Interstate Telemedicine for Urologic Cancer Care.

PURPOSE: US states eased licensing restrictions on telemedicine during the COVID-19 pandemic, allowing interstate use. As waivers expire, optimal uses of telemedicine must be assessed to inform policy, legislation, and clinical care. We assessed whether telemedicine visits provided the same patient experience as in-person visits, stratified by in- vs out-of-state residence, and examined the financial burden. MATERIALS AND METHODS: Patients seen in person and via telemedicine for urologic cancer care at a major regional cancer center received a survey after their first appointment (August 2019-June 2022) on satisfaction with care, perceptions of communication during their visit, travel time, travel costs, and days of work missed. RESULTS: Surveys were completed for 1058 patient visits (N = 178 in-person, N = 880 telemedicine). Satisfaction rates were high for all visit types, both interstate and in-state care (mean score 60.1-60.8 [maximum 63], P > .05). More patients convening interstate telemedicine would repeat that modality (71%) than interstate in-person care (61%) or in-state telemedicine (57%). Patients receiving interstate care had significantly higher travel costs (median estimated visit costs $200, IQR $0-$800 vs median $0, IQR $0-$20 for in-state care, P < .001); 55% of patients receiving interstate in-person care required plane travel and 60% required a hotel stay. CONCLUSIONS: Telemedicine appointments may increase access for rural-residing patients with cancer. Satisfaction outcomes among patients with urologic cancer receiving interstate care were similar to those of patients cared for in state; costs were markedly lower. Extending interstate exemptions beyond COVID-19 licensing waivers would permit continued delivery of high-quality urologic cancer care to rural-residing patients.

Patient-centered outcomes of telehealth for the care of rural-residing patients with urologic cancer.

BACKGROUND: Patients residing in rural areas with urologic cancers confront significant obstacles in obtaining oncologic care. In the Pacific Northwest, a sizeable portion of the population lives in a rural county. Telehealth offers a potential access solution. METHODS: Patients receiving urologic care through telehealth or an in-person appointment at the Fred Hutchinson Cancer Center in Seattle, Washington, were surveyed to assess appointment-related satisfaction and travel costs. Patients' residences were classified as rural or urban based on their self-reported ZIP code. Median patient satisfaction scores and appointment-related travel costs were compared by rural versus urban residence within telehealth and in-person appointment groups using Wilcoxon signed-rank or χ2 testing. RESULTS: A total of 1091 patients seen for urologic cancer care between June 2019 and April 2022 were included, 28.7% of which resided in a rural county. Patients were mostly non-Hispanic White (75%) and covered by Medicare (58%). Among rural-residing patients, telehealth and in-person appointment groups had the same median satisfaction score (61; interquartile ratio, 58, 63). More rural-residing than urban-residing patients in the telehealth appointment groups strongly agreed that "Considering the cost and time commitment of my appointment, I would choose to meet with my provider in this setting in the future" (67% vs. 58%, p = .03). Rural-residing patients with in-person appointments carried a higher financial burden than those with telehealth appointments (medians, $80 vs. $0; p <.001). CONCLUSIONS: Appointment-related costs are high among rural-residing patients traveling for urologic oncologic care. Telehealth provides an affordable solution that does not compromise patient satisfaction.

Clinical Utility of 4Kscore®, ExosomeDx™ and Magnetic Resonance Imaging for the Early Detection of High Grade Prostate Cancer.

