Development and Validation of a Prostate Biopsy Risk Calculator in Black Men.

PURPOSE: We sought to develop and validate a prostate biopsy risk calculator for Black men and compare it with the Prostate Cancer Prevention Trial version 2.0, Prostate Biopsy Collaborative Group, and Kaiser Permanente Prostate Cancer Risk Calculators for the detection of Gleason Grade Group (GG) ≥ 2 prostate cancer (PCa). MATERIALS AND METHODS: We prospectively recruited 2 cohorts of men undergoing prostate biopsy from 5 facilities in Chicago. The first cohort was split into development (70%) and internal validation (30%) groups. The second was used for external validation. Iterative logistic regression was used to develop 3 models for predicting GG ≥ 2 PCa. Models were compared for discrimination using the C statistics, calibration curves, and net benefit curves. The frequency of unnecessary biopsies and missed PCas was compared at 10% and 30% risk thresholds. RESULTS: The 2 cohorts included 393 and 292 Black men, respectively. Our first model, Mistry-Sun 1, used serum PSA and prior negative biopsy. Mistry-Sun 2 added abnormal digital rectal exam (DRE) and an interaction term with abnormal DRE and PSA to Mistry-Sun 1. Mistry-Sun 3 added prostate volume, abnormal DRE, and age to Mistry-Sun 1. The C statistics were 0.74, 0.74, and 0.78, respectively, and were similar to or higher than established calculators. At the 10% and 30% risk thresholds our models had the fewest unnecessary biopsies and an appropriate proportion of missed GG ≥ 2 PCas. CONCLUSIONS: Tailoring a risk calculator to detect clinically significant PCa in Black men may improve biopsy decision-making and outcomes compared to tools developed in non-Black populations.

Genetic loci associated with skin pigmentation in African Americans and their effects on vitamin D deficiency.

A recent genome-wide association study (GWAS) in African descent populations identified novel loci associated with skin pigmentation. However, how genomic variations affect skin pigmentation and how these skin pigmentation gene variants affect serum 25(OH) vitamin D variation has not been explored in African Americans (AAs). In order to further understand genetic factors that affect human skin pigmentation and serum 25(OH)D variation, we performed a GWAS for skin pigmentation with 395 AAs and a replication study with 681 AAs. Then, we tested if the identified variants are associated with serum 25(OH) D concentrations in a subset of AAs (n = 591). Skin pigmentation, Melanin Index (M-Index), was measured using a narrow-band reflectometer. Multiple regression analysis was performed to identify variants associated with M-Index and to assess their role in serum 25(OH)D variation adjusting for population stratification and relevant confounding variables. A variant near the SLC24A5 gene (rs2675345) showed the strongest signal of association with M-Index (P = 4.0 x 10-30 in the pooled dataset). Variants in SLC24A5, SLC45A2 and OCA2 together account for a large proportion of skin pigmentation variance (11%). The effects of these variants on M-Index was modified by sex (P for interaction = 0.009). However, West African Ancestry (WAA) also accounts for a large proportion of M-Index variance (23%). M-Index also varies among AAs with high WAA and high Genetic Score calculated from top variants associated with M-Index, suggesting that other unknown genomic factors related to WAA are likely contributing to skin pigmentation variation. M-Index was not associated with serum 25(OH)D concentrations, but the Genetic Score was significantly associated with vitamin D deficiency (serum 25(OH)D levels less than 12 ng/mL) (OR, 1.30; 95% CI, 1.04-1.64). The findings support the hypothesis suggesting that skin pigmentation evolved responding to increased demand for subcutaneous vitamin D synthesis in high latitude environments.

Urotrauma Guideline 2020: AUA Guideline.

