR scores (κ = 0.55) was moderate and slightly superior to that for TCL (κ = 0.43). Except for TCL among inexperienced readers (κ = 0.34), reader experience did not affect interreader agreement. CONCLUSION: A Likert score conveying the degree of suspicion at multiparametric MRI is a stronger predictor of EPE than is either ESUR score or TCL and may facilitate informed decision making, patient counseling, and treatment planning.

Differences at Presentation and Treatment of Testicular Cancer in Hispanic Men: Institutional and National Hospital-based Analyses.

OBJECTIVE: To describe epidemiologic patterns, stage at presentation, histology, and treatment differences associated with Hispanic men diagnosed with testicular germ cell tumor (TGCT). Hispanics are the fastest growing demographic in the United States and reports suggest that the incidence of TGCT is rising most rapidly in this demographic, yet little is known about TGCTs in Hispanic patients. MATERIALS AND METHODS: We compared patient factors, tumor characteristics, treatment patterns, and outcomes of non-Hispanic white (NHW) vs Hispanic patients at our own institution in North Texas from 2010 to 2016. The findings were corroborated by analyzing the National Cancer Database testicular cancer registry from 2004 to 2014. RESULTS: We identified 154 patients with TGCT at our institution, of which 89 were NHW (56.0%) and 65 were Hispanic (40.9%). A review of the National Cancer Database identified 49,607 NHW patients (81.5%) and 6724 Hispanic patients (11.0%) diagnosed with TGCT. At presentation, Hispanic patients were approximately 5 years younger than NHW patients, delay seeking care for testicular cancer, were more likely to have nonseminomatous histology, had a larger tumor size, and had a higher disease burden at presentation. Additionally, we identified differences in treatment patterns at the national level. CONCLUSION: Differences in outcomes and treatment patterns of Hispanic and NHW patients with TGCT may represent underlying socioeconomic issues and access to care; however, discrepancies in age of onset and histology of TGCT between Hispanic and NHW patients may signify differences in tumor biology or risk factors. We suggest that this possibility be explored further as we embark upon the genomic classification of TGCT.

Survival Outcomes of Men with Lymph Node-positive Prostate Cancer After Radical Prostatectomy: A Comparative Analysis of Different Postoperative Management Strategies.

BACKGROUND: Optimal management of patients with lymph node metastasis (LNM) after radical prostatectomy (RP) remains undefined. OBJECTIVE: We evaluated the association between three different management strategies and survival in prostate cancer with LNM after RP. DESIGN, SETTING, AND PARTICIPANTS: We analyzed data of 1338 patients with LNM after RP from three tertiary care centers. Three hundred and eighty-seven patients (28%) were observed, 676 (49%) received lifelong adjuvant androgen deprivation therapy (ADT), and 325 (23%) received adjuvant external beam radiation therapy (EBRT) and ADT. Three hundred and sixty-eight men were followed for more than 10 yr. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Primary outcome measure was overall survival (OS). Secondary outcomes were cancer-specific survival (CSS) and other-cause mortality. Kaplan-Meier methods were used to visualize OS for the three treatment groups. Cox proportional hazards regression was utilized to compare OS and CSS among the three groups. RESULTS AND LIMITATIONS: ADT+EBRT was associated with better OS than ADT alone (hazard ratio [HR]: 0.46, 95% confidence interval [CI]: 0.32-0.66, p<0.0001) or observation (HR: 0.41, 95% CI: 0.27-0.64, p<0.0001). Higher-risk patients benefited more from ADT+EBRT than lower-risk patients. Ten-year mortality risk difference between ADT+EBRT, observation, or ADT alone ranged from 5% in low-risk patients to 40% in high-risk patients. Adjuvant ADT+EBRT was also associated with better CSS than observation or ADT alone (p<0.0001), ADT had better CSS compared to observation (HR: 0.64, 95% CI: 0.43-0.95, p=0.027). However, ADT was associated with an increased risk of other-cause mortality (HR: 3.05, 95% CI: 1.45-6.40, p=0.003) compared with observation, resulting in similar OS between ADT and observation (HR: 0.90, 95% CI: 0.65-1.25, p=0.5). While selection bias might remain, its effect would operate in the opposite direction to our findings. CONCLUSIONS: In men with LNM after RP, ADT+EBRT improved survival over either observation or adjuvant ADT alone. This survival benefit increases with higher-risk disease. PATIENT SUMMARY: Lymph node metastasis following radical prostatectomy is associated with poor survival outcomes. However, we found that adjuvant androgen deprivation therapy with external beam radiation therapy improved survival in these patients.