PURPOSE: We aimed to evaluate 4Kscore® and ExosomeDx™ with multiparametric magnetic resonance imaging in the detection of high grade prostate cancer and number of biopsies avoided. MATERIAL AND METHODS: Patients had 1 liquid biomarker test with or without multiparametric magnetic resonance imaging. High grade prostate cancer was defined as Gleason grade group 2 or greater. The overall number of avoided biopsies (with Gleason grade 1 or less), and number of missed Gleason grade 2 or greater cancer among the biopsied patients, were determined. RESULTS: Of the 783 patients in the overall cohort 419 (53.5%) underwent biopsy. 4Kscore and ExosomeDx scores higher than the manufacturers' cut point were associated with PI-RADS™ scores 3 to 5 and Gleason grade 2 or greater prostate cancer. Limiting biopsy to the men with liquid biomarker scores above the manufacturers' cut point would have resulted avoiding 29.5% to 39.9% unnecessary biopsies overall, while missing 4.0% to 4.8% Gleason grade 2 or greater prostate cancer in the biopsy group. Screening algorithms with up-front liquid biomarker testing followed by multiparametric magnetic resonance imaging if the biomarker is above the manufacturers' cut point, then followed by biopsy if the multiparametric magnetic resonance imaging is positive or if 4Kscore 20 or greater or ExosomeDx 19 or greater would have missed 4.8% to 5.6% of Gleason grade 2 or greater prostate cancer in the biopsy group while avoiding 39.4% to 43.0% biopsies and 29.5% to 39.9% multiparametric magnetic resonance imaging overall. Similar algorithms with up-front multiparametric magnetic resonance imaging followed by liquid biomarker testing for negative multiparametric magnetic resonance imaging would have missed 2.4% of Gleason grade 2 or greater prostate cancer in the biopsy group but only avoided 17.2% 19.3% biopsies overall. CONCLUSIONS: Screening algorithms with up-front liquid biomarker testing followed by multiparametric magnetic resonance imaging and biopsy at certain biomarker thresholds could reduce unnecessary biopsies, multiparametric magnetic resonance imaging and overdetection of Gleason grade 1 prostate cancer.

Measuring quality of urology care using a qualified clinical data registry.

PURPOSE OF REVIEW: Qualified clinical data registries (QCDRs) serve as a framework for quality improvement efforts, clinical research endeavors, and participation in reimbursement incentive programs. However, the measurement of quality and the recommendations to guide QCDRs in developing new quality measures is a complex process. In this review, we highlight the government policies that lead to the creation of QCDRs, how QCDR quality measures are developed, and the current QCDRs that focus on urological care. RECENT FINDINGS: QCDRs facilitate participation in the merit-based incentive payment system for reimbursement adjustments. Most QCDRs leverage existing clinical guidelines in the development of new quality measures. In 2018, there are four urology QCDRs with quality measures for many urological conditions. These QCDRs form the infrastructure for quality improvement and provide new resources for research endeavors. SUMMARY: Quality measurement within QCDRs will allow urologists to focus improvement efforts to deliver high-quality urological care while also facilitating reimbursement incentives and creating novel research datasets.

Prostate Cancer Markers.

Diagnostic biomarkers derived from blood, urine, or prostate tissue provide additional information beyond clinical calculators to determine the risk of detecting high-grade prostate cancer. Once diagnosed, multiple markers leverage prostate cancer biopsy tissue to prognosticate clinical outcomes, including adverse pathology at radical prostatectomy, disease recurrence, and prostate cancer mortality; however the clinical utility of some outcomes to patient decision making is unclear. Markers using tissue from radical prostatectomy specimens provide additional information about the risk of biochemical recurrence, development of metastatic disease, and subsequent mortality beyond existing multivariable clinical calculators (the use of a marker to simply sub-stratify risk groups such as the NCCN groups is of minimal value). No biomarkers currently available for prostate cancer have been prospectively validated to be predict an improved clinical outcome for a specific therapy based on the test result; however, further research and development of these tests may produce a truly predictive biomarker for prostate cancer treatment.

Practice-Level Variation in Opioid-Free Discharge Following Surgery for T1 Renal Masses: A MUSIC-KIDNEY Analysis.

INTRODUCTION: Opioid prescription following surgery has played a role in the current opioid epidemic. We evaluated practice-level variation in opioid prescribing following surgery for cT1 renal masses and examined the relationships between opioid-free discharge and postoperative emergency department (ED) visits and readmissions. METHODS: We retrospectively examined all T1 renal mass (RM) patients with data regarding postoperative opioid prescriptions within the Michigan Urological Surgery Improvement Collaborative-Kidney Mass: Identifying and Defining Necessary Evaluation and Therapy (MUSIC-KIDNEY) registry from April 2021 to March 2023. Patients were stratified into those who received opioids at discharge and those with opioid-free discharge. Associations with patient, tumor, and surgical factors were evaluated. Rates of postoperative ED visits and readmissions within 30 days were compared between cohorts. Practice-level variation was assessed. RESULTS: Of 414 patients who underwent surgery for T1 RM across 15 practices in MUSIC-KIDNEY, 23.7% had opioid-free discharge. Practice-level variation in rates of opioid-free discharge ranged from 6.7% to 55.0%. For patients prescribed opioids, the median number of pills was 10 (IQR 6-12). Patients with cT1b masses were more likely to have opioid-free discharge (44.9% vs 32%, OR 0.44; 95% CI 0.22-0.89). Rates of 30-day ED visits (7.0% vs 3.1%) and readmissions (4.1% vs 2.0%) were lower in the opioid-free discharge group but did not reach statistical significance. CONCLUSIONS: MUSIC-KIDNEY data suggest opioid-free discharge is not associated with increased rates of postoperative ED visits or readmissions. There exists wide practice-level variation in opioid prescriptions following surgery for T1 RM in the state of Michigan. Similar variation likely exists throughout the United States, and best surgical practice suggests reduction in opioid prescribing after nephrectomy.

