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).

Complications in the Early Recovery Period After Radical Cystectomy-Real Data From Impartial Inpatient Rehabilitation.

PURPOSE: To examine postoperative complications after radical cystectomy (RC) and creation of an ileum conduit (IC) or a neobladder (NB), and to identify preoperative risk factors in a contemporary series of bladder cancer patients. PATIENTS AND METHODS: The study relied on prospectively collected data for 842 patients, who underwent inpatient rehabilitation (IR) after RC and urinary diversion (IC n = 447, NB n = 395) between April 2018 and December 2019. Postoperative complications until the end of IR were assessed according to the Clavien-Dindo classification. Uni- and multivariate analyses were performed to identify predictors for complications. RESULTS: A total of 2689 complications occurred in 813 patients (96.6%). High-grade complications occurred more frequently before IR onset (25.5% vs. 5.7%; P < .001), whereas a higher percentage of low-grade complications occurred during IR (89.0% vs. 77.8%; P < .001). The most common complication categories were genitourinary (60.9%), infectious (54.0%) and gastrointestinal (49.2%). Rates of high-grade complications do not differ between IC and NB patients (26.8% vs. 31.6%, P = .126). Independent predictors for overall complications were NB (odds ratio [OR] 21.520; P < .001), age ≥70 years (OR 2.522; P = .027) and higher body mass index (OR 1.153, P = .008). Risk factors for high-grade complications were NB (OR 1.448; P = .039) and Charlson Comorbidity Index ≥2 (OR 1.999; P = .001). Hospital readmission rate was 9.4%. CONCLUSION: Our study revealed significantly higher overall and high-grade complication rates after RC with IC or NB creation than previously published. A high percentage of low-grade complications occur after hospital discharge. The hospital readmission rate was lower compared to historical data.

[Impact of the COVID-19 pandemic on urology residency training programs in Germany]. / Auswirkungen der COVID-19 Pandemie auf die urologische Weiterbildung in Deutschland.

BACKGROUND: Several international medical societies reported a negative impact on urology residency training programs due to the COVID-19 pandemic. OBJECTIVES: The aim of this study was to investigate the impact of the pandemic on urological residency in Germany. MATERIALS AND METHODS: From the 20th of May 2020 until the 20th of June 2020, a Germany-wide online survey on the continuing residency training was distributed via the members of the working group, social media (Facebook, Twitter, Instagram) and the German Society of Residents in Urology (GeSRU e.V.) newsletter. The survey covered 3 topics: 1) basic characteristics of the participants, 2) general and 3) subjective influence of the COVID-19 pandemic on clinics and further residency training. RESULTS: A total of 50 residents took part in the survey; 54% were women. The median age was 31 years. Most of the participants were in their 2nd (22%) and 5th (26%) year of training and worked in a university hospital (44%) or in a clinic of maximum care (30%). 38% of the respondents stated that they only served urological emergencies during the COVID-19 pandemic. For 28% this meant a very large delay (80-100%) in the specialisation, while 28% stated only a minor impact. 66% documented training impairments caused by fewer operations, low patient numbers in the outpatient department (50%), congress (50%) and workshop (44%) cancellations. 46% of residents reported direct contact with COVID-19 patients while 10% were deployed on interdisciplinary IMC units. Numerous physical distancing and hygiene measures have been implemented by the clinics. CONCLUSION: On average, around 50% of the urology residents indicated significant restrictions in training due to the COVID-19 pandemic in Germany. The delay in training cannot currently be measured in units of time, but it can be assumed that training for residents during the pandemic is likely to be of a lower quality compared to previous generations.

Different patients, different preferences: A multicenter assessment of patients' personality traits and anxiety in shared decision making.

