Avoiding Prostate Biopsies in Patients at Low Risk for Prostate Cancer: A Prospective Evaluation of a PSA-Density-Based Safety Net.

INTRODUCTION AND OBJECTIVES: Decision-making to perform prostate biopsy should include individual risk assessment. Patients classified as low risk by the Rotterdam Prostate Cancer Risk Calculator are advised to forego biopsy (PBx). There is concern about missing clinically significant prostate cancer (csPCa). A clear pathway for follow-up is needed. MATERIAL AND METHODS: Data for 111 consecutive patients were collected. Patients were encouraged to adhere to a PSA-density-based safety net after PBx was omitted. Cut off values indicating a re-evaluation were PSA density >0.15 ng/mL/ccm in PBx-naïve patients and >0.2 ng/mL/ccm in men with past-PBx. Primary endpoint was whether men had their PSA taken regularly. Secondary endpoint was whether a new multiparametric MRI was performed when PSA-density increased. Tertiary endpoint was whether biopsy was performed when risk stratification revealed an increased risk. RESULTS: Median follow-up was 12 months (IQR 9-15 months). The primary endpoint was reached by 97.2% (n = 106). The secondary endpoint was reached by 30% (n = 3). The tertiary endpoint was reached by 50% (n = 2). Histopathologic analyses revealed csPCa in none of these cases. Risk stratification did not change (p = 0.187) with the majority of patients (89.2%, n = 99). CONCLUSION: The concern of missing csPCa when omitting PBx in the risk-stratified pathway may be negated. Changes in risk stratification during follow-up should lead to subsequent PBx. We suggest implementing a safety net based on PSA density and digital rectal examination (DRE).

PROPOSe: A Real-life Prospective Study of Proclarix, a Novel Blood-based Test to Support Challenging Biopsy Decision-making in Prostate Cancer.

BACKGROUND: Prostate-specific antigen (PSA)-based detection of prostate cancer (PCa) often leads to negative biopsy results or detection of clinically insignificant PCa, more frequently in the PSA range of 2-10 ng/ml, in men with increased prostate volume and normal digital rectal examination (DRE). OBJECTIVE: This study evaluated the accuracy of Proclarix, a novel blood-based diagnostic test, to help in biopsy decision-making in this challenging patient population. DESIGN, SETTING, AND PARTICIPANTS: Ten clinical sites prospectively enrolled 457 men presenting for prostate biopsy with PSA between 2 and 10 ng/ml, normal DRE, and prostate volume ≥35 cm3. Transrectal ultrasound-guided and multiparametric magnetic resonance imaging (mpMRI)-guided biopsy techniques were allowed. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Serum samples were tested blindly at the end of the study. Diagnostic performance of Proclarix risk score was established in correlation to systematic biopsy outcome and its performance compared with %free PSA (%fPSA) and the European Randomised Study of Screening for Prostate Cancer (ERSPC) risk calculator (RC) as well as Proclarix density compared with PSA density in men undergoing mpMRI. RESULTS AND LIMITATIONS: The sensitivity of Proclarix risk score for clinically significant PCa (csPCa) defined as grade group (GG) ≥2 was 91% (n = 362), with higher specificity than both %fPSA (22% vs 14%; difference = 8% [95% confidence interval {CI}, 2.6-14%], p = 0.005) and RC (22% vs 15%; difference = 7% [95% CI, 0.7-12%], p = 0.028). In the subset of men undergoing mpMRI-fusion biopsy (n = 121), the specificity of Proclarix risk score was significantly higher than PSA density (26% vs 8%; difference = 18% [95% CI, 7-28%], p < 0.001), and at equal sensitivity of 97%, Proclarix density had an even higher specificity of 33% [95% CI, 23-43%]. CONCLUSIONS: In a routine use setting, Proclarix accurately discriminated csPCa from no or insignificant PCa in the most challenging patients. Proclarix represents a valuable rule-out test in the diagnostic algorithm for PCa, alone or in combination with mpMRI. PATIENT SUMMARY: Proclarix is a novel blood-based test with the potential to accurately rule out clinically significant prostate cancer, and therefore to reduce the number of unneeded biopsies.