PURPOSE: The authors of this guideline reviewed the urologic trauma literature to guide clinicians in the appropriate methods of evaluation and management of genitourinary injuries. MATERIALS AND METHODS: The Panel amended the Guideline in 2020 to reflect additional literature published through February 2020. When sufficient evidence existed, the Panel assigned the body of evidence a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, the Panel provided additional information as Clinical Principles and Expert Opinions (See table 1[Table: see text]). RESULTS: The Panel updated a total of six existing statements on renal, ureteral, bladder, urethra, and genital trauma. Additionally, four new statements were added based on literature released since the 2017 amendment. Statement 5b was added based on new evidence for treatment of hemodynamically unstable patients with renal trauma. Statement 20b was added based on new literature for percutaneous or open suprapubic tube placement following pelvic fracture urethral injury. Statements 30a and 30b were also added to provide guidance on ultrasonography for blunt scrotal injuries suggestive of testicular rupture and for performing surgical exploration with repair or orchiectomy for penetrating scrotal injuries respectively. CONCLUSIONS: These evidence-based updates to the AUA Guidelines further inform the treatment of urotrauma.

Performance of Prostate Health Index in Biopsy Naïve Black Men.

PURPOSE: The Prostate Health Index is validated for prostate cancer detection but has not been well validated for Gleason grade group 2-5 prostate cancer detection in Black men. We hypothesize that the Prostate Health Index has greater accuracy than prostate specific antigen for detection of Gleason grade group 2-5 prostate cancer. We estimated probability of overall and Gleason grade group 2-5 prostate cancer across previously established Prostate Health Index ranges and identified Prostate Health Index cutoffs that maximize specificity for Gleason grade group 2-5 prostate cancer with sensitivity >90%. MATERIALS AND METHODS: We recruited a "cancer-free" Black control cohort (135 patients) and a cohort of biopsy naïve Black men (158) biopsied for elevated prostate specific antigen. Descriptive statistics compared the prostate cancer cases and controls and the frequency of Gleason grade group 2-5 prostate cancer across Prostate Health Index scores. Receiver operating characteristics compared the discrimination of prostate specific antigen, Prostate Health Index and other prostate specific antigen related biomarkers. Sensitivity and specificity for Gleason grade group 2-5 prostate cancer detection were assessed at prostate specific antigen and Prostate Health Index thresholds alone and in series. RESULTS: Of biopsied subjects 32.9% had Gleason grade group 2-5 prostate cancer. In Blacks with prostate specific antigen from 4.0-10.0 ng/ml, Prostate Health Index and prostate specific antigen had similar discrimination for Gleason grade group 2-5 prostate cancer (0.63 vs 0.57, p=0.27). In Blacks with prostate specific antigen ≤10.0, a threshold of prostate specific antigen ≥4.0 had 90.4% sensitivity for Gleason grade group 2-5 prostate cancer; a threshold of prostate specific antigen ≥4.0 with Prostate Health Index ≥35.0 in series avoided unnecessary biopsy in 33.0% of men but missed 17.3% of Gleason grade group 2-5 prostate cancer. Prostate specific antigen ≥4.0 with Prostate Health Index ≥28.0 in series spared biopsy in 17.9%, while maintaining 90.4% sensitivity of Gleason grade group 2-5 prostate cancer. CONCLUSIONS: The Prostate Health Index has moderate accuracy in detecting Gleason grade group 2-5 prostate cancer in Blacks, but Prostate Health Index ≥28.0 can be safely used to avoid some unnecessary biopsies in Blacks.

Pre-diagnostic carbohydrate intake and treatment failure after radical prostatectomy for early-stage prostate cancer.

PURPOSE: An association between dietary carbohydrate intake and prostate cancer (PCa) prognosis is biologically plausible, but data are scarce. This prospective cohort study examined the relation between pre-diagnostic carbohydrate intake and treatment failure following radical prostatectomy for clinically early-stage PCa. METHODS: We identified 205 men awaiting radical prostatectomy and assessed their usual dietary intake of carbohydrates using the 110-item Block food frequency questionnaire. We also evaluated carbohydrate intake quality using a score based on the consumption of sugars relative to fiber, fat, and protein. Logistic regression analyzed their associations with the odds of treatment failure, defined as a detectable and rising serum prostate-specific antigen (PSA) or receiving androgen deprivation therapy (ADT) within 2 years. RESULTS: Sucrose consumption was associated with a higher odds and fiber consumption with a lower odds of ADT after accounting for age, race/ethnicity, body mass index, and tumor characteristics (odds ratio [OR] (95% confidence interval [CI]) 5.68 (1.71, 18.9) for 3rd vs. 1st sucrose tertile and 0.88 (0.81, 0.96) per gram of fiber/day, respectively). Increasing carbohydrate intake quality also associated with a lower odds of ADT (OR (95% CI) 0.78 (0.66, 0.92) per unit increase in score, range 0-12). CONCLUSIONS: Pre-diagnostic dietary carbohydrate intake composition and quality influence the risk of primary treatment failure for early-stage PCa. Future studies incorporating molecular aspects of carbohydrate metabolism could clarify possible underlying mechanisms.