OBJECTIVE: Patient-centered care and shared decision making (SDM) are generally recognized as the gold standard for medical consultations, especially for preference-sensitive decisions. However, little is known about psychological patient characteristics that influence patient-reported preferences. We set out to explore the role of personality and anxiety for a preference-sensitive decision in bladder cancer patients (choice of urinary diversion, UD) and to determine if anxiety predicts patients' participation preferences. METHODS: We recruited a sample of bladder cancer patients (N = 180, primarily male, retired) who awaited a medical consultation on radical cystectomy and their choice of UD. We asked patients to fill in a set of self-report questionnaires before this consultation, including measures of treatment preference, personality (BFI-10), anxiety (STAI), and participation preference (API and API-Uro), as well as sociodemographic characteristics. RESULTS: Most patients (79%) indicated a clear preference for one of the treatment options (44% continent UD, 34% incontinent UD). Patients who reported more conscientiousness were more likely to prefer more complex methods (continent UD). The majority (62%) preferred to delegate decision making to healthcare professionals. A substantial number of patients reported elevated anxiety (32%), and more anxiety was predictive of higher participation preference, specifically for uro-oncological decisions (ß = 0.207, p < 0.01). CONCLUSIONS: Our findings provide insight into the role of psychological patient characteristics for SDM. Aspects of personality such as conscientiousness influence treatment preferences. Anxiety contributes to patients' motivation to be involved in pertinent decisions. Thus, personality and negative affect should be considered to improve SDM.

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.

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.

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.

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.

Increased Severe Adverse Outcomes and Decreased Emergency Room Visits for Pyelonephritis: First Report of Collateral Damage during COVID-19 Pandemic in Urology.

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic is disrupting urology health-care worldwide. Reduced emergency room visits resulting in adverse outcomes have most recently been reported in pediatrics and cardiology. We aimed to compare patients with emergency room visits for pyelonephritis in 2019 (pre-COVID-19 era) and within the first wave of pandemic in 2020 (COVID-19 era) with regard to the number of visits and severe adverse disease outcomes. METHODS: We performed a retrospective multicentre study comparing characteristics and outcomes of patients with pyelonephritis, excluding patients with hydronephrosis due to stone disease, in 10 urology departments in Germany during a 1-month time frame in March and April in each 2019 and 2020. RESULTS: The number of emergency room visits for pyelonephritis in the COVID-19 era was lower (44 patients, 37.0%) than in the pre-COVID-19 era (76 patients, 63.0%), reduction rate: 42.1% (p = 0.003). Severe adverse disease outcome was more frequent in the COVID-19 era (9/44 patients, 20.5%) than in the pre-COVID-19 era (5/76 patients, 6.6%, p = 0.046). In detail, 7 versus 3 patients needed monitoring (15.9 vs. 3.9%), 2 versus no patients needed intensive-care treatment (4.5 vs. 0%), 2 versus no patients needed drain placement (4.5 vs. 0%), 2 versus no patients had a nephrectomy (4.5 vs. 0%), and 2 versus 1 patient died (4.5 vs. 1.3%). CONCLUSION: This report of collateral damage during CO-VID-19 showed that emergency room visits were decreased, and severe adverse disease outcomes were increased for patients with pyelonephritis in the COVID-19 era. Health authorities should set up information campaign programs actively encouraging patients to utilize emergency room services in case of severe symptoms specifically during the actual second wave of pandemic.

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.

Contemporary national trends in prostate cancer risk profile at diagnosis.