Psychosocial Distress in the Early Recovery Period after Radical Prostatectomy.

PURPOSE: This study aimed to evaluate psychosocial distress in the context of continence and oncological outcome during the early recovery period after radical prostatectomy (RP) for prostate cancer. PATIENTS AND METHODS: Retrospectively collected data from 587 patients who underwent inpatient rehabilitation after RP in 2016 and 2017 were analyzed. Psychosocial distress (measured by using a Questionnaire on Stress in Cancer Patients [QSC-R10]) and continence status (urine loss on a 24-h pad test and urine volume on uroflowmetry) were evaluated at the beginning (T1) and end (T2) of a 3-week inpatient rehabilitation. Multivariate logistic regression was performed to identify predictors for high distress (QSC-R10 score ≥15). RESULTS: The median patient age was 65 years. At the start of rehabilitation, 204 patients (34.8%) demonstrated high distress. Psychosocial distress decreased significantly (p < 0.001) from a median of 11.0 at T1 (median 16 days after surgery) to a median of 6.0 at T2 (median 37 days after surgery). Complete continence increased significantly (p < 0.001) from 39.0% at T1 to 58.9% at T2. The median urine volume increased significantly (p < 0.001) from 161 mL at T1 to 230 mL at T2. Often, distress is higher in younger patients, whereas incontinence is higher in older patients. Multivariate logistic regression analysis identified age ≤69 years (p = 0.001) and tumor stage ≥pT3 (p = 0.006) as independent predictors of high distress. CONCLUSIONS: Distress and incontinence decreased significantly during the 3 weeks of inpatient rehabilitation after RP. Patient age ≤69 years and tumor stage ≥pT3 are independent predictors of high psychosocial distress.

Comparison of prostate cancer detection rates in patients undergoing MRI/TRUS fusion prostate biopsy with two different software-based systems.

BACKGROUND: Magnetic resonance imaging (MRI)-targeted prostate biopsy is a routinely used diagnostic tool for prostate cancer (PCa) detection. However, a clear superiority of the optimal approach for software-based MRI processing during biopsy procedures is still unanswered. To investigate the impact of robotic approach and software-based image processing (rigid vs. elastic) during MRI/transrectal ultrasound (TRUS) fusion prostate biopsy (FBx) on overall and clinically significant (cs) PCa detection. METHODS: The study relied on the instructional retrospective biopsy data collected data between September 2013 and August 2017. Overall, 241 men with at least one suspicious lesion (PI-RADS ≥ 3) on multiparametric MRI underwent FBx. The study protocol contains a systematic 12-core sextant biopsy plus 2 cores per targeted lesion. One experienced urologist performed 1048 targeted biopsy cores; 467 (45%) cores were obtained using rigid processing, while the remaining 581 (55%) cores relied on elastic image processing. CsPCa was defined as International Society of Urological Pathology (ISUP) grade ≥ 2. The effect of rigid versus elastic FBx on overall and csPCa detection rates was determined. Propensity score weighting and multivariable regression models were used to account for potential biases inherent to the retrospective study design. RESULTS: In multivariable regression analyses, age, prostate-specific antigen (PSA), and PIRADS ≥ 3 lesion were related to higher odds of finding csPCa. Elastic software-based image processing was independently associated with a higher overall PCa (odds ratio [OR] = 3.6 [2.2-6.1], p < 0.001) and csPCa (OR = 4.8 [2.6-8.8], p < 0.001) detection, respectively. CONCLUSIONS: Contrary to existing literature, our results suggest that the robotic-driven software registration with elastic fusion might have a substantial effect on PCa detection.

How Many Cores Should Be Sampled during Systematic Prostate Biopsy in Case of Negative Multiparametric Magnetic Resonance Imaging? Analysis of 274 Men with Clinical Suspicion of Prostate Cancer.