A comparative effectiveness analysis of the PBCG vs. PCPT risks calculators in a multi-ethnic cohort.

BACKGROUND: Predictive models that take race into account like the Prostate Cancer Prevention Trial Risk Calculator 2.0 (PCPT RC) and the new Prostate Biopsy Collaborative Group (PBCG) RC have been developed to equitably mitigate the overdiagnosis of prostate specific antigen (PSA) screening. Few studies have compared the performance of both calculators across racial groups. METHODS: From 1485 prospectively recruited participants, 954 men were identified undergoing initial prostate biopsy for abnormal PSA or digital rectal examination in five Chicago hospitals between 2009 and 2014. Discrimination, calibration, and frequency of avoided biopsies were calculated to assess the performance of both risk calculators. RESULTS: Of 954 participants, 463 (48.5%) were Black, 355 (37.2%) were White, and 136 (14.2%) identified as Other. Biopsy results were as follows: 310 (32.5%) exhibited no cancer, 323 (33.9%) indolent prostate cancer, and 321 (33.6%) clinically significant prostate cancer (csPCa). Differences in area under the curve (AUC)s for the detection of csPCa between PCPT and PBCG were not statistically different across all racial groups. PBCG did not improve calibration plots in Blacks and Others, as it showed higher levels of overprediction at most risk thresholds. PCPT led to an increased number of avoidable biopsies in minorities compared to PBCG at the 30% threshold (68% vs. 28% of all patients) with roughly similar rates of missed csPCa (23% vs. 20%). CONCLUSION: Significant improvements were noticed in PBCG's calibrations and net benefits in Whites compared to PCPT. Since PBCG's improvements in Blacks are disputable and potentially biases a greater number of low risk Black and Other men towards unnecessary biopsies, PCPT may lead to better biopsy decisions in racial minority groups. Further comparisons of commonly used risk calculators across racial groups is warranted to minimize excessive biopsies and overdiagnosis in ethnic minorities.

Usefulness of Preoperative Ultrasound for the Evaluation of Testicular Rupture in the Setting of Scrotal Gunshot Wounds.

PURPOSE: A scrotal gunshot wound may result in testicular injury, necessitating urgent scrotal exploration and attempted testicular salvage. Scrotal ultrasound is highly sensitive and specific for testicular rupture in the setting of blunt scrotal trauma but it has been poorly studied in the setting of scrotal gunshot wounds. Our objective was to determine the accuracy of scrotal ultrasound to identify testicular rupture following a scrotal gunshot wound. MATERIALS AND METHODS: We retrospectively reviewed the records of patients with a scrotal gunshot wound from 2003 to 2014 in whom preoperative ultrasound was done prior to scrotal exploration. A heterogeneous echo pattern of testicular parenchyma with contour loss was considered a positive examination for testicular rupture. Patients underwent scrotal exploration within 24 hours of presentation. The sensitivity and specificity of ultrasound were estimated and compared to operative findings. ROC curve analysis was done. RESULTS: Of 75 patients who sustained a scrotal gunshot wound ultrasound was positive in 30 and negative in 45. No ultrasound revealed bilateral injuries. Scrotal exploration demonstrated a total of 40 testicular ruptures in 35 patients, of which 30 testicles were salvaged. Ten orchiectomies were performed. The sensitivity and specificity of ultrasound were 60% and 95%, respectively, with 16 missed injuries and 6 false-positive findings. Positive predictive value was 80% and negative predictive value was 87%. The ROC AUC was 0.79. In 6 of the 16 missed injuries there was an ipsilateral hematocele or hematoma. CONCLUSIONS: The sensitivity of scrotal ultrasound is limited for evaluating testicular rupture after a scrotal gunshot wound. Large coincident hematoceles or hematomas may obscure the diagnosis of testicular rupture. Negative ultrasound should not preclude scrotal exploration after a scrotal gunshot wound is sustained.

