Robotic versus open radical cystectomy for bladder cancer: evaluation of complications, survival, and opioid prescribing patterns.

We aim to compare complications, readmission, survival, and prescribing patterns of opioids for post-operative pain management for Robotic-assisted laparoscopic radical cystectomy (RARC) as compared to open radical cystectomy (ORC). Patients that underwent RARC or ORC for bladder cancer at a tertiary care center from 2005 to 2021 were included. Recurrence-free survival (RFS) and overall survival (OS) were evaluated with Kaplan-Meier curves and multivariable Cox proportional hazards regression models. Comparisons of narcotic usage were completed with oral morphine equivalents (OMEQ). Multivariable linear regression was used to assess predictors of OMEQ utilization. A total of 128 RARC and 461 ORC patients were included. There was no difference in rates of Clavien-Dindo grade ≥ 3 complications between RARC and ORC (36.7 vs 30.1%, p = 0.16). After a mean follow up of 3.4 years, RFS (HR 0.96, 95%CI 0.58-1.56) and OS (HR 0.69, 95%CI 0.46-1.05) were comparable between RARC and ORC. There was no difference in the narcotic usage between patients in the RARC and ORC groups during the last 24 h of hospitalization (median OMEQ: 0 vs 0, p = 0.33) and upon discharge (median OMEQ: 178 vs 210, p = 0.36). Predictors of higher OMEQ discharge prescriptions included younger age [(- )3.46, 95%CI (-)5.5-(-)0.34], no epidural during hospitalization [- 95.85, 95%CI (- )144.95-(- )107.36], and early time-period of surgery [(- )151.04, 95%CI (- )194.72-(- )107.36]. RARC has comparable 90-day complication rates and early survival outcomes to ORC and remains a viable option for bladder cancer. RARC results in comparable levels of opioid utilization for pain management as ORC.

The rising incidence of ductal adenocarcinoma and intraductal carcinoma of the prostate: Diagnostic accuracy of biopsy, MRI-visibility, and outcomes.

INTRODUCTION: Ductal adenocarcinoma (DA) and intraductal carcinoma (IDC) of the prostate are associated with higher stage disease at radical prostatectomy (RP). We evaluated diagnostic accuracy of biopsy, MRI-visibility, and outcomes for patients undergoing RP with DA/IDC histology compared to pure acinar adenocarcinoma (AA) of the prostate. MATERIALS AND METHODS: A retrospective cohort study of men receiving RP between 2014 and 2021 revealing AA, DA, or IDC on final pathology was conducted. Multivariable logistic regression and Cox proportional hazards regression models were employed. RESULTS: A total of 609 patients were included with 103 found to have DA/IDC. Patients with DA/IDC were older and had higher PSA, biopsy grade group (GG), RP GG, and other pathologic findings (extraprostatic extension, lymphovascular invasion, perineural invasion, pN stage) compared to AA patients (all P < 0.05). On multivariable analysis, higher age, RP GG, and pT3a were associated with DA/IDC on RP (all P < 0.05). Sensitivity and specificity of biopsy compared to RP for diagnosis of DA/IDC was 29.1% (16.7% DA, 27.8% IDC) and 96.6% (99.3% DA, 96.6% IDC), respectively. In a subset of 281 men receiving MRI, PI-RADS distribution was similar for patients with DA/IDC vs. AA (90.7% vs. 80.7% with PI-RADS 4-5 lesions, P = 0.23) with slightly higher biopsy sensitivity (41.9%). DA/IDC was associated with worse BCR (HR = 1.77, P = 0.02) but not biopsy DA/IDC (P = 0.90). CONCLUSIONS: Sensitivity of prostate biopsy was low for detection of DA/IDC histology at RP. Patients with DA/IDC histology had unfavorable pathologic features at RP and worse BCR. Of patients with DA/IDC at RP, 90.7% were categorized as PI-RADS 4 to 5 on preoperative MRI.