INTRODUCTION: This study aimed to investigate the number of cores needed in a systematic biopsy (SB) in men with clinical suspicion of prostate cancer (PCa) but negative prebiopsy multiparametric magnetic resonance imaging and to test prostate-specific antigen (PSA) density as an indicator for reduced SB. METHODS: Two hundred and seventy-four patients were analyzed, extracted from an institutional database. Detection rates of any PCa and clinically significant (CS) PCa for different reduced biopsy protocols were compared by using Fisher's exact test. RESULTS: In total, 12-core SB revealed PCa in 103 (37.6%) men. Detection rates of reduced biopsy protocols were 74 (27%, 6-core) and 82 (29.9%, 8-core). Regarding CSPCa, 12-core SB revealed a detection rate of 26 (9.5%). Reduced biopsy protocols detected less CSPCa: 15 (5.5%) and 18 (6.6%), respectively. All differences were statistically significant, p < 0.05. PSA density ≥0.15 did not help to filter out men in whom a reduced biopsy may be sufficient. CONCLUSIONS: Twelve-core SB still has the highest detection rate of any PCa and CSPCa compared to reduced biopsy protocols. If the investigator and patient agree - based on individual risk calculation - to perform a biopsy, this SB should contain at least 12 cores regardless of PSA density.

Identification of patients at risk for biochemical recurrence after radical prostatectomy with intra-operative frozen section.

OBJECTIVE: To identify patients at risk for biochemical recurrence (BCR) of prostate cancer (PCa) after radical prostatectomy (RP) with intra-operative whole-mount frozen section (FS) of the prostate. MATERIAL AND METHODS: We examined differences in BCR between patients with initial negative surgical margins at FS, patients with final negative surgical margins with initial positive margins at FS without residual PCa after secondary tumour resection, and patients with final negative surgical margins with initially positive margins at FS with residual PCa in the secondary tumour resection specimen. Institutional data of 883 consecutive patients undergoing RP were collected. Intra-operative whole-mount FS was routinely used to check for margin status and, if necessary, to resect more periprostatic tissue in order to achieve negative margins. Patients with lymph node-positive disease or final positive surgical margins were excluded from the analysis. Kaplan-Meier curves and multivariable Cox proportional hazards regression analyses adjusting for clinical covariates were employed to examine differences in biochemical recurrence-free survival (BRFS) according to the resection status mentioned above. RESULTS: The median follow-up was 22.4 months. The 1- and 2-year BRFS rates in patients with (81.0% and 72.9%, respectively; P = 0.001) and without residual PCa (90.3% and 82.3%, respectively; P = 0.033) after secondary tumour resection were significantly lower compared to patients with initial R0 status (93.4% and 90.9%, respectively). On multivariable Cox regression only residual PCa in the secondary tumour resection was associated with a higher risk of BCR compared to initial R0 status (hazard ratio 1.99, 95% confidence interval 1.01-3.92; P = 0.046). CONCLUSION: Despite being classified as having a negative surgical margin, patients with residual PCa in the secondary tumour resection specimen face a high risk of BCR. These findings warrant closer post-RP surveillance of this particular subgroup. Further research of this high-risk subset of patients should focus on examining whether these patients benefit from early salvage therapy and how resection status impacts oncological outcomes in the changing landscape of PCa treatment.

Probability of Prostate Cancer Diagnosis following Negative Systematic and Targeted MRI: Transrectal Ultrasound Fusion Biopsy: A Real-Life Observational Study.

INTRODUCTION: The risk of occult prostate carcinoma (PCa) after negative multiparametric MRI (mpMRI)-transrectal fusion biopsy (F-Bx) is unknown. To determine the false-negative predictive value, we examined PCa detection after prior negative F-Bx. METHODS: Between December 2012 and November 2016, 491 patients with suspected PCa and suspicious mpMRI findings underwent transrectal F-Bx. Patients with benign pathology (n = 191) were eligible for our follow-up (FU) survey. Patient characteristics and clinical parameters were correlated to subsequent findings of newly detected PCa. RESULTS: Complete FU with a median of 31 (interquartile range: 17-39) months was available for 176/191 (92.2%) patients. Of those, 54 men had either surgical interventions on the prostate or re-Bxs. Newly detected PCa was evident in 14/176 (7.95%) patients stratified to ISUP ≤2 in 10 and ≥3 in 4 cases. The comparison of patients with newly detected PCa to those without cancerous findings in FU showed significant differences in prostate-specific antigen (PSA) density (0.16 vs. 0.13 ng/mL2) and prostate volume (45 vs. 67 mL, both p < 0.05). Both factors are significant predictors for newly detected cancer after initial negative F-Bx. CONCLUSION: Only PSA density (>0.13 ng/mL2) and small prostate volume are significant predictors for newly detected PCa after initial negative F-Bx. Despite negative mpMRI/TRUS F-Bx results, patients should be further monitored due to a risk of developing PCa over time. Notwithstanding the limitation of our study that not all patients underwent another Bx, we assume that the false-negative rate is low but existing. Our data represent a real-world scenario.