T4 urothelial carcinoma in undiagnosed closed bladder exstrophy in a post-menopausal female.

It is rare to see an adult presenting with exstrophy of the bladder. Malignant conversion in exstrophy occurs in 4%, with adenocarcinoma as the most common histopathology. We report the first case of metastatic high grade urothelial carcinoma with squamous and sarcomatoid differentiation arising from undiagnosed, closed bladder exstrophy in a female at advanced age with associated bilateral deep vein thrombosis and clot retention. The patient developed clinical progression of disease despite neoadjuvant gemcitabine-cisplatin and salvage (or palliative) radiotherapy. To the best of our knowledge, this is the first reported case of a primary urothelial malignancy in occult bladder exstrophy.

Race and BMI modify associations of calcium and vitamin D intake with prostate cancer.

BACKGROUND: African Americans have disproportionately higher burden of prostate cancer compared to European Americans. However, the cause of prostate cancer disparities is still unclear. Several roles have been proposed for calcium and vitamin D in prostate cancer pathogenesis and progression, but epidemiologic studies have been conducted mainly in European descent populations. Here we investigated the association of calcium and vitamin D intake with prostate cancer in multiethnic samples. METHODS: A total of 1,657 prostate cancer patients who underwent screening and healthy controls (888 African Americans, 620 European Americans, 111 Hispanic Americans, and 38 others) from Chicago, IL and Washington, D.C. were included in this study. Calcium and vitamin D intake were evaluated using food frequency questionnaire. We performed unconditional logistic regression analyses adjusting for relevant variables. RESULTS: In the pooled data set, high calcium intake was significantly associated with higher odds for aggressive prostate cancer (ORQuartile 1 vs. Quartile 4 = 1.98, 95% C.I.: 1.01-3.91), while high vitamin D intake was associated with lower odds of aggressive prostate cancer (ORQuartile 1 vs. Quartile 4 = 0.38, 95% C.I.: 0.18-0.79). In African Americans, the association between high calcium intake and aggressive prostate cancer was statistically significant (ORQuartile 1 vs. Quartile 4 = 4.28, 95% C.I.: 1.70-10.80). We also observed a strong inverse association between total vitamin D intake and prostate cancer in African Americans (ORQuartile 1 vs. Quartile 4 = 0.06, 95% C.I.: 0.02-0.54). In European Americas, we did not observe any significant associations between either calcium or vitamin D intake and prostate cancer. In analyses stratifying participants based on Body Mass Index (BMI), we observed a strong positive association between calcium and aggressive prostate cancer and a strong inverse association between vitamin D intake and aggressive prostate cancer among men with low BMI (<27.8 kg/m2), but not among men with high BMI (≥27.8 kg/m2). Interactions of race and BMI with vitamin D intake were significant (P Interaction < 0.05). CONCLUSION: Calcium intake was positively associated with aggressive prostate cancer, while vitamin D intake exhibited an inverse relationship. However, these associations varied by race/ethnicity and BMI. The findings from this study may help develop better prostate cancer prevention and management strategies.

Common vitamin D pathway gene variants reveal contrasting effects on serum vitamin D levels in African Americans and European Americans.

Vitamin D deficiency is more common among African Americans (AAs) than among European Americans (EAs), and epidemiologic evidence links vitamin D status to many health outcomes. Two genome-wide association studies (GWAS) in European populations identified vitamin D pathway gene single-nucleotide polymorphisms (SNPs) associated with serum vitamin D [25(OH)D] levels, but a few of these SNPs have been replicated in AAs. Here, we investigated the associations of 39 SNPs in vitamin D pathway genes, including 19 GWAS-identified SNPs, with serum 25(OH)D concentrations in 652 AAs and 405 EAs. Linear and logistic regression analyses were performed adjusting for relevant environmental and biological factors. The pattern of SNP associations was distinct between AAs and EAs. In AAs, six GWAS-identified SNPs in GC, CYP2R1, and DHCR7/NADSYN1 were replicated, while nine GWAS SNPs in GC and CYP2R1 were replicated in EAs. A CYP2R1 SNP, rs12794714, exhibited the strongest signal of association in AAs. In EAs, however, a different CYP2R1 SNP, rs1993116, was the most strongly associated. Our models, which take into account genetic and environmental variables, accounted for 20 and 28 % of the variance in serum vitamin D levels in AAs and EAs, respectively.

