Racial disparity in the utilization of immunotherapy for advanced prostate cancer.

PURPOSE: To identify whether there was a disparity in the utilization of immunotherapy in the treatment of black patients with metastatic castration resistant prostate cancer (mCRPC). METHODS: Using the National Cancer Database, we identified patients between 2010- 2015 with likely minimally/asymptomatic mCRPC. We analyzed annual trends for chemotherapy and immunotherapy use and compared utilization by demographic and clinical features. Multivariable analysis was performed to determine predictors of receiving immunotherapy vs chemotherapy. RESULTS: We identified 1301 patients with likely mCRPC. The majority were non Hispanic White (NHW - 63 %) and 23 % were non-Hispanic Black (NHB). Overall, there was increased utilization of immunotherapy in mCRPC from 2010 onwards, with the peak occurring in 2014 (4.6 %). Chemotherapy use increased significantly, peaking in 2014 to 26.1 %. However, the increased utilization of immunotherapy in the mCRPC was mainly seen in White patients: from 50 % to 74.2 % of the cohort. Conversely, there was a decrease in utilization of immunotherapy among Black mCPRC patients: from 50 % to 25.8 %. On multivariable analysis, there was no statistically significant difference between treatment types by race. CONCLUSION: FDA approval of Sipuleucel-T for mCRPC led to increased utilization of immunotherapy shortly thereafter, but this was mainly noted in white patients. Black patients comparatively did not exhibit increased utilization of this novel agent after 2010. Further studies are necessary to help understand barriers to access to new treatment in mCRPC and eliminate the burden of disease in minority populations."

Increase in searches for erectile dysfunction during winter: seasonal variation evidence from Google Trends in the United States.

Several diseases associated with erectile dysfunction (ED), such as type 2 diabetes mellitus (T2DM) and coronary artery disease (CAD), are known to have seasonal variation, with increased incidence during winter months. However, no literature exists on whether this chronological-seasonal evolution is also present within ED symptomatology. We hypothesized ED would follow the seasonal pattern of its lifestyle-influenced comorbid conditions and exhibit increased incidence during winter months. In order to investigate the seasonal variation of ED in the United States between 2009 and 2019, Internet search query data were obtained using Google Trends. Normalized search volume was determined during the winter and summer seasons for ED, other diseases known to be significantly associated with ED (T2DM and CAD), kidney stones (positive control), and prostate cancer (negative control). There were significantly more internet search queries for ED during the winter than during the summer (p = 0.001). CAD and T2DM also had significantly increased search volume during winter months compared to summer months (p < 0.001 and p = 0.011, respectively). By contrast, searches for kidney stones were significantly increased in the summer than in the winter (p < 0.001). There was no significant seasonal variation in the relative search frequency for prostate cancer (p = 0.75). In conclusion, Google Trends internet search data across a ten-year period in the United States suggested a seasonal variation in ED, which implies an increase in ED during winter. This novel finding in ED epidemiology may help increase awareness of ED's associated lifestyle risk factors, which may facilitate early medical evaluation and treatment for those at risk of both ED and cardiovascular disease.

Safe transition to opioid-free pathway after robotic-assisted laparoscopic prostatectomy.

To determine whether local anesthetic infiltration and non-narcotic pain medications can safely reduce or eliminate opioid use following robotic-assisted laparoscopic prostatectomy while maintaining adequate pain control. After initiation of this quality-improvement project, patients undergoing robotic-assisted laparoscopic prostatectomy had surgeon-administered local anesthesia around all incisions into each successive layer from peritoneum to skin, with the majority infiltrated into the transversus abdominis muscle plane and posterior rectus sheath of the midline extraction incision. Post-operatively patients received scheduled acetaminophen plus ketorolac, renal function permitting. A retrospective review was performed for all cases over 19 months, spanning project implementation. 157 cases (76 in opioid-free pathway, 81 in standard pathway) were included. Five patients (6.6%) in the opioid-free pathway required post-operative opioids while inpatient, versus 61 (75.3%) in the standard pathway, p < .001. Mean patient-reported pain score on each post-operative day was lower in the opioid-free pathway compared to the standard pathway [day 0: 2.4 (SD 2.6) vs. 3.9 (SD 2.7), p < .001; day 1: 1.4 [SD 1.6] vs. 3.3 (SD 2.2), p < .001; day 2 0.9 (SD 1.5) vs. 2.6 (SD 1.9), p < .001]. Fewer post-operative complications were seen in the opioid-free pathway versus standard [0 vs. 5 (6.2%), p = 0.028], and there was no statistically significant difference in number of emergency room visits or readmissions within 3 weeks of surgery. The use of surgeon-administered local anesthetic plus scheduled non-narcotic analgesics can safely and significantly reduce opioid use after robotic-assisted laparoscopic prostatectomy while improving pain control.