Changing the Prostate Cancer Detection Paradigm: Clinical Application of European Association of Urology Guideline-recommended Magnetic Resonance Imaging-based Risk Stratification in Men with Suspected Prostate Cancer.

BACKGROUND: Multiparametric magnetic resonance imaging using the Prostate Imaging Reporting and Data System version 2.1 allows for a personalized, risk-stratified approach to indicating prostate biopsies (PBx) in order to reduce PBx and concomitant complications in men with suspected prostate cancer (PCa). One way to achieve this goal is to implement the risk-stratified pathway (RSP) using the Rotterdam Prostate Cancer Risk Calculator. OBJECTIVE: To describe the clinical implementation of the RSP and to examine its impact on the number of PBx and the resulting changes in the PCa detection pattern compared with men undergoing PBx in a detection-focused pathway (DFP) without prior risk assessment. DESIGN, SETTING, AND PARTICIPANTS: An institutional dataset of 505 consecutive patients with suspected PCa between July 2019 and February 2020 was used. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Chi-square test and Mann-Whitney U test were employed to examine differences in the number of PBx and the PCa detection pattern between the DFP (n = 195, 38.6%) and the RSP (n = 310, 61.4%). To minimize differences in risk stratification, inverse probability of treatment weighting was used. RESULTS AND LIMITATIONS: After implementing the RSP, the overall biopsy rate could be reduced by 11.2% (100% vs 88.8%, p < 0.001. Additionally, compared with the DFP, the number of biopsy cores per patient was reduced in the RSP (14 [interquartile range {IQR} 14-15] vs 14 [IQR 6-14], p < 0.001) and the detection of clinically significant PCa was increased (44.3% vs 57.7%, p = 0.038). Overdiagnosis of clinically insignificant disease was decreased in the RSP (22.8% vs 12.6%, p = 0.039). CONCLUSIONS: Implementation of the RSP in clinical practice reduced the number of PBx and brought forth a shift in the PCa detection pattern toward clinically significant disease, while reducing overdiagnosis of clinically insignificant disease. PATIENT SUMMARY: In this study, we examined the impact of risk stratification on the number of prostate biopsies (PBx) and the consecutive detection pattern in men with suspected prostate cancer (PCa). We found that the risk-stratified pathway reduced the number of PBx while simultaneously shifting the PCa detection pattern toward clinically significant PCa.

Institutional Adoption and Apprenticeship of Fusion Targeted Prostate Biopsy: Does Experience Affect the Cancer Detection Rate?

INTRODUCTION: There are limited data on the learning curve of magnetic resonance imaging/transrectal ultrasound (MRI/TRUS)-fusion targeted prostate biopsies (tBx). OBJECTIVE: The aim of this study was to investigate the difference in prostate cancer (PCa) detection rate between an experienced urologist and novice resident performing tBx. METHODS: A total of 183 patients underwent tBx from 2012 to 2016 for a total of 518 tBx cores. Biopsies in this study were performed by an experienced urologist (investigator A) or a novice resident (investigator B). The outcome was the detection of PCa on tBx. Using a multivariable logistic regression model, we estimated odds ratios for the detection of PCa. Inverse probability treatment weighting (IPTW) was used to balance patients' baseline characteristics and compare detection rates of PCa. Before performance of tBx, all patients underwent MRI. RESULTS: On multivariable logistic regression analysis, investigator experience was associated with a higher odds of detection of PCa (OR = 1.003; 95% confidence interval 1.002-1.006, p = 0.037). After IPTW adjustment, there was no significant difference between the detection rate of investigator A (23%) and investigator B (32%; p = 0.457). CONCLUSIONS: Data revealed a positive association between investigator experience and the odds of PCa detection, although there was no difference in the detection rates of the investigators.