Telemedicine for Multidisciplinary Urologic Cancer Care: A Prospective Single Institution Study.

BACKGROUND: We rapidly implemented a telemedicine Multidisciplinary Urologic Cancer Clinic (MDUCC) at the University of Washington/Seattle Cancer Care Alliance during the peak of the COVID-19 Public Health Emergency to maintain our ability to provide multidisciplinary cancer care. We report our experiences though assessment of patient-reported outcomes from our telemedicine MDUCC. METHODS: Video visits with a urologic oncologist, medical oncologist, and radiation oncologist were conducted in the same format as our in-person MDUCC. We prospectively collected patient demographic and clinical data. Patients were invited to complete a post-visit survey that assessed satisfaction, provider trust, travel time, and costs of the telemedicine visit. We estimated travel distances and times from each patient's home to our clinic. RESULTS: Among invited patients, twenty-four patients completed a survey after their telemedicine MDUCC visit. Twenty patients (83%) were at home during the visit. Most (85%) were men, Caucasian (79%), and were being seen in our Bladder Cancer MDUCC (83%). All twenty-four patients responded that they would be willing to have future appointments via telemedicine; eighteen patients (75%) strongly agreed that the encounter was high quality; 19 patients strongly agreed that they were satisfied with their visit. Patients saved an estimated average one-way travel distance of 145 miles and one-way travel time of 179 minutes to convene a telemedicine visit. CONCLUSIONS: Telemedicine MDUCCs are feasible and effective in providing access to multidisciplinary urologic cancer care. Patient satisfaction was high, and many patients were spared a substantial travel burden. Telemedicine may continue to be leveraged to improve access to multidisciplinary urologic cancer care.

Inpatient urological surgery at critical access hospitals in the United States.

PURPOSE: To better understand urological care delivery in rural communities, we evaluated the utilization, outcomes and costs of inpatient urological surgery at critical access hospitals. MATERIALS AND METHODS: Using data from the AHA (American Hospital Association) and NIS (Nationwide Inpatient Sample), we identified all urological surgical admissions to critical and noncritical access hospitals from 2005 through 2009. We compared the distribution of urological procedures, hospital mortality, length of stay and costs for patients undergoing common urological operations at critical vs noncritical access hospitals. RESULTS: Of the 1,292 critical and 3,760 noncritical access hospitals reporting to the AHA 450 (35%) and 1,372 (36%), respectively, had at least 1 year of data available in the NIS. We identified 333,925 urological surgical admissions, including 2,286 (0.7%) to critical access hospitals. Overall, at least 1 inpatient urological operation was performed at only 45% of critical access hospitals vs 91% of noncritical access hospitals (p <0.001). The distribution of urological surgeries differed between critical and noncritical access hospitals (p <0.001) with a greater prevalence of operations for benign indications at critical access hospitals. For 6 common inpatient urological surgeries we found no meaningful difference in in-hospital mortality and prolonged length of stay between patients treated at critical vs noncritical access hospitals. However, costs at critical access hospitals were universally higher. CONCLUSIONS: Inpatient urological surgery is performed at only a few critical access hospitals. While in-hospital mortality and length of stay are largely indistinguishable between critical and noncritical access hospitals, the higher costs at critical access hospitals may pose a challenge to improving rural access to urological care.

Accuracy of determining small renal mass management with risk stratified biopsies: confirmation by final pathology.