Comparative analysis of 1152 African-American and European-American men with prostate cancer identifies distinct genomic and immunological differences.

Racial disparities in prostate cancer have not been well characterized on a genomic level. Here we show the results of a multi-institutional retrospective analysis of 1,152 patients (596 African-American men (AAM) and 556 European-American men (EAM)) who underwent radical prostatectomy. Comparative analyses between the race groups were conducted at the clinical, genomic, pathway, molecular subtype, and prognostic levels. The EAM group had increased ERG (P < 0.001) and ETS (P = 0.02) expression, decreased SPINK1 expression (P < 0.001), and basal-like (P < 0.001) molecular subtypes. After adjusting for confounders, the AAM group was associated with higher expression of CRYBB2, GSTM3, and inflammation genes (IL33, IFNG, CCL4, CD3, ICOSLG), and lower expression of mismatch repair genes (MSH2, MSH6) (p < 0.001 for all). At the pathway level, the AAM group had higher expression of genes sets related to the immune response, apoptosis, hypoxia, and reactive oxygen species. EAM group was associated with higher levels of fatty acid metabolism, DNA repair, and WNT/beta-catenin signaling. Based on cell lines data, AAM were predicted to have higher potential response to DNA damage. In conclusion, biological characteristics of prostate tumor were substantially different in AAM when compared to EAM.

Durability of Digital Flexible Ureteroscope in University Hospital and Ambulatory Surgical Center: Is It Time to Rethink?

Introduction and Objectives: Published literature on damages to a digital flexible ureteroscope (DFU) examines a limited number of ureteroscopes and shows wide variation in its durability. The aim of this study was to compare the primary damage location, causes of DFU damages, and the durability of Karl Storz Flex-Xc digital ureteroscope between University Hospital (UH) and Ambulatory Care Surgery Center (ASC). We also evaluated the available literature on the durability of DFU. Methods: Each damaged DFU prospectively underwent a manufacturer's evaluation to determine the reason for return and primary site of damage. Hospital data on the number of ureteroscopic procedures and damaged DFUs over 3 years were retrospectively reviewed. The possible reason for the damage was classified as either intraoperative or between the procedures. The durability of DFUs, type, and cause of damage were compared between the UH and nonteaching ASC. A chi-square test was utilized for categorical variables. When cell frequencies were <5, Fisher's exact test was used. Results: During the study period, 1211 ureteroscopies were performed and 143 ureteroscopes were returned to the manufacturer. The mean number of uses was 7.45 at the UH and 16.5 at the ASC. The location and cause of damage were similar at both locations. The most common locations of primary damage were at the angle cover (70.6%) and instrument channel (19.2%). Most damage occurred during the handling of the ureteroscopes between surgical procedures (78%). On review of the literature, we found that DFUs were 6 times more durable in a nonteaching hospital. Conclusions: The DFU was more than two times as durable in the ASC as in the UH. Most incidents occurred during handling between surgical procedures. Future research is needed to examine the impact of training and certification of support staff on durability of DFUs.

Robotic Pyelolithotomy for the Intact Removal of a Complete Staghorn Calculus: A Feasible Approach Even After a Previous Open Pyelolithotomy.