Association between Development of Metabolic Acidosis and Improvement of Urinary Continence after Ileal Neobladder Creation.

PURPOSE: Ileal neobladder construction is a common choice for orthotopic urinary diversion following radical cystectomy. We investigated risk factors for metabolic acidosis during the early recovery period. MATERIALS AND METHODS: This study relied on retrospectively collected data on 345 patients who underwent inpatient rehabilitation after radical cystectomy and ileal neobladder construction for bladder cancer between January 2014 and March 2017. Acid-base status, use of sodium bicarbonate to correct metabolic acidosis and continence status were evaluated at the beginning and end of 3 weeks of inpatient rehabilitation. Multivariate logistic regression analysis was performed to identify risk factors associated with the development of metabolic acidosis. RESULTS: At the start of rehabilitation a median of 29 days after surgery (IQR 23-37) 200 patients (58.0%) had metabolic acidosis. During the inpatient rehabilitation period the need for oral sodium bicarbonate replacement due to acidosis increased significantly from 45.2% to 86.7% of patients (p <0.001) while urine loss measured by a 24-hour pad test decreased significantly from a median of 387 (IQR 98-918) to 88 gm (IQR 5-388, p <0.001). The median base excess was within the normal range (-1.2 mmol/l, IQR -2.4 - 0.0) at the end of inpatient rehabilitation. Decreased urinary leakage was identified as an independent risk factor for metabolic acidosis.Conclusions:The risk of metabolic acidosis after neobladder construction correlated with continuously improved continence in the early recovery period. Therefore, during this period the acid-base status should be assessed more frequently to identify metabolic acidosis.

Salvage lymph node dissection in hormone-naïve men: How effective is surgery?

OBJECTIVE: Salvage lymph node dissection (SLND) is still a questionable treatment approach for patients with nodal recurrence of prostate cancer after radical prostatectomy. We assessed the oncological benefit after SLND in hormone-naïve patients as well as the diagnostic accuracy of preoperative prostate-specific membrane antigen (PSMA) positron emission tomography-computed tomography (PET/CT) scanning. MATERIAL AND METHODS: The study relied on retrospective collected data of 43 hormone-naïve men who received transperitoneal SLND between February 2011 and March 2017 at our institution. The oncological outcome for each patient was observed by serum prostate-specific antigen testing. Postoperative complications within 30 and 90 days were assessed according to the Clavien-Dindo classification. The accuracy of PSMA PET/CT was characterized by calculated sensitivity, specificity, positive, and negative predictive values. RESULTS: Overall 8 patients (18.6%) had a complete biochemical response 40 days after SLND. The median time from SLND to biochemical recurrence was 2 months. Adjuvant treatment encompassing radiotherapy, androgen deprivation therapy, or a combination of both, was administrated in 62.8%. According to the Clavien-Dindo classification, no high-grade complications were observed. Sensitivity and specificity for PSMA PET/CT were respectively 32% (95% confidence interval [CI]: 17.21-51.59) and 91.74% (95% CI: 85.45-95.45). Calculated positive predictive values (PPV) and negative predictive values (NPV) of PSMA PET/CT were 44.44% (95% CI: 25.98-64.58) and 86.72% (95% CI: 83.23-89.57). CONCLUSIONS: For most hormone-naïve men with a nodal recurrence of prostate cancer transperitoneal SLND is neither an appropriate treatment to cure nor an option to delay the need for salvage hormone manipulation. PSMA PET/CT scans in hormone-naïve patients are currently too imprecise to diagnose metastatic sites.

Contemporary perceptions of human papillomavirus and penile cancer: Perspectives from a national survey.