PURPOSE: We assess the accuracy of a biopsy directed treatment algorithm in correctly assigning active surveillance vs treatment in patients with small renal masses by comparing biopsy results with final surgical pathology. MATERIALS AND METHODS: From 1999 to 2011, 151 patients with small renal masses 4 cm or smaller underwent biopsy and subsequent surgical excision. Biopsy revealed cell type and grade in 133 patients, allowing the hypothetical assignment of surveillance vs treatment using an algorithm incorporating small renal mass size and histological risk group. We compared the biopsy directed management recommendation with the ideal management as defined by final surgical pathology. RESULTS: Biopsy called for surveillance of 36 small renal masses and treatment of 97 small renal masses. Final pathology showed 11 patients initially assigned to surveillance should have been assigned to treatment (8.3% of all patients, 31% of those recommended for surveillance), whereas no patients moved from treatment to surveillance. Agreement between biopsy and final pathology was 92%. Using management based on final pathology as the reference standard, biopsy had a negative predictive value of 0.69 and positive predictive value 1.0 for determining management. Of the 11 misclassified cases, 7 had a biopsy indicating grade 1 clear cell renal cancer which was upgraded to grade 2 (5) or grade 3 (2). After modifying the histological risk group assignment to account for undergrading of clear cell renal cancer, agreement improved to 97%, with a negative predictive value of 0.86 and a positive predictive value of 1.0. CONCLUSIONS: Our results suggest that compared to final pathology, biopsy of small renal masses accurately informs an algorithm incorporating size and histological risk group that directs the management of small renal masses.

Blood and urine biomarkers in prostate cancer: Are we ready for reflex testing in men with an elevated prostate-specific antigen?

OBJECTIVE: There is no consensus on the role of biomarkers in determining the utility of prostate biopsy in men with elevated prostate-specific antigen (PSA). There are numerous biomarkers such as prostate health index, 4Kscore, prostate cancer antigen 3, ExoDX, SelectMDx, and Mi-Prostate Score that may be useful in this decision-making process. However, it is unclear whether any of these tests are accurate and cost-effective enough to warrant being a widespread reflex test following an elevated PSA. Our goal was to report on the clinical utility of these blood and urine biomarkers in prostate cancer screening. METHODS: We performed a systematic review of studies published between January 2000 and October 2020 to report the available parameters and cost-effectiveness of the aforementioned diagnostic tests. We focus on the negative predictive value, the area under the curve, and the decision curve analysis in comparing reflexive tests due to their relevance in evaluating diagnostic screening tests. RESULTS: Overall, the biomarkers are roughly equivalent in predictive accuracy. Each test has additional clinical utility to the current diagnostic standard of care, but the added benefit is not substantial to justify using the test reflexively after an elevated PSA. CONCLUSIONS: Our findings suggest these biomarkers should not be used in binary fashion and should be understood in the context of pre-existing risk predictors, patient's ethnicity, cost of the test, patient life-expectancy, and patient goals. There are more recent diagnostic tools such as multi-parametric magnetic resonance imaging, polygenic single-nucleotide panels, IsoPSA, and miR Sentinel tests that are promising in the realm of prostate cancer screening and need to be investigated further to be considered a consensus reflexive test in the setting of prostate cancer screening.

Interprofessional Consultations (eConsults) in Urology.

INTRODUCTION: An interprofessional consultation (eConsult) is an asynchronous form of telehealth whereby a primary care provider requests electronic consultation with a specialist in place of an in-person consultation. While eConsults have been successfully implemented in many medical specialties, their use in the practice of urology is relatively unknown. METHODS: We included data from four academic institutions: University of Michigan, University of California -San Francisco, University of Washington, and Montefiore Medical Center. We included every urological eConsult performed at each institution from the launch of their respective programs through August 2019. We considered an eConsult "converted" when the participating urologist recommended a full in-person evaluation. We report eConsult conversion rate, response time, completion time, and diagnosis categories. RESULTS: A total of 462 urological eConsults were requested. Of these, 36% were converted to a traditional in-person visit. Among resolved eConsults, with data on provider response time available (n=119),53.8% of eConsults were addressed in less than 1 day; 28.6% in 1 day; 8.4% in 2 days; 3.4% in 3 days; 3.4% in 4 days; 1.7% in 5 days; and 0.8% in ≥6 days. Among resolved eConsults, with data on provider completion time available (n=283), 50.2% were completed in 1-10 minutes; 46.7% in 11-20 minutes; 2.8% in 21-30 minutes; and less than 1% in ≥31 minutes. DISCUSSION: Our study suggests that eConsults are an effective avenue for urologists to provide recommendations for many common non-surgical urological conditions and thus avoid a traditional in-person for low-complexity situations. Further investigation into the impact of eConsults on healthcare costs and access to urological care are necessary.