Usage and survival implications of surgical staging of inguinal lymph nodes in intermediate- to high-risk, clinical localized penile cancer: A propensity-score matched analysis.

OBJECTIVES: To evaluate the usage of surgical staging of inguinal lymph nodes (SSILNs) in the United States for intermediate to high-risk, clinically localized penile squamous cell cancer (SCC), to explore patient and hospital factors associated with omission of this staging, and to evaluate the effect on survival. PATIENTS AND METHODS: Retrospective, observational study using the National Cancer Database from 2004 to 2014 of 1,689 men diagnosed with pT1b-T3, cN0 penile SCC, who by current guidelines should receive SSILNs-either by inguinal lymph node (ILN) dissection or sentinel node biopsy. Binomial logistic regression analysis was performed to determine predictors of SSILNs. Multivariate Cox regression analysis was performed to determine the impact of SSILNs on survival in the overall and propensity-score matched patient populations. RESULTS: Only 25.3% of patients underwent SSILNs. Increasing patient age, higher comorbidity status, lower pathologic stage, Medicaid insurance, and treatment at a nonacademic facility were independent factors associated with the omission of SSILNs. Omission of SSILNs was an independent predictor of overall mortality, both in the overall patient population after multivariate adjustment, HR = 1.46 [(95% CI: 1.14-1.88), P = 0.003], and in the propensity-score matched adjusted population, HR = 1.59 [(95% CI: 1.20-2.13), P = 0.001]. Limitations include an inability to distinguish biopsy from ILN dissection and those inherent in observational study design. CONCLUSION: Utilization of SSILN for penile SCC is low and has not changed significantly since the publication of guidelines in the United States. In particular, nonacademic institutions were less likely to adhere to recommendations for performance of SSILNs. We found the omission of SSILNs is associated with a significant increase in mortality.

Improved Magnetic Resonance Imaging-Pathology Correlation With Imaging-Derived, 3D-Printed, Patient-Specific Whole-Mount Molds of the Prostate.

OBJECTIVES: The aim of this study was to compare the anatomical registration of preoperative magnetic resonance imaging (MRI) and prostate whole-mount obtained with 3D-printed, patient-specific, MRI-derived molds (PSM) versus conventional whole-mount sectioning (WMS). MATERIALS AND METHODS: Based on an a priori power analysis, this institutional review board-approved study prospectively included 50 consecutive men who underwent 3 T multiparametric prostate MRI followed by radical prostatectomy. Two blinded and independent readers (R1 and R2) outlined the contours of the prostate, tumor, peripheral, and transition zones in the MRI scans using regions of interest. These were compared with the corresponding regions of interest from the whole-mounted histopathology, the reference standard, using PSM whole-mount results obtained in the study group (n = 25) or conventional WMS in the control group (n = 25). The spatial overlap across the MRI and histology data sets was calculated using the Dice similarity coefficient (DSC) for the prostate overall (DSCprostate), tumor (DSCtumor), peripheral (DSCPZ), and transition (DSCTZ) zone. Results in the study and control groups were compared using Wilcoxon rank sum test. RESULTS: The MRI histopathology anatomical registration for the prostate gland overall, tumor, peripheral, and transition zones were significantly superior with the use of PSMs (DSCs for R1: 0.95, 0.86, 0.84, and 0.89; for R2: 0.93, 0.75, 0.78, and 0.85, respectively) than with the use of standard WMS (R1: 0.85, 0.46, 0.66, and 0.69; R2: 0.85, 0.46, 0.66, and 0.69) (P < 0.0001). CONCLUSIONS: The use of PSMs for prostate specimen whole-mount sectioning provides significantly superior anatomical registration of in vivo multiparametric MRI and ex vivo prostate whole-mounts than conventional WMS.