OBJECTIVE: To describe the steps and technique of a robotic pyelolithotomy for complete removal of a left staghorn stone after a previous open pyelolithotomy. METHODS: The patient is placed in a left modified flank position with 4 laparoscopic ports placed: 12mm port for camera paramedian to the left of the midline, 8mm robotic port left lower quadrant at the level of the umbilicus, 8mm robotic port midclavicular line 2 finger breaths below the costal margin, 12mm Airseal assistant port paramedian infraumbilical. The white line of Toldt was incised and the colon was mobilized medially. Anterior Gerota's fascia was opened and tacked to the lateral abdominal wall exposing renal pelvis and parenchyma. An intraoperative ultrasound confirmed the underlying stone. A V-shaped Gil-Vernet pyelolithotomy incision was made and Prograsp forceps were used to manipulate the stone out of the renal pelvis. The collecting system was inspected and irrigated using the robotic lens. The pyelotomy was closed with 4-0 Monocryl suture on a TF needle in 2 lengths of suture, superiorly and inferiorly. Gerota's fascia was closed over the renal pelvis and the kidney was re-retroperitonealized by tacking the colon to the white line of Toldt. The specimen was retrieved through a mini-Pfannenstiel incision via a specimen bag. The patient was discharged on postoperative day 1 and seen in clinic 5 weeks later for stent removal. CONCLUSIONS: Robotic pyelolithotomy is a minimally invasive alternative that can be offered to patients with complete staghorn stones even after major open stone surgery. However case selection for this approach relies on the stone burden primarily in a dilated renal pelvis with limited calyceal projections. It is imperative to review preoperative imaging to understand the calyceal anatomy and the rotation required to free the stone from the collecting system.

Lowering positive margin rates at radical prostatectomy by color coding of biopsy specimens to permit individualized preservation of the neurovascular bundles: is it feasible? a pilot investigation

ABSTRACT Objective: To evaluate whether color-coding of prostate core biopsy specimens aids in preservation of the neurovascular bundles from an oncological perspective. Materials and Methods: MRI guided transrectal ultrasound and biopsy of the prostate were performed in 51 consecutive patients suspected of being at high risk for harboring prostate cancer. Core specimens were labeled with blue dye at the deep aspect and red dye at the superficial peripheral aspect of the core. The distance from the tumor to the end of the dyed specimen was measured to determine if there was an area of normal tissue between the prostate capsule and tumor. Results: Of the 51 patients undergoing prostate biopsy, 30 (58.8%) were found to have cancer of the prostate: grade group 1 in 13.7%, 2 in 25.5%, 3 in 7.8%, 4 in 7.8% and 5 in 3.9% of the cohort. A total of 461 cores were analyzed in the cohort, of which 122 showed cancer. Five patients opted to undergo robotic assisted laparoscopic radical prostatectomy. No patients had a positive surgical margin (PSM) or extra prostatic extension (EPE) on radical prostatectomy if there was a margin of normal prostatic tissue seen between the dye and the tumor on prostate biopsy. Conclusion: Color-coding of prostate biopsy core specimens may assist in tailoring the approach for preservation of the neurovascular bundles without compromising early oncological efficacy. Further study is required to determine whether this simple modification of the prostate biopsy protocol is valuable in larger groups of patients.

Lowering positive margin rates at radical prostatectomy by color coding of biopsy specimens to permit individualized preservation of the neurovascular bundles: is it feasible? a pilot investigation.

OBJECTIVE: To evaluate whether color-coding of prostate core biopsy specimens aids in preservation of the neurovascular bundles from an oncological perspective. MATERIALS AND METHODS: MRI guided transrectal ultrasound and biopsy of the prostate were performed in 51 consecutive patients suspected of being at high risk for harboring prostate cancer. Core specimens were labeled with blue dye at the deep aspect and red dye at the superficial peripheral aspect of the core. The distance from the tumor to the end of the dyed specimen was measured to determine if there was an area of normal tissue between the prostate capsule and tumor. RESULTS: Of the 51 patients undergoing prostate biopsy, 30 (58.8%) were found to have cancer of the prostate: grade group 1 in 13.7%, 2 in 25.5%, 3 in 7.8%, 4 in 7.8% and 5 in 3.9% of the cohort. A total of 461 cores were analyzed in the cohort, of which 122 showed cancer. Five patients opted to undergo robotic assisted laparoscopic radical prostatectomy. No patients had a positive surgical margin (PSM) or extra prostatic extension (EPE) on radical prostatectomy if there was a margin of normal prostatic tissue seen between the dye and the tumor on prostate biopsy. CONCLUSION: Color-coding of prostate biopsy core specimens may assist in tailoring the approach for preservation of the neurovascular bundles without compromising early oncological efficacy. Further study is required to determine whether this simple modification of the prostate biopsy protocol is valuable in larger groups of patients.