Smoking and prostate cancer in a multi-ethnic cohort.

BACKGROUND: Prostate cancer (PCa) and smoking-related morbidity disproportionately burdens African American (AA) men. Smoking is associated with high-grade PCa and incidence, but few studies have focused on AA men. This study aims to determine the effect of tobacco-use on odds of PCa and of high-grade PCa in a population of predominantly AA men. METHODS: This is a cross-sectional study evaluating smoking and PCa status in men with incident PCa and screened healthy controls. Altogether, 1,085 men (527 cases and 558 controls), age ≥ 40 years were enrolled through outpatient urology clinics in two US cities from 2001 to 2012. Validated questionnaires were used to gather clinical and socioeconomic data. RESULTS: The cases and controls were predominantly AA (79.9% and 71.3%, respectively, P = 0.01). AA men smoked more frequently (53.4% vs. 47.9%, P < 0.001) and quit less frequently than European American (EA) men (31.5% vs. 40.4%, P = 0.01). AA heavy smokers had increased odds of PCa diagnosis (OR 2.57, 95% CI 1.09, 6.10) and high-grade cancer (OR 1.89, 95% CI 1.03, 3.48) relative to never smokers and light smokers. Among AAs, heavy smokers had lower odds of NCCN low PCa recurrence risk stratification. AA former smokers had a trend for increased odds of high-grade cancer compared to never smokers. The associations between smokings, cancer diagnosis and cancer grade did not reach statistical significance in EA men. CONCLUSION: We found ethnic differences in smoking behavior. Heavy smoking is associated with increased odds of PCa and of higher Gleason grade in AA men.

Genitourinary skin and soft tissue infections: a prospective contemporary evaluation of causative pathogens.

PURPOSE: Prior literature identified anaerobes as the predominant causative organisms in genitourinary skin and soft tissue infections. However, the increasing prevalence of community acquired, methicillin resistant Staphylococcus aureus infection has brought about the growing need to reevaluate these infections and their causative organisms. We examined the causative organisms and risk factors in suppurative superficial genitourinary infections, and evaluated the growing role of community acquired, methicillin resistant S. aureus. MATERIALS AND METHODS: We performed a single institution, prospective assessment of 60 adults who presented between August 2008 and July 2010 with genitourinary skin and soft tissue infections requiring incision and drainage. Patients completed a standardized, nonvalidated questionnaire before undergoing débridement of the site. RESULTS: A total of 60 patient specimens were obtained and 92 bacterial pathogens were isolated. Of these pathogens 55% were aerobes. S. aureus was the most predominant cultured organism, representing 25% of all cultured organisms, and 65% of these isolates were community acquired, methicillin resistant S. aureus. The most commonly associated comorbidities included diabetes mellitus, tobacco smoking and heavy alcohol use. HIV/AIDS showed a statistically significant association with community acquired, methicillin resistant S. aureus infection (OR 11.00, 95% CI 1.05-115.51, p = 0.0456), as did the cumulative number of community acquired, methicillin resistant S. aureus risk factors (OR 2.64, 95% CI 1.31-5.33, p = 0.007). CONCLUSIONS: Aerobic organisms now account for most of these infections and community acquired, methicillin resistant S. aureus has emerged as a significant causative organism. Populations that may be at increased risk for these infections include patients with diabetes mellitus, heavy alcohol users and tobacco smokers. In patients with HIV/AIDS or multiple community acquired, methicillin resistant S. aureus risk factors the latter organism is more likely to be the causative organism.

Brief smoking cessation intervention: a prospective trial in the urology setting.