Anti-inflammatory use may not negatively impact oncologic outcomes following intravesical BCG for high-grade non-muscle-invasive bladder cancer.

PURPOSE: To evaluate whether anti-inflammatory agents affect outcomes in patients receiving intravesical BCG therapy for high-grade (HG) non-muscle-invasive bladder cancer (NMIBC). METHODS: We reviewed the records of 203 patients in a prospective database of HG NMIBC from 2006 to 2012 at a single institution. Patients who had muscle-invasive disease (n = 32), low-grade pathology (n = 4), underwent early cystectomy within 3 months (n = 25), had <3 months of follow-up (n = 11), or did not receive an induction course of intravesical BCG (n = 32) were excluded. Clinicopathologic data were tabulated including demographics, comorbidities, pathologic stage and grades, intravesical therapy, and concomitant use of aspirin, NSAIDs, COX inhibitors, and statins. Multivariate Cox regression analysis explored predictive factors for recurrence, progression (stage progression or progression to cystectomy), cancer-specific survival (CSS), and overall survival (OS). RESULTS: Ninety-nine patients with HG NMIBC who received at least one induction course of intravesical BCG were identified, with median follow-up of 31.4 months. There were 20 (20.2 %) deaths, including 6 (6.1 %) patients with bladder cancer-related mortality. 13 % patients experienced tumor progression and 27 % underwent cystectomy following failure of intravesical therapy. Anti-inflammatory use included statins (65 %), aspirin (63 %), or non-aspirin NSAIDs/COX inhibitors (26 %). Anti-inflammatory use was not significantly predictive of recurrence, progression, or mortality outcomes on Cox regression. CIS stage was associated with higher progression, while age, BMI, and Charlson score were independent predictors of overall mortality. CONCLUSION: Despite speculation of inhibitory effects on BCG immunomodulation there was no evidence that anti-inflammatory agents impacted oncologic outcomes in patients receiving BCG for HG NMIBC.

Cell-cycle markers do not improve discrimination of EORTC and CUETO risk models in predicting recurrence and progression of non-muscle-invasive high-grade bladder cancer.

PURPOSE: To assess if a panel of cell-cycle markers could improve the discrimination of European Organization for Research and Treatment of Cancer (EORTC) and Spanish Urological Club for Oncological Treatment (CUETO) models in predicting recurrence and progression of high-grade non-muscle-invasive bladder cancer (NMIBC). MATERIALS AND METHODS: Between January 2007 and January 2012, every patient with high-grade NMIBC treated with transurethral resection of bladder underwent immunohistochemical staining for 5 biomarkers (p21, p27, p53, KI-67, and cyclin E1). We excluded patients who had muscle-insvasive disease, underwent early cystectomy, and those with incomplete follow-up. Kaplan-Meier curves assessed recurrence and progression-free survival. Univariate and multivariate Cox regression analysis assessed the predictive ability of markers after correcting for EORTC or CUETO risk scores. Harrel concordance index assessed for discrimination. RESULTS: There were 131 patients with a median follow-up of 31.1 months. Stage was Ta (50%), T1 (44%), and Tis (8%). For 95 patients this was the primary tumor. Intravesical therapy was used in 76% of cases of which 45% had maintenance. Recurrence-free survival rates at 6, 12, and 24 months were 68.9%, 52.1%, and 33.2%, respectively, whereas progression-free survival rate at 6, 12, and 24 months were 93.8%, 88%, and 84.3%, respectively. No differences in survival based on number of altered markers were noted. Biomarker status was neither a significant predictor of recurrence nor progression. Marker alterations marginally improved discrimination of EORTC and CUETO models, which were confirmed to be mediocre. CONCLUSIONS: Markers were not significant predictors of recurrence nor progression in patients with high-grade NMIBC and their addition to prediction models is of little benefit.

Concordance in Biomarker Status Between Bladder Tumors at Time of Transurethral Resection and Subsequent Radical Cystectomy: Results of a 5-year Prospective Study.