Prostate cancer in renal transplant recipients

ABSTRACT As patients with end-stage renal disease are receiving renal allografts at older ages, the number of male renal transplant recipients (RTRs) being diagnosed with prostate cancer (CaP) is increasing. Historically, the literature regarding the management of CaP in RTR's is limited to case reports and small case series. To date, there are no standardized guidelines for screening or management of CaP in these complex patients. To better understand the unique characteristics of CaP in the renal transplant population, we performed a literature review of PubMed, without date limitations, using a combination of search terms including prostate cancer, end stage renal disease, renal transplantation, prostate cancer screening, prostate specific antigen kinetics, immuno-suppression, prostatectomy, and radiation therapy. Of special note, teams facilitating the care of these complex patients must carefully and meticulously consider the altered anatomy for surgical and radiotherapeutic planning. Active surveillance, though gaining popularity in the general low risk prostate cancer population, needs further study in this group, as does the management of advance disease. This review provides a comprehensive and contemporary understanding of the incidence, screening measures, risk stratification, and treatment options for CaP in RTRs.

Perineal urethrostomy: Still Essential in the Armamentarium for Transurethral Surgery.

A 69-year-old morbidly obese man presented with hematuria caused by a large anterior wall bladder tumor. The mass was inaccessible for resection by standard means due to the patient's obesity and phallic length. A perineal urethrostomy was required to enable complete resection. This age-old technique is revisited for the benefit of this generation's urologists.

Prostate cancer in renal transplant recipients.

As patients with end-stage renal disease are receiving renal allografts at older ages, the number of male renal transplant recipients (RTRs) being diagnosed with prostate cancer (CaP) is increasing. Historically, the literature regarding the management of CaP in RTR's is limited to case reports and small case series. To date, there are no standardized guidelines for screening or management of CaP in these complex patients. To better understand the unique characteristics of CaP in the renal transplant population, we performed a literature review of PubMed, without date limitations, using a combination of search terms including prostate cancer, end stage renal disease, renal transplantation, prostate cancer screening, prostate specific antigen kinetics, immunosuppression, prostatectomy, and radiation therapy. Of special note, teams facilitating the care of these complex patients must carefully and meticulously consider the altered anatomy for surgical and radiotherapeutic planning. Active surveillance, though gaining popularity in the general low risk prostate cancer population, needs further study in this group, as does the management of advance disease. This review provides a comprehensive and contemporary understanding of the incidence, screening measures, risk stratification, and treatment options for CaP in RTRs.

Intentional Omission of Ureteral Stents During Robotic-assisted Intracorporeal Ureteroenteric Anastomosis: Is It Safe and Feasible?

OBJECTIVE: To describe the surgical technique we used to perform a stentless intracorporeal ureteroenteric anastomosis and to determine the outcomes in this initial series. METHODS: We performed a retrospective review of a prospective database of all patients undergoing robotic-assisted intracorporeal urinary diversion with stentless ureteroenteric anastomosis between March 2014 and July 2016. Diversions were performed at the time of either robotic-assisted laparoscopic cystectomy for bladder cancer or urinary diversion for other indications. RESULTS: A total of 10 patients underwent implantation of 20 ureters into the intestine via a robotic-assisted approach with intentional omission of stents. Median body mass index was 29.57 (first quartile 23.68, third quartile 34.69). Median American Society of Anesthesiologists score was 3 (range 2-3). Seven patients had intracorporeal ileal conduit reconstruction and 3 patients had an intracorporeal neobladder creation. There were no patients who developed a stricture of the ureter nor did any patient develop a leak at the ureteroenteric anastomosis. All patients had normal serum creatinine at least 4 weeks after surgery, and all patients had follow-up computed tomography of the kidneys, which were normal. The median follow-up was 8 months (first quartile = 3 months, third quartile = 17 months). CONCLUSION: Robotic intracorporeal urinary diversion with intentional omission of ureteral stents is a safe and feasible option when establishing continuity of the genitourinary and gastrointestinal tracts.

Robotic assisted laparoscopic radical cystectomy with stentless intracorporeal modified Ves.Pa neobladder: early experience.