BACKGROUND: Over the past decade prostate cancer (PCa) diagnostic approaches have evolved away from aggressive prostate-specific antigen (PSA) screening. While a goal of these changes is to decrease over diagnosis and treatment, little is known about the downstream effects on PCa risk distribution at the time of diagnosis. To better understand these effects, we used a national cohort of men to investigate temporal trends in PCa risk profile at diagnosis. METHODS: Using the National Cancer Database, we identified men diagnosed with biopsy-confirmed clinically localized prostate adenocarcinoma (T1-4N0M0) from 2004 to 2014. We assessed temporal trends in proportional distribution of National Comprehensive Cancer Network risk groups as well as their sub-components (PSA, Gleason score, clinical T stage). We also evaluated trends in these sub-components among men with intermediate- and high-risk disease as well as those with metastatic disease. RESULTS: In our cohort of 755,567 men diagnosed between 2004 and 2014, there was a decrease in the proportion of men diagnosed with low-risk PCa (38.32 to 27.23%, p < 0.001) and a consequent increase in the proportion of localized intermediate-risk (40.49 to 46.72%, p < 0.001) and high-risk diagnoses (21.19 to 26.05%, p < 0.001). This was primarily driven by an increased proportion of Gleason 7 and Gleason 8-10 cancer, respectively. The number of men presenting with metastatic disease consistently increased from 3251 (2.88%) in 2004 to 6886 (7.19%) in 2014 (p < 0.001). CONCLUSIONS: The proportion of localized intermediate/high risk and metastatic PCa has substantially increased over the past decade, while the proportion of low-risk disease has decreased. This shift has been primarily driven by increased diagnosis of high-grade disease. National guidelines advising against PSA screening may have contributed to these findings.

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.

Transurethral resection of bladder tumours: established and new methods of tumour visualisation.

Transurethral resection (TUR) of bladder tumours does not only serve diagnostic purposes by securing histological proof of the disease but might also resemble the final therapy. During recent years, technical innovations improved the intraoperative detection and visibility of tumourous lesions during TUR. The most important techniques, which have individually found their way into international guidelines, are photodynamic imaging (PDI) and narrowband imaging (NBI). Furthermore, there are more or less experimental approaches such as optical coherence tomography (OCT), confocal laser endomicroscopy (CLE), red/green/blue analysis (RGB) of WLC. Moreover, the combination of two or more techniques in a multiparametric setting is another development in improving intraoperative imaging. The aim of this review is to describe today's knowledge of the more established methods and to depict the most recent developments in intraoperative imaging.

Integrated Fourier Transform Infrared Imaging and Proteomics for Identification of a Candidate Histochemical Biomarker in Bladder Cancer.

Histopathological differentiation between severe urocystitis with reactive urothelial atypia and carcinoma in situ (CIS) can be difficult, particularly after a treatment that deliberately induces an inflammatory reaction, such as intravesical instillation of Bacillus Calmette-Guèrin. However, precise grading in bladder cancer is critical for therapeutic decision making and thus requires reliable immunohistochemical biomarkers. Herein, an exemplary potential biomarker in bladder cancer was identified by the novel approach of Fourier transform infrared imaging for label-free tissue annotation of tissue thin sections. Identified regions of interest are collected by laser microdissection to provide homogeneous samples for liquid chromatography-tandem mass spectrometry-based proteomic analysis. This approach afforded label-free spatial classification with a high accuracy and without interobserver variability, along with the molecular resolution of the proteomic analysis. Cystitis and invasive high-grade urothelial carcinoma samples were analyzed. Three candidate biomarkers were identified and verified by immunohistochemistry in a small cohort, including low-grade urothelial carcinoma samples. The best-performing candidate AHNAK2 was further evaluated in a much larger independent verification cohort that also included CIS samples. Reactive urothelial atypia and CIS were distinguishable on the basis of the expression of this newly identified and verified immunohistochemical biomarker, with a sensitivity of 97% and a specificity of 69%. AHNAK2 can differentiate between reactive urothelial atypia in the setting of an acute or chronic cystitis and nonmuscle invasive-type CIS.

Facility Level Variation in Rates of Definitive Therapy for Low Risk Prostate Cancer in Men with Limited Life Expectancy: An Opportunity for Value Based Care Redesign.