INTRODUCTION: We aimed to assess the contemporary knowledge of human papillomavirus (HPV) and its association with penile cancer in a nationwide cohort from the U.S. METHODS: We used the Health Information National Trends Survey (HINTS), a cross-sectional telephone survey performed in the U.S. initiated by the National Cancer Institute. The most recent iteration, HINTS 4 Cycle 4, was conducted in mail format between August 19 and November 17, 2014. Primary endpoints included knowledge of HPV and its causal relationship to penile cancer. Baseline characteristics included sex, age, education, race and ethnicity, income, residency, personal or family history of cancer, health insurance status, and internet use. Multivariable logistic regression assessed predictors of HPV and penile cancer knowledge. RESULTS: An unweighted sample of 3376 respondents was extracted from the HINTS 4, Cycle 4. Whereas 64.4% of respondents had heard of HPV, only 29.5% of these were aware that it could cause penile cancer. Men were significantly less likely to have heard of HPV than women (odds ratio [OR] 0.32; 95% confidence interval [CI] 0.24-0.43). Older age; African-American, Asian, and "other race"; being married; from a lower education bracket; having a personal cancer history; and those without internet access were significantly less likely to have heard of HPV. None of our examined variables were independent predictors for the knowledge of the association of penile cancer and HPV. CONCLUSIONS: Our analysis of a large, nationally representative survey demonstrates that the majority of the American public is familiar with HPV, but lack a meaningful understanding between this virus and penile cancer. Primary care providers and specialists should be encouraged to intensify counselling about this significant association as a primary preventive measure of this potentially fatal disease.

De novo neurogenic bladder dysfunction after salvage lymph node dissection in patients with nodal recurrence of prostate cancer.

AIMS: To examine the impact of Salvage lymph node dissection (SLND) on bladder function and oncological outcome in hormone naïve patients with nodal recurrence of prostate cancer (PCa) after radical prostatectomy (RP). METHODS: In a prospective study between October 2015 and November 2016, 20 patients underwent transperitoneal SLND for nodal recurrence of PCa after RP at our institution. Standardized urodynamics were performed pre- and postoperatively after 6 weeks, 3, and 6 to 12 months. Prostate-specific antigen (PSA) levels were used to monitor the oncological outcome. Perioperative outcomes encompassed, among others, type of complications after surgery classified to Clavien-Dindo. RESULTS: The proportion of patients with neurogenic bladder dysfunction was postoperative at 6 weeks, 3, and 6 to 12 months 78.5%, 70%, and 45.5%, respectively. Compared to preoperative urodynamics, follow-ups revealed a statistical significant cleavage of bladder wall compliance until six to twelve months after SLND (34.5 vs 22 mL/cmH2 O, P = 0.044). Referring to the oncological outcome all patients experienced a PSA progression, 10 patients (50%) within 11 weeks after surgery. Overall, four patients (20%) suffered from a postoperative complication after SLND, which comprises Clavien grade I-IIIa. CONCLUSIONS: Transperitoneal SLND, as a treatment option for patients with nodal recurrence of PCa after RP reveals additional potential pitfalls than previously reported. Urodynamics reveal a significant impact of SLND on postoperative functional bladder dysfunctions. Therefore, informed consent prior to SLND should include the risk of persistent low compliance bladder.

Impact of testosterone replacement therapy on thromboembolism, heart disease and obstructive sleep apnoea in men.

OBJECTIVES: To assess the association of testosterone replacement therapy (TRT) with thromboembolism, cardiovascular disease (stroke, coronary artery disease and heart failure) and obstructive sleep apnoea (OSA). METHODS: A cohort of 3 422 male US military service members, retirees and their dependents, aged 40-64 years, was identified, who were prescribed TRT between 2006 and 2010 for low testosterone levels. The men in this cohort were matched on a 1:1 basis for age and comorbidities to men without a prescription for TRT. Event-free survival and rates of thromboembolism, cardiovascular events and OSA were compared between men using TRT and the control group, with a median follow-up of 17 months. RESULTS: There was no difference in event-free survival with regard to thromboembolism (P = 0.239). Relative to controls, men using TRT had improved cardiovascular event-free survival (P = 0.004), mainly as a result of lower incidence of coronary artery disease (P = 0.008). The risk of OSA was higher in TRT users (2-year risk 16.5% [95% confidence interval 15.1-18.1] in the TRT group vs 12.7% [11.4-14.1] in the control group. CONCLUSIONS: This study adds to growing evidence that the cardiovascular risk associated with TRT may be lower than once feared. The elevated risk of OSA in men using TRT is noteworthy.