PURPOSE: To assess the concordance rate in alterations of molecular markers at the time of transurethral resection (TUR) and subsequent radical cystectomy (RC) among patients with high-grade urothelial carcinoma of the bladder (UCB). METHODS: We prospectively performed immunohistochemical staining p53, p21, p27, Ki-67 and cyclin E1 on TUR and on RC specimens from 102 patients treated with RC and bilateral lymphadenectomy for high-grade UCB. We analyzed the concordance rate of individual markers and of the number of altered markers. Concordant and discordant findings were reported in the overall population and according to clinical stage. RESULTS: Median patient age was 74 years (IQR 67-79) and mostly male (86%). Median time from TUR to RC was 1.5 months (IQR 1.0-2.4). Clinical stage at time of RC was cTa/Tis/T1 in 50% , cT2 in 47% , and cT4 in 1% of patients Nine (9%) patients received neoadjuvant chemotherapy. The concordance of biomarkers between TUR and RC specimens was 92.2% , 77.5% , 80.4% , 77.5% , and 83.3% for cyclin E1, p21, p27, p53 and Ki-67, respectively. The concordance between number of altered biomarkers was 51.0%. CONCLUSIONS: The rate of individual marker alterations at time of TUR closely approximates that found at RC specimens. However, the correlation of number of altered markers is lower. Molecular marker status at TUR could help predict the marker status at RC and may help guide multimodal therapeutic planning.

Impact of stage migration and practice changes on high-risk prostate cancer: results from patients treated with radical prostatectomy over the last two decades.

OBJECTIVE: To evaluate the impact of year of surgery on clinical, pathological and oncological outcomes of patients with high-risk prostate cancer. PATIENTS AND METHODS: We evaluated 1 033 patients with clinically high-risk prostate cancer, defined as the presence of at least one of the following risk factors: preoperative prostate-specific antigen (PSA) level >20 ng/mL, and/or clinical stage ≥T3, and/or biopsy Gleason score ≥8. Patients were treated between 1990 and 2013 at a single institution. The year-by-year trends in clinical and pathological characteristics were examined. Multivariable Cox regression analysis was used to test the relationship between year of surgery and oncological outcomes. RESULTS: We observed a decrease over time in the proportion of patients with high-risk disease (preoperative PSA >20 ng/mL or clinical stage cT3). A trend in the opposite direction was seen for biopsy Gleason score ≥8 tumours. We observed a considerable increase in the median number of lymph nodes removed, which was associated with an increased rate of lymph node invasion (LNI). On multivariable Cox regression analysis, year of surgery was associated with a reduced risk of biochemical recurrence (hazard ratio [HR] per 5-year interval 0.90, 95% confidence interval [CI] 0.84-0.96; P = 0.01) and distant metastasis (HR per 5-year interval 0.91, 95% CI 0.83-0.99; P = 0.039), after adjusting for age, preoperative PSA, pathological stage, LNI, surgical margin status, and pathological Gleason score. CONCLUSIONS: In this single-centre study, an increased diagnosis of localized and less extensive high-grade prostate cancer was observed over the last two decades. Patients with high-risk disease who were selected for radical prostatectomy showed better cancer control over time. Better definitions of what constitutes high-risk prostate cancer among contemporary patients are needed.

Comparison of Outcomes Between Preoperatively Potent Men Treated with Focal Versus Whole Gland Cryotherapy in a Matched Population.