PURPOSE: Urologists have an important role in the treatment of tobacco related diseases, such as kidney and bladder cancer. Despite this role, urologists receive little training in promoting tobacco cessation. We prospectively evaluated a brief smoking cessation intervention offered by a urologist at an outpatient clinic. MATERIALS AND METHODS: Between 2009 and 2011 adult smokers from a single institution urology clinic were enrolled in a prospective, brief intervention trial or in usual care as controls. All patients were assessed by the validated Fagerström test for nicotine dependence and the readiness to quit questionnaire. Trial patients received a 5-minute brief smoking cessation intervention. The primary outcome was abstinence at 1 year and the secondary outcome was the number of attempts to quit. Multivariate logistic regression was used to identify factors associated with the quit rate and quit attempts. RESULTS: A total of 179 patients were enrolled in the study, including 100 in the brief smoking cessation intervention, 41 in the brief smoking cessation intervention plus nicotine replacement therapy and 38 usual care controls. Of the participants 81.0% were 40 years old or older with a mean ± SD 11.26 ± 7.23 pack-year smoking history. Mean readiness to quit and tobacco dependence scores were similar in the 2 arms (p = 0.25 and 0.92, respectively). The 1-year quit rate in the brief smoking cessation intervention group was 12.1% vs 2.6% in the usual care group (OR 4.44, p = 0.163) Adding nicotine replacement therapy increased the quit rate to 19.5% (vs usual care OR 9.91, p = 0.039). Patients who received the brief smoking cessation intervention were significantly more likely to attempt to quit (OR 2.31, p = 0.038). Increased readiness scores were associated with an increased quit rate and increased quit attempts. CONCLUSIONS: Urologists can successfully implement a brief smoking cessation intervention program. Our study highlights the role of the urologist in providing smoking cessation assistance and the significant impact of brief, simple advice about quitting smoking on the smoker quit rate.

Impact of genomic testing on urologists' treatment preference in favorable risk prostate cancer: A randomized trial.

INTRODUCTION: The Oncotype Dx Genomic Prostate Score (GPS) is a 17-gene relative expression assay that predicts adverse pathology at prostatectomy. We conducted a novel randomized controlled trial to assess the impact of GPS on urologist's treatment preference for favorable risk prostate cancer (PCa): active surveillance versus active treatment (i.e., prostatectomy/radiation). This is a secondary endpoint from the ENACT trial which recruited from three Chicago hospitals from 2016 to 2019. METHODS: Ten urologists along with men with very low to favorable-intermediate risk PCa were included in the study. Participants were randomly assigned to standardized counseling with or without GPS assay. The main outcome was urologists' preference for active treatment at Visit 2 by study arm (GPS versus Control). Multivariable best-fit binary logistic regressions were constructed to identify factors independently associated with urologists' treatment preference. RESULTS: Two hundred men (70% Black) were randomly assigned to either the Control (96) or GPS arm (104). At Visit 2, urologists' preference for prostatectomy/radiation almost doubled in the GPS arm to 29.3% (29) compared to 14.1% (13) in the Control arm (p = 0.01). Randomization to the GPS arm, intermediate NCCN risk level, and lower patient health literacy were predictors for urologists' preference for active treatment. DISCUSSION: Limitations included sample size and number of urologists. In this study, we found that GPS testing reduced urologists' likelihood to prefer active surveillance. CONCLUSIONS: These findings demonstrate how obtaining prognostic biomarkers that predict negative outcomes before treatment decision-making might influence urologists' preference for recommending aggressive therapy in men eligible for active surveillance.

Race and insurance status are risk factors for orchiectomy due to testicular trauma.