Patterns and timing of perioperative blood transfusion and association with outcomes after radical cystectomy.

BACKGROUND: Perioperative blood transfusion (PBT) has been associated with worse outcomes across tumor types, including bladder cancer. We report our institutional experience with PBT utilization in the setting of radical cystectomy (RC) for patients with bladder cancer, exploring whether timing of PBT receipt influences perioperative and oncologic outcomes. METHODS: Consecutive patients with bladder cancer treated with RC were identified. PBT was defined as red blood cell transfusion during RC or the postoperative admission. Clinicopathologic and peri and/or postoperative parameters were extracted and compared between patients who did and did not receive PBT using Mann Whitney U Test, chi-square, and log-rank test. Overall (OS) and recurrence-free survival (RFS) were estimated with the Kaplan Meier method. Univariate/multivariate logistic and Cox proportional hazards regression were used to identify variables associated with postoperative and oncologic outcomes, respectively. RESULTS: The cohort consisted of 747 patients (77% men; median age 67 years). Median follow-up was 61.5 months (95% CI 55.8-67.2) At least one postoperative complication (90-day morbidity) occurred in 394 (53%) patients. Median OS and RFS were 91.8 months (95% CI: 76.0-107.6) and 66.0 months (95% CI: 48.3-83.7), respectively. On multivariate analysis, intraoperative, but not postoperative, BT was independently associated with shorter OS (HR: 1.74, 95% CI: 1.32-2.29) and RFS (HR: 1.55, 95%CI: 1.20-2.01), after adjusting for relevant clinicopathologic variables. PBT (intra- or post- operative) was significantly associated with prolonged postoperative hospitalization ≥10 days. CONCLUSIONS: Intraoperative BT was associated with inferior OS and RFS, and PBT overall was associated with prolonged hospitalization following RC. Further studies are needed to validate this finding and explore potential causes for this observation.

Response to Neoadjuvant Chemotherapy and Survival in Micropapillary Urothelial Carcinoma: Data From a Tertiary Referral Center and the Surveillance, Epidemiology, and End Results (SEER) Program.

BACKGROUND: Micropapillary urothelial carcinoma (MPC) is a rare urothelial carcinoma variant with conflicting data guiding clinical practice. In this study, we explored oncologic outcomes in relation to neoadjuvant chemotherapy (NAC) in a retrospective cohort of patients with MPC, alongside data from Surveillance, Epidemiology, and End Results (SEER)-Medicare. PATIENTS AND METHODS: We retrospectively identified patients with MPC or conventional urothelial carcinoma (CUC) without any variant histology undergoing radical cystectomy (RC) in our institution (2003-2018). SEER-Medicare was also queried to identify patients diagnosed with MPC (2004-2015). Clinicopathologic data and treatment modalities were extracted. Overall survival (OS) was estimated with the Kaplan-Meier method. Mann-Whitney-Wilcoxon and chi-square tests were used for comparative analysis and Cox regression for identifying clinical covariates associated with OS. RESULTS: Our institutional database yielded 46 patients with MPC and 457 with CUC. In SEER-Medicare, 183 patients with MPC were identified, and 63 (34%) underwent RC. In the institutional cohort, patients with MPC had significantly higher incidence of cN+ (17% vs. 8%), pN+ stage (30% vs. 17%), carcinoma-in-situ (43% vs. 25%), and lymphovascular invasion (30% vs. 16%) at RC versus those with CUC (all P < .05). Pathologic complete response (ypT0N0) to NAC was 33% for MPC and 35% for CUC (P = .899). Median OS was lower for institutional MPC versus CUC in univariate analysis (43.6 vs. 105.3 months, P = .006); however, MPC was not independently associated with OS in the multivariate model. Median OS was 25 months in the SEER MPC cohort for patients undergoing RC, while NAC was not associated with improved OS in that group. CONCLUSION: Pathologic response to NAC was not significantly different between MPC and CUC, while MPC histology was not an independent predictor of OS. Further studies are needed to better understand biological mechanisms behind its aggressive features as well as the role of NAC in this histology variant.

Long-term outcomes of nephroureterectomy versus endoscopic management for upper tract urothelial carcinoma.