The association of hypoalbuminemia with early perioperative outcomes - A comprehensive assessment across 16 major procedures.

BACKGROUND: Poor nutritional status is thought to influence peri- and postoperative outcomes. We assessed the association of hypoalbuminemia, a surrogate for poor nutritional status, with perioperative outcomes in patients undergoing one of 16 major surgical procedures. METHODS: Patients undergoing one of 16 major surgeries were identified using the ACS-NSQIP (2005-2011). Risk-adjusted logistic regression models examined the association of hypoalbuminemia on perioperative outcomes. RESULTS: Overall, 204,819 complete cases were identified, of whom 25.4% underwent major cardiovascular, 19.0% orthopedic and 55.6% oncologic surgery. Patients with hypoalbuminemia had significantly higher rates of complications, reoperations, readmissions, prolonged length-of-stay and mortality (all p < 0.001). After adjustment, hypoalbuminemia was an independent predictor of overall complications in 12 of the procedures examined and 30-day mortality in 11 of the procedures. Individual perioperative complication profile varied widely among procedures. CONCLUSIONS: Hypoalbuminemia exerts significant impact on perioperative outcomes. Its effect is procedure-specific and thus warrants targeted management strategies to improve surgical outcomes. In the absence of clear recommendations, our findings invite surgeons to assess preoperative albumin levels and to manage nutritional status accordingly.

Effect of Hospital and Surgeon Case Volume on Perioperative Quality of Care and Short-term Outcomes After Radical Cystectomy for Muscle-invasive Bladder Cancer: Results From a European Tertiary Care Center Cohort.

BACKGROUND: Case volume has been suggested to affect surgical outcomes in different arrays of procedures. We aimed to delineate the relationship between case volume and surgical outcomes and quality of care criteria of radical cystectomy (RC) in a prospectively collected multicenter cohort. PATIENTS AND METHODS: This was a retrospective analysis of a prospectively collected European cohort of patients with bladder cancer treated with RC in 2011. We relied on 479 and 459 eligible patients with available information on hospital case volume and surgeon case volume, respectively. Hospital case volume was divided into tertiles, and surgeon volume was dichotomized according to the median annual number of surgeries performed. Binomial generalized estimating equations controlling for potential known confounders and inter-hospital clustering assessed the independent association of case volume with short-term complications and mortality, as well as the fulfillment of quality of care criteria. RESULTS: The high-volume threshold for hospitals was 45 RCs and, for high-volume surgeons, was > 15 cases annually. In adjusted analyses, high hospital volume remained an independent predictor of fewer 30-day (odds ratio, 0.34; P = .002) and 60- to 90-day (odds ratio, 0.41; P = .03) major complications but not of fulfilling quality of care criteria or mortality. No difference between surgeon volume groups was noted for complications, quality of care criteria, or mortality after adjustments. CONCLUSION: The coordination of care at high-volume hospitals might confer a similar important factor in postoperative outcomes as surgeon case volume in RC. This points to organizational elements in high-volume hospitals that enable them to react more appropriately to adverse events after surgery.

A Nationwide Survey of Prostate Specific Antigen Based Screening and Counseling for Prostate Cancer.