PURPOSE: Race and insurance status independently predict outcome disparities after trauma. Black patients, Hispanic patients, uninsured patients and patients who live farther from trauma centers have a worse outcome after trauma than others. To our knowledge it is unknown whether these factors have a role in the testicular salvage rate after testicular trauma. We used NTDB (National Trauma Data Bank®) to investigate whether socioeconomic status, race and rural location predict testicular salvage. MATERIALS AND METHODS: Patients who sustained testicular trauma were identified in NTDB, version 9.1. Procedure codes for orchiectomy vs testicular repair were used to determine the risk of testicular salvage. Rural location was determined by matching the injury with the urban influence code. Univariate analysis of the influence of patient age, injury severity, race, insurance status and rural location was performed. Multivariate longitudinal analysis was done to identify orchiectomy predictors. RESULTS: Of 635,013 trauma cases 980 (0.2%) involved testicular injury. Of these patients 108 (11.0%) underwent orchiectomy and 58 (5.9%) underwent testicular repair. Self-paying patients had a statistically higher rate of orchiectomy than those with private insurance (79.2% vs 48.0%, p = 0.006). Black patients had a statistically higher rate of orchiectomy than white patients (75.8% vs 53.7%, p = 0.009). No difference in the orchiectomy rate was seen between Hispanic and nonHispanic patients (68.0% vs 65.8%, p = 0.84). In terms of rurality the incidence location was similar for orchiectomy and testicular repair, including urban 46.3% and 39.7%, rural 6.5% and 3.5%, suburban 2.8% and 1.7%, and wilderness 0.9% and 3.5%, respectively (p = 0.55). No statistically significant differences were found in age (31 vs 29 years, p = 0.42), injury severity score (5.8 vs 5.8, p = 0.99), hospital stay (8.4 vs 6.7 days, p = 0.41), intensive care unit stay (14.4 vs 9.6 days, p = 0.41) or ventilator days (18.2 vs 10.2, p = 0.24) for orchiectomy and testicular repair cases. CONCLUSIONS: Although age, injury severity score, hospital stay, intensive care unit stay and days of ventilator support are similar for patients who underwent orchiectomy vs testicular repair, the orchiectomy rate was higher for uninsured and black patients. Further studies are needed to elucidate the reasons for this disparity. Standardized protocols to manage testicular injury may decrease these disparities.

Ethnicity and smoking status are associated with awareness of smoking related genitourinary diseases.

PURPOSE: Cigarette smoking is a recognized risk factor for kidney cancer, bladder cancer and erectile dysfunction. However, little is known regarding patient knowledge of these associations. We evaluated awareness of smoking as a risk factor for genitourinary disease and identified variables associated with awareness. MATERIALS AND METHODS: We performed a cross-sectional study in a convenience sample of 535 patients who presented to a urology clinic at a major public hospital between 2009 and 2011. Patient demographics and knowledge were captured in a self-reported questionnaire evaluating awareness of smoking as a risk factor for bladder, kidney and lung cancer, and erectile dysfunction. Factors associated with the awareness of smoking and genitourinary disease were identified by multivariable logistic regression. RESULTS: Urology patients generally had low overall awareness of smoking related genitourinary disease. Only 33.5%, 25.2% and 24.2% of patients identified smoking as a risk factor for kidney cancer, bladder cancer and erectile dysfunction, respectively, compared to 94.0% who identified it as a risk factor for lung cancer. Patients from ethnic minorities and current smokers consistently showed a more pronounced lack of awareness of the link between smoking and these diseases. Generally Hispanic and black patients were 2 to 3 times more likely than white patients to be unaware of the association of smoking with the diseases (p = 0.0019 to 0.059). Smokers were twice as likely as nonsmokers to be unaware of the link of smoking with kidney and bladder cancer (p = 0.025 and 0.0509, respectively). CONCLUSIONS: Our study highlights the need for increased awareness of smoking related genitourinary diseases, especially among minority patients and smokers. This study draws attention to an opportunity for urologists to provide smoking cessation assistance and education for this patient population.

Enzalutamide Monotherapy vs Active Surveillance in Patients With Low-risk or Intermediate-risk Localized Prostate Cancer: The ENACT Randomized Clinical Trial.