This study aimed at demonstrating the feasibility of robotic assisted laparoscopic radical cystectomy with pure intracorporeal modified Ves.Pa neobladder with stentless ureteroileal anastomosis. Pure intracorporeal robotic assisted laparoscopic technique has been recently developed with a select number of high-volume centers utilizing various operative and neobladder techniques. We reviewed the patient characteristics, operative details and perioperative courses in the two patients who have undergone robotic assisted laparoscopic radical cystectomy with pure intracorporeal modified Ves.Pa neobladder and one who has undergone the Hautmann W neobladder. These results were compared to other contemporary robotic neobladder series. We demonstrate technical success with similar operative and perioperative results with the modified Ves.Pa neobladder. The robotic pure intracorporeal modified Ves.Pa neobladder is a technically feasible operation and may be easier to perform compared to other neobladders. Initial experience suggests operative time and perioperative outcomes are similar to other robotic techniques.

Renal fungus ball: a challenging clinical problem.

INTRODUCTION: We describe a case of renal pelvi-ureteric fungus ball managed with placement of two nephrostomy tubes and amphotericin B irrigation through a nephrostomy tube with the other to free drain. CASE REPORT: A 46-year-old man with uncontrolled Type 2 diabetes mellitus was referred to the urology clinic for workup of recurrent urinary tract infection. Urine culture grew Candida albicans. The patient was started on oral fluconazole therapy. Cystoscopy and cystogram revealed a grade 3 left vesicoureteral reflux and right retrograde pyelogram revealed a filling defect in the right renal pelvis extending into the proximal ureter with severe hydroureteronephrosis. Two nephrostomy tubes were placed (mid-pole and lower pole) to ensure that the system was not obstructed. Amphotericin B (50 mg/1000 ml normal saline) irrigation was then instilled through the mid-pole nephrostomy tube at a rate of 30 ml/h with the lower pole nephrostomy tube to free drain. An antegrade nephrostogram was performed after 5 days of amphotericin B instillation, showing complete resolution of the fungus ball. The patient is awaiting definitive minimally invasive management of the distal ureteral narrowing. COMMENTS: Renal and pelvi-ureteric fungus ball is a challenging clinical entity. It must be addressed promptly and efficiently to be successful. We describe a minimally invasive approach that was tolerated well and resulted in complete clearance of the fungus ball in a relatively short time frame.

Central zone lesions on magnetic resonance imaging: Should we be concerned?

INTRODUCTION AND OBJECTIVE: The Prostate Imaging Reporting and Data System (PI-RADS) score was developed to evaluate lesions in the peripheral and transition zone on multiparametric magnetic resonance imaging (mpMRI) of the prostate. We aim to determine if the PI-RADS scoring system can be used to evaluate central zone lesions on mpMRI. MATERIALS AND METHODS: A retrospective review of 73 patients who underwent mpMRI/ultrasound (US) fusion-guided biopsy of 143 suspicious lesions between February 2014 and October 2015 was performed. All patients underwent a 3T mpMRI. Indications for mpMRI included an abnormal digital rectal examination, PSA velocity >0.75ng/dl/y, and patients on active surveillance. The mpMRI sequence involved T2-weighted imaging, diffusion-weighted imaging, and dynamic contrast enhancement. Using 3-dimensional model software (Invivo Corporation, Gainesville, FL, USA), a minimum of 3 magnetic resonance imaging (MRI)/US fusion-guided biopsy samples were taken from each prostate lesion seen on mpMRI irrespective of PI-RADS score, using local anesthesia in an outpatient clinic setting. RESULTS: A total of 73 patients underwent MRI/US fusion-guided biopsy of 85 peripheral zone lesions, 31 transitional zone lesions, and 27 central zone lesions. Only 2 (7%) of central zone lesions were positive for prostate cancer. Both patients had lesions which were graded as PI-RADS 3. Both the patients had multifocal lesions that encompassed≥50% of the central and transition zones on the sagittal view MRI images. Both patients previously had transrectal US-guided biopsy of the prostate which was negative for cancer. Both patients underwent a robotic-assisted laparoscopic prostatectomy, each revealing high-grade cancer. CONCLUSIONS: Lesions involving only the central gland/zone seen on MRI are less concerning for malignancy and should not be given equal weight as peripheral zone lesions. In this series, no lesions involving solely the central gland/zone, regardless of PI-RADS score, was positive for malignancy on MRI/US fusion-guided biopsy. Consideration of a modified PI-RADS scoring system should be given to help identify central zone lesions with malignant potential.