PURPOSE: We compared outcomes in patients treated with nephroureterectomy vs nephron sparing endoscopic surgery for upper tract urothelial carcinoma. MATERIALS AND METHODS: Patients treated at our institution for upper tract urothelial carcinoma from 1996 to 2004 were monitored for upper tract and bladder recurrence, metastasis, and cancer specific and overall survival. Outcomes were compared between treatment groups by univariate and multivariate analyses based on pertinent pathological and demographic variables. RESULTS: Of 96 renal units 62 underwent immediate nephroureterectomy and 34 were managed endoscopically. Median followup in all survivors was 77 months. Overall nephroureterectomy and endoscopy complication rates were 29% and 9.3%, respectively. In patients with low grade tumors the 5-year metastasis-free survival rate after nephroureterectomy and endoscopy was 88% and 94%. The corresponding 5-year cancer specific and overall survival rates were 89% vs 100% and 72% vs 75%, respectively. Of endoscopic cases 84% had at least 1 ipsilateral recurrence. Multivariate analysis revealed that only tumor grade was significantly associated with metastasis-free survival while grade and body mass index correlated with cancer specific survival, and Charlson Comorbidity index and grade impacted overall survival. Treatment group was not associated with survival outcome. CONCLUSIONS: When technically feasible and in select patients, endoscopic management provides cancer related and overall survival equivalent to that of nephroureterectomy in patients with low grade upper tract urothelial carcinoma at the cost of frequent re-treatments in many patients. Nephroureterectomy is standard treatment for high grade cancer when there is a normal contralateral kidney but endoscopy should be considered when there are imperative indications for nephron sparing.

Risk stratification metrics for bladder cancer: Comprehensive Geriatric Assessments.

Despite advances in surgical technique and perioperative care pathways, complication rates following radical cystectomy for bladder cancer remain high and perioperative outcomes for elderly patients are suboptimal. Furthermore, subjective risk assessments of patients with bladder cancer, with a high prevalence of complex comorbidity burden and risk of frailty, may result in undertreatment of patients assumed to be poor operative candidates. A critical component of preoperative patient counseling and treatment selection is accurate and objective preoperative risk appraisal. Comprehensive Geriatric Assessments are multi-domain evaluations of the medical, functional, and psychosocial aspects of health designed specifically for use in elderly patients with the objective of identifying vulnerabilities that may be targeted with interventions for improvement. While currently recommended by multiple guideline bodies for use in the preoperative evaluation of elderly patients with bladder cancer there is a paucity of data describing their use in contemporary clinical practice. Herein, then, we will describe the components of a Comprehensive Geriatric Assessments and propose strategies for their integration into the preoperative surgical workflow.

Location of Recurrence by Gallium-68 PSMA-11 PET Scan in Prostate Cancer Patients Eligible for Salvage Radiotherapy.

OBJECTIVE: To identify locations of recurrence after radical prostatectomy (RP) with prostate-specific antigen (PSA) <2 by Gallium-68 prostate-specific membrane antigen (PSMA)-11 Positron Emission Tomography (PET) imaging, and to determine whether standard nodal radiation fields would cover the location of prostate cancer recurrence. MATERIALS AND METHODS: We performed a retrospective review of patients with PSMA-PET imaging for biochemical recurrence following RP with PSA ≤2.0 ng/mL and assessed if the recurrent disease was within standard radiation target volumes. We compared patient and clinical variables between men with recurrences covered by standard salvage radiation fields and those with recurrences outside of standard fields. RESULTS: We identified 125 patients for study inclusion. The median PSA at imaging was 0.40 ng/mL (interquartile range 0.28-0.63). PSMA-avid disease was found in 66 patients (53%). Of these, 25 patients (38%) had PSMA-avid lesions found outside of the pelvis, 33 (50%) had lesions confined to the pelvic lymph nodes and prostate bed, and 8 (12%) men had PSMA-avid recurrence only in the prostate bed. Salvage radiation including standard Intensity Modulated Radiation Therapy (IMRT) pelvic nodal volumes would not cover PSMA-avid nodal disease in 38 men (30%). PSA at the time of imaging was statistically associated with having PSMA-avid disease outside of standard nodal fields (P <.01). CONCLUSION: The 68Ga-PSMA-11 PET detects disease in a majority of patients with PSA ≤2.0 following RP. Nearly one-third of men had PSMA-avid disease that would be missed by standard radiation fields. This imaging modality may dramatically impact the design and use of post-RP salvage radiotherapy.