MRI vs Transrectal Ultrasound to Estimate Prostate Volume and PSAD: Impact on Prostate Cancer Detection.

OBJECTIVES: To compare multiparametric magnetic resonance imaging (mpMRI) and transrectal ultrasound (TRUS) to estimate prostate volume and prostate specific antigen density (PSAD) as well as subsequent impact on prostate cancer (PCa) detection. METHODS: Patients referred for mpMRI prior to mpMRI-TRUS fusion-guided prostate biopsy between 2015 and 2020 were identified. Volume and calculated PSAD by mpMRI and TRUS were compared. Associations with presence of any PCa and clinically significant PCa (csPCa; Gleason ≥3 + 4) were evaluated using linear regression (interaction by volume quartile), logistic regression, and receiver operating characteristics. RESULTS: Among 640 men, TRUS underestimated prostate volume relative to mpMRI (median 49.2cc vs. 54.1cc) with 8% lower volume per cc up to 77.5cc (First-third quartile) and 39% lower volume per additional cc above 77.5cc (fourth quartile). For men undergoing radical prostatectomy, mpMRI had a higher correlation coefficient relative to TRUS (0.913 vs 0.878) when compared to surgical pathology. mpMRI PSAD had slightly higher odds vs TRUS PSAD for detecting any PCa (OR 2.94 and OR 2.78, both P <.001) or csPCa (OR 4.20 and OR 4.02, both P <.001). AUC improvements were of borderline significance for mpMRI vs. TRUS PSAD for any PCa (0.689 vs 0.675, P = .05) and not significant for csPCa (0.732 vs 0.722, P = .20). PSAD was not associated with PCa detection for prostates ≥77.5cc. CONCLUSION: TRUS underestimates prostate volume relative to mpMRI. PSAD based on mpMRI may be better associated with detection of PCa compared to TRUS, but utility of PSAD may be limited for larger prostates.

MRI versus non-MRI diagnostic pathways before radical prostatectomy: Impact on nerve-sparing, positive surgical margins, and biochemical recurrence.

PURPOSE: Magnetic resonance imaging (MRI) prior to biopsy has improved detection of clinically significant prostate cancer (CaP), but its impact on surgical outcomes is less well established. We compared MRI vs. non-MRI diagnostic pathways among patients receiving radical prostatectomy (RP) for impact on surgical outcomes. MATERIALS AND METHODS: Men diagnosed with CaP and receiving RP at Loyola University Medical Center (2014-2021) were categorized into MRI or non-MRI diagnostic pathways based on receipt of MRI before prostate biopsy. Primary outcomes of interest included positive surgical margin (PSM) rates, the performance of bilateral nerve-sparing, and biochemical recurrence (BCR). Multivariable logistic regression models, Kaplan-Meier curves, and Cox proportional hazards regression were employed. RESULTS: Of 609 patients, 281 (46.1%) were in the MRI and 328 (53.9%) in the non-MRI groups. MRI patients had similar PSA, biopsy grade group (GG) distribution, RP GG, pT stage, and RP CaP volume compared to non-MRI patients. PSM rates were not statistically different for the MRI vs. non-MRI groups (22.8% vs. 26.8%, P = 0.25). Bilateral nerve-sparing rates were higher for the MRI vs. non-MRI groups (OR 1.95 (95%CI 1.32-2.88), P = 0.001). The MRI group demonstrated improved BCR (HR 0.64 (95%CI 0.41-0.99), P = 0.04) after adjustment for age, PSA, RP GG, pT, pN, and PSM status. On meta-analysis, a 5.2% PSM reduction was observed but high heterogeneity for use of nerve-sparing. CONCLUSIONS: An MRI-based diagnostic approach selected patients for RP with a small reduction in PSM rates, greater utilization of bilateral nerve-sparing, and improved cancer control by BCR compared to a non-MRI approach even after adjustment for known prognostic factors.

Multifocality of Prostate Cancer and Candidacy for Focal Therapy Based on Magnetic Resonance Imaging.