INTRODUCTION: Controversy surrounds prostate specific antigen screening following the 2012 U.S. Preventive Services Task Force grade D recommendation. There is limited evidence evaluating patterns of prostate specific antigen counseling and patient perceptions of the prostate specific antigen test since 2012. We evaluated the association between prostate cancer screening counseling and patient sociodemographic factors in a nationally representative sample. METHODS: Using data from the 2013 Health Information National Trends Survey we identified 768 male respondents age 40 to 75 years without a prior prostate cancer diagnosis. Using logistical regression we assessed trends in prostate cancer screening, counseling and prostate specific antigen use. RESULTS: Overall 54.1% of respondents reported ever having a prostate specific antigen test. Men undergoing prostate specific antigen testing were more likely to have had a prior cancer diagnosis other than prostate cancer (OR 3.93, 95% CI 1.19-12.94) and to have had at least some college education (OR 11.35, 95% CI 3.29-39.04). Men 40 to 49 years old had decreased odds of undergoing prostate specific antigen testing compared to men 50 to 69 years old (OR 0.20, 95% CI 0.10-0.39). History of cancer (OR 2.50, 95% CI 1.19-5.26) was associated with greater odds of being counseled on the potential adverse effects of prostate cancer treatment. Younger men (age 40 to 49 years) had decreased odds of discussing the prostate specific antigen test with a health care professional (OR 0.32, 95% CI 0.16-0.62) and being informed of the controversy surrounding prostate specific antigen screening (OR 0.35, 95% CI 0.13-0.95). CONCLUSIONS: We show that certain men receive substantially different prostate specific antigen screening counseling, which may impact shared patient-provider decision making before prostate specific antigen counseling.

Widespread use of internet, applications, and social media in the professional life of urology residents.

INTRODUCTION: Digital media have revolutionized communication and information dissemination in healthcare. We aimed to quantify and evaluate professional digital media use among urology residents. METHODS: We designed a 17-item survey to assess usage and perceived usefulness of digital media, as well as communication type and device type and distributed it via email to 143 Canadian and 721 German urology residents. RESULTS: In total, 58 (41% response rate) residents from Canada and 170 (24% response rate) from Germany reported professional usage rates of 100% on the internet, 89% on apps, and 46% on social media (SoMe). For professional use, residents spent a median of 30 minutes per day on the internet, 10 minutes on apps, and 15 minutes on SoMe. 100% rated the internet, 89% apps, and 31% SoMe as useful for clinical practice. Most (94%) used digital media for communication with colleagues and 23% for communication with patients. Digital media use was allocated to desktop computers (55%) and mobile devices (45%). Canadian residents had higher usage rates of apps (96% vs. 86%; p=0.042) and SoMe (65% vs. 39%; p=0.002) and longer daily usage times for the internet, apps, and SoMe than German residents (p<0.001 each). CONCLUSIONS: Digital media are an integral part of the daily professional practice of urology residents, reflected by high usage rates and perceived usefulness of the internet and apps, and the growing importance of SoMe. Urologists should strive to progressively exhaust the vast potential of digital media for academic and clinical practice.

Pneumonia after Major Cancer Surgery: Temporal Trends and Patterns of Care.

Rationale. Pneumonia is a leading cause of postoperative complication. Objective. To examine trends, factors, and mortality of postoperative pneumonia following major cancer surgery (MCS). Methods. From 1999 to 2009, patients undergoing major forms of MCS were identified using the Nationwide Inpatient Sample (NIS), a Healthcare Cost and Utilization Project (HCUP) subset, resulting in weighted 2,508,916 patients. Measurements. Determinants were examined using logistic regression analysis adjusted for clustering using generalized estimating equations. Results. From 1999 to 2009, 87,867 patients experienced pneumonia following MCS and prevalence increased by 29.7%. The estimated annual percent change (EAPC) of mortality after MCS was -2.4% (95% CI: -2.9 to -2.0, P < 0.001); the EAPC of mortality associated with pneumonia after MCS was -2.2% (95% CI: -3.6 to 0.9, P = 0.01). Characteristics associated with higher odds of pneumonia included older age, male, comorbidities, nonprivate insurance, lower income, hospital volume, urban, Northeast region, and nonteaching status. Pneumonia conferred a 6.3-fold higher odd of mortality. Conclusions. Increasing prevalence of pneumonia after MCS, associated with stable mortality rates, may result from either increased diagnosis or more stringent coding. We identified characteristics associated with pneumonia after MCS which could help identify at-risk patients in order to reduce pneumonia after MCS, as it greatly increases the odds of mortality.