Periprostatic Fat: A Risk Factor for Prostate Cancer?

OBJECTIVE: To evaluate whether periprostatic fat volume and periprostatic fat ratio as determined by multiparametric magnetic resonance imaging (mpMRI) correlate with the presence of high-grade prostate cancer. MATERIALS AND METHODS: A total of 295 consecutive patients (median age: 64, range: 38-84) underwent mpMRI of the prostate gland between August 2013 and February 2015. All patients underwent a 3 Tesla mpMRI. Using DynaCAD (Invivo, Gainesville, FL), we calculated the prostate volume and volume of the periprostatic fat seen on mpMRI. The periprostatic fat ratio was calculated using the formula periprostatic fat volume/prostate volume. RESULTS: A higher periprostatic fat volume (P <.001) and a higher periprostatic fat ratio (P <.001) were significantly associated with a higher Gleason score. Periprostatic fat ratio is a better predictor of higher Gleason score compared with periprostatic fat volume (P < .001). There was no correlation observed between periprostatic fat ratio and prostate-specific antigen (median: 7.34, range: 0.36-59.7, P = .274), age (median: 64, range: 38-84, P = .665), or body mass index (median: 28.33, range: 17.99-45.44, P = .310). Patients with a higher periprostatic fat ratio were more likely to undergo intervention for prostate cancer. CONCLUSION: A higher periprostatic fat ratio is significantly associated with a higher Gleason score. Periprostatic fat ratio is a better predictor of higher Gleason score compared with periprostatic fat volume and may be an important risk factor in diagnosing patients with higher grade prostate cancer.

Upper Tract Urothelial Carcinoma in the Genetically Predisposed Patient: Role of Urinary Markers in Predicting Recurrence.

Background: Upper tract urothelial carcinoma (UTUC) is an uncommon disease that is diagnosed clinically by the selective use of urine cytology, urine biomarkers, and imaging of the upper tract. We present a case of a patient with Lynch syndrome and high-grade UTUC that was diagnosed by an abnormal Cxbladder assay, prompting further endoscopic examination. Case Presentation: A 59-year-old Caucasian female with a history of endometrial cancer and bladder cancer with Lynch syndrome presented for evaluation of recurrent urothelial carcinoma. Her previous bladder tumors have been T1 high grade and Ta high grade and have been treated with resection and multiple cycles of intravesical Bacillus Calmette-Guerin (BCG) therapy. She had also undergone a robotic left distal ureterectomy and psoas hitch for a high-grade distal ureteral tumor. Surveillance cystoscopy 7 months after revealed a biopsy-confirmed bladder tumor, which was resected, and she was started on maintenance BCG therapy. At presentation, follow-up urine cytology and UroVysion studies were negative. Cxbladder test was also initially negative. However, during close clinical monitoring, the Cxbladder test became positive. Cystoscopy was once more performed, which was unremarkable. Bilateral ureteroscopy was performed, revealing high-grade upper tract renal papillary carcinoma (UTUC) in the left renal pelvis. The patient declined a nephroureterectomy. She was treated with two sessions of holmium laser ablation of the left renal pelvis tumor and underwent 6 weekly courses of BCG + interferon instilled into her left renal pelvis using a 5F open-ended catheter. Repeat urine cytology, UroVysion, and Cxbladder tests were negative after completion of upper tract BCG therapy. Conclusion: Cxbladder test may be useful and an adjunct to urine cytology and the UroVysion FISH assay to evaluate patients at high risk for recurrent UTUC.

Totally intracorporeal robot-assisted laparoscopic reverse seven ileal ureteric reconstruction.

We describe the first reported case of completely intracorporeal robot-assisted laparoscopic reverse seven ileal ureteric reconstruction. The patient was a woman with bilateral, long segment ureteric strictures secondary to pelvic surgery and radiation. This report demonstrates that robotic reconstruction is a viable option even in a complex patient with a hostile abdomen.