BACKGROUND AND PURPOSE: The refinement in the localization of prostate cancer tumor foci through transperineal template-mapping biopsies and MRI has led to an increased interest in lesion-directed focal prostatic cryoablation. Data are lacking, however, that compare the outcomes of whole-gland (WG) to focal ablation therapy (FT). The aim of our study was to assess both oncologic and functional outcomes between WG and FT cryoablation of the prostate after having matched patients for preoperative characteristics. PATIENTS AND METHODS: We matched with a 1:1 ratio 317 men who underwent FT with 317 who underwent WG treatment in the Cryo Online Data (COLD) registry between 2007 and 2013. All patients were low-risk according to the D'Amico risk groups and were matched according to age at surgery. We only included preoperatively potent men. Oncologic outcomes were biochemical recurrence (BCR) free-survival defined according to the American Society for Radiation Oncology (ASTRO) and Phoenix criteria and assessed by Kaplan-Meier curves. Only patients with prostate-specific antigen (PSA) nadir data were included in oncologic outcome analysis. Functional outcomes were assessed at 6, 12, and 24 months after the procedure for erectile function (defined as ability to have intercourse with or without erectile aids), urinary continence, urinary retention, and rates of fistula formation. RESULTS: Median age at the time of the procedure was 66.5 years (standard deviation [SD] 6.6 y), and median follow-up time was 58.3 months. After surgery, 30% (n=95) and 17% (n=55) of the men who received WG and FT, respectively, underwent biopsy, with positive biopsy rates of 11.6% and 14.5%, respectively. BCR-free survival rates at 60 months according to the Phoenix definition were 80.1% and 71.3% in the WG and FT cohorts, respectively, with a hazard ratio of 0.827; according to the ASTRO definition, they were 82.1% and 73%, respectively (all P ≥ 0.1). Erectile function data at 24 months was available for 172 WG and 160 FT treated men. Recovery of erection was achieved in 46.8% and 68.8% of patients in the WG and FT cohorts, respectively (P=0.001). Urinary function data at 24 months was available for 307 WG and 313 FT patients. Continence rates were 98.7% and 100% for WG and FT groups, respectively (P=0.02). Urinary retention at 6, 12, and 24 months was reported in 7.3%, 1.9%, and 0.6%, respectively, in the WG arm, and in 5%, 1.3%, and 0.9%, respectively, in the FT arm. Finally, only one fistula was reported in each group. CONCLUSIONS: Men with low-risk prostate cancer who underwent FT cryoablation had comparable BCR-survival rates at 60 months to patients treated with WG. However, FT patients had higher erectile function preservation rates at 24 months post-procedure. Urinary continence, retention and fistula rates were similar between the two treatment groups.

Impact of the Site of Metastases on Survival in Patients with Metastatic Prostate Cancer.

BACKGROUND: Limited data exist on the impact of the site of metastases on survival in patients with stage IV prostate cancer (PCa). OBJECTIVE: To investigate the role of metastatic phenotype at presentation on mortality in stage IV PCa. DESIGN, SETTING, AND PARTICIPANTS: Overall, 3857 patients presenting with metastatic PCa between 1991 and 2009, included in the Surveillance Epidemiology and End Results-Medicare database were evaluated. OUTCOME MEASUREMENTS AND STATISTIC ANALYSES: Overall and cancer-specific survival rates were estimated in the overall population and after stratifying patients according to the metastatic site (lymph node [LN] alone, bone, visceral, or bone plus visceral). Multivariable Cox regression analyses tested the relationship between the site of metastases and survival. All analyses were repeated in a subcohort of patients with a single metastatic site involved. RESULTS AND LIMITATIONS: Respectively, 2.8%, 80.2%, 6.1%, and 10.9% of patients presented with LN, bone, visceral, and bone plus visceral metastases at diagnosis. Respective median overall survival and cancer-specific survival were 43 mo and 61 mo for LN metastases, 24 mo and 32 mo for bone metastases, 16 mo and 26 mo for visceral metastases, and 14 mo and 19 mo for bone plus visceral metastases (p<0.001). In multivariable analyses, patients with visceral metastases had a significantly higher risk of overall and cancer-specific mortality versus those with exclusively LN metastases (p<0.001). The unfavorable impact of visceral metastases persisted in the oligometastatic subgroup. Our study is limited by its retrospective design. CONCLUSIONS: Visceral involvement represents a negative prognostic factor and should be considered as a proxy of more aggressive disease in patients presenting with metastatic PCa. This parameter might indicate the need for additional systemic therapies in these individuals. PATIENT SUMMARY: Patients with visceral metastases should be considered as affected by more aggressive disease and might benefit from the inclusion in clinical trials evaluating novel molecules.