OBJECTIVES: To determine the prevalence of multiparametric magnetic resonance imaging (mpMRI)-detected and targeted biopsy-confirmed multifocal and unifocal prostate cancer (PCa) among patients with Prostate Imaging Reporting and Data System (PI-RADS) ≥3 lesions. Focal therapy (FT) options for PCa are tied to accurate spatial identification on mpMRI. METHODS: Men without prior diagnosis of PCa receiving mpMRI, targeted and systematic prostate biopsy in the Prospective Loyola Urology mpMRI (PLUM) Prostate Biopsy Cohort from 2015-2021 were included. Patients with PI-RADS ≥3 lesions were classified by mpMRI lesion location, targeted biopsy, and systematic biopsy. Patients with single biopsy-confirmed grade group (GG) 2 lesions and concordant systematic biopsy were defined as FT candidates. Multivariable logistic regression evaluated predictors of mpMRI-undetected contralateral PCa. RESULTS: Of 897 patients, 450 (50.2%) had a single, 141 (15.7%) had multiple unilateral, and 306 (34.1%) had bilateral mpMRI lesions. 28.7% had a single targeted biopsy-confirmed lesion while 10.4% were multifocal. Among single targeted biopsy-confirmed patients, 92/257 (35.8%) had contralateral PCa missed by mpMRI with DRE, PSA, and biopsy history identified as independent predictors. Systematic biopsy findings dropped the rate of single confirmed lesions from 28.7% to 18.4% and multifocal PCa increased from 10.4% to 20.6%. After GG restrictions, 61/897 (6.8%) remained potential FT candidates. CONCLUSIONS: Among men with clinical suspicion of prostate cancer receiving mpMRI, 28.7% had a single targeted biopsy-confirmed lesion and 10.4% had multifocality on mpMRI, but many mpMRI-undetected contralateral PCa were identified. Only 6.0% of biopsy-naïve men remained with a single GG2 mpMRI lesion potentially amenable to FT.

A noncanonical inhibitory circuit dampens behavioral sensitivity to light.

Retinal ganglion cells (RGCs) drive diverse, light-evoked behaviors that range from conscious visual perception to subconscious, non-image-forming behaviors. It is thought that RGCs primarily drive these functions through the release of the excitatory neurotransmitter glutamate. We identified a subset of melanopsin-expressing intrinsically photosensitive RGCs (ipRGCs) in mice that release the inhibitory neurotransmitter γ-aminobutyric acid (GABA) at non-image-forming brain targets. GABA release from ipRGCs dampened the sensitivity of both the pupillary light reflex and circadian photoentrainment, thereby shifting the dynamic range of these behaviors to higher light levels. Our results identify an inhibitory RGC population in the retina and provide a circuit-level mechanism that contributes to the relative insensitivity of non-image-forming behaviors at low light levels.

Overlapping morphological and functional properties between M4 and M5 intrinsically photosensitive retinal ganglion cells.

Multiple retinal ganglion cell (RGC) types in the mouse retina mediate pattern vision by responding to specific features of the visual scene. The M4 and M5 melanopsin-expressing, intrinsically photosensitive retinal ganglion cell (ipRGC) subtypes are two RGC types that are thought to play major roles in pattern vision. The M4 ipRGCs overlap in population with ON-alpha RGCs, while M5 ipRGCs were recently reported to exhibit opponent responses to different wavelengths of light (color opponency). Despite their seemingly distinct roles in visual processing, previous reports have suggested that these two populations may exhibit overlap in their morphological and functional properties, which calls into question whether these are in fact distinct RGC types. Here, we show that M4 and M5 ipRGCs are distinct morphological classes of ipRGCs, but they cannot be exclusively differentiated based on color opponency and dendritic morphology as previously reported. Instead, we find that M4 and M5 ipRGCs can only be distinguished based on soma size and the number of dendritic branch points in combination with SMI-32 immunoreactivity. These results have important implications for clearly defining RGC types and their roles in visual behavior.