Importance: There are few published studies prospectively assessing pharmacological interventions that may delay prostate cancer progression in patients undergoing active surveillance (AS). Objective: To compare the efficacy and safety of enzalutamide monotherapy plus AS vs AS alone in patients with low-risk or intermediate-risk prostate cancer. Design, Setting, and Participants: The ENACT study was a phase 2, open-label, randomized clinical trial conducted from June 2016 to August 2020 at 66 US and Canadian sites. Eligible patients were 18 years or older, had received a diagnosis of histologically proven low-risk or intermediate-risk localized prostate cancer within 6 months of screening, and were undergoing AS. Patients were monitored during 1 year of treatment and up to 2 years of follow-up. Data analysis was conducted in February 2021. Interventions: Randomized 1:1 to enzalutamide, 160 mg, monotherapy for 1 year or continued AS, as stratified by cancer risk and follow-up biopsy type. Main Outcomes and Measures: The primary end point was time to pathological or therapeutic prostate cancer progression (pathological, ≥1 increase in primary or secondary Gleason pattern or ≥15% increased cancer-positive cores; therapeutic, earliest occurrence of primary therapy for prostate cancer). Secondary end points included incidence of a negative biopsy result, percentage of cancer-positive cores, and incidence of a secondary rise in serum prostate-specific antigen (PSA) levels at 1 and 2 years, as well as time to PSA progression. Adverse events were monitored to assess safety. Results: A total of 114 patients were randomized to treatment with enzalutamide plus AS and 113 to AS alone; baseline characteristics were similar between treatment arms (mean [SD] age, 66.1 [7.8] years; 1 Asian individual [0.4%], 21 Black or African American individuals [9.3%], 1 Hispanic individual [0.4%], and 204 White individuals [89.9%]). Enzalutamide significantly reduced the risk of prostate cancer progression by 46% vs AS (hazard ratio, 0.54; 95% CI, 0.33-0.89; P = .02). Compared with AS, odds of a negative biopsy result were 3.5 times higher; there was a significant reduction in the percentage of cancer-positive cores and the odds of a secondary rise in serum PSA levels at 1 year with treatment with enzalutamide; no significant difference was observed at 2 years. Treatment with enzalutamide also significantly delayed PSA progression by 6 months vs AS (hazard ratio, 0.71; 95% CI, 0.53-0.97; P = .03). The most commonly reported adverse events during enzalutamide treatment were fatigue (62 [55.4%]) and gynecomastia (41 [36.6%]). Three patients in the enzalutamide arm died; none were receiving the study drug at the time of death. No deaths were considered treatment-related. Conclusions and Relevance: The results of this randomized clinical trial suggest that enzalutamide monotherapy was well-tolerated and demonstrated a significant treatment response in patients with low-risk or intermediate-risk localized prostate cancer. Enzalutamide may provide an alternative treatment option for patients undergoing AS. Trial Registration: ClinicalTrials.gov Identifier: NCT02799745.

A latent class analysis of health behavior changes after cancer diagnosis among Hispanic/Latino cancer survivors.

PURPOSE: We aimed to identify subgroups of Hispanic/Latino (H/L) cancer survivors with distinct health behavior patterns and their associated sociodemographic, medical, and psychosocial characteristics. METHODS: Baseline data were used from a randomized clinical trial evaluating the efficacy of an enhanced patient navigation intervention in H/L cancer survivors. Participants (n = 278) completed the Lifestyle Behavior Scale and validated questionnaires on health-related quality of life (HRQOL), supportive care needs, distress, and satisfaction with cancer care. Latent class analysis was used to determine the latent classes and associated characteristics. RESULTS: Three latent classes emerged: class 1 (survivors who increased health behaviors [e.g., exercising and eating healthy] since diagnosis); class 2 (no changes in health behaviors since diagnosis); and class 3 (a "mixed class," with a higher or lower engagement across various health behaviors since diagnosis). Participants in class 1 were significantly more educated and less likely to be foreign born. Participants in class 2 were significantly older and more likely to have prostate cancer. H/L cancer survivors in class 3 had a significantly lower income, were less educated, and reported greater unmet supportive care needs, more distress, and poorer HRQOL. CONCLUSIONS: Survivors who report engaging in health behaviors less frequently since diagnosis may be experiencing psychosocial challenges and health disparities. IMPLICATIONS FOR CANCER SURVIVORS: Hispanic/Latino cancer survivors may benefit from screening for social determinants of health and mental health needs, prompt referral to supportive care services, community resources, and public services, and participating in culturally informed psychosocial interventions to address their unique needs.