PURPOSE: We sought to identify facility level variation in the use of definitive therapy among men diagnosed with clinically localized, low risk prostate cancer who were more than 65 years old and had a limited life expectancy of less than 10 years. MATERIALS AND METHODS: Using data from the National Cancer Database we identified 18,178 men older than 65 years with less than a 10-year life expectancy receiving definitive therapy at a total of 1,172 facilities for biopsy confirmed localized, low risk prostate cancer diagnosed between January 2004 and December 2013. A multilevel, hierarchical, mixed effects logistic regression model was fitted to predict the odds of receiving definitive therapy. RESULTS: Overall 18,178 men (76%) older than 65 years with limited life expectancy and a diagnosis of low risk prostate cancer received definitive therapy, although the rate of therapy decreased significantly with time (p <0.001). Patients receiving definitive therapy were more often younger (80 years or older vs 66 to 69 years OR 0.12, 95% CI 0.09-0.15, p <0.001) and white rather than black (OR 0.86, 95% CI 0.75-0.98, p = 0.03). Conversely, being uninsured (OR 0.37, 95% CI 0.21-0.63, p <0.001) and receiving care at an academic medical center (OR 0.36, 95% CI 0.28-0.46, p <0.001) conferred decreased odds of undergoing definitive therapy. The proportion of men undergoing definitive therapy ranged from 0.12% to 100% across facilities. CONCLUSIONS: We found significant facility level variation in rates of definitive therapy in men with localized prostate cancer and limited life expectancy. Health care providers and policy makers alike should be aware of the varying frequency with which this potentially low value service is performed.

Neoadjuvant Androgen Deprivation Therapy Prior to Radical Prostatectomy: Recent Trends in Utilization and Association with Postoperative Surgical Margin Status.

PURPOSE: In this study, we sought to describe the contemporary trends in utilization of neoadjuvant androgen deprivation therapy (ADT). As a secondary endpoint, we assessed the community-level effect of neoadjuvant ADT on positive surgical margins after radical prostatectomy (RP). METHODS: Using the National Cancer Database (2004-2014), we identified patients with clinically localized prostate cancer (PCa) [cT1-4N0M0] treated with RP. The estimated annual percentage change (EAPC) mixed linear regression methodology was used for temporal trend analysis of neoadjuvant ADT. Observed differences in baseline characteristics between patients treated with neoadjuvant ADT versus those who were not were then controlled for using an inverse probability of treatment weighting (IPTW) approach. IPTW-adjusted analyses were then performed to examine the odds of positive surgical margins. RESULTS: Overall, 8184 (2.12%) and 377,843 (97.88%) individuals with PCa were treated with neoadjuvant ADT prior to RP versus RP only, respectively. There was a consistent trend in decreasing use of neoadjuvant ADT over time, with a nadir observed in 2011 [EAPC - 8.08; 95% confidence interval (CI) - 11.7 to - 4.32; p < 0.05]. In IPTW-adjusted analyses, the odds of positive surgical margins were lower in patients receiving neoadjuvant ADT with low-risk [odds ratio (OR) 0.65; 95% CI 0.51-0.84; p < 0.001] and intermediate-risk [OR 0.76; 95% CI 0.69-0.85; p < 0.001] PCa. CONCLUSIONS: After a period of steady decline, there appears to be a modest trend towards increased utilization of neoadjuvant ADT in more recent years. We found an association between neoadjuvant ADT and decreased odds of positive surgical margins among low- and intermediate-risk patients.

Testicular cancer guideline adherence and patterns of care in Germany: A nationwide survey.

Testicular cancer has excellent cure rates; however, poor guideline adherence can lead to inappropriate management, with a detrimental effect on outcomes. Therefore, we aimed to investigate the current patterns of care for testicular cancer patients and to evaluate guideline adherence. A 19-item survey was distributed among German urologists between September 2015 and September 2016. The response rate was 45% (411/920). Staging imaging of the chest was performed by computed tomography (CT) in 85.5% and X-ray in 17.7%, and for the abdomen, by CT in 83.7% and by magnetic resonance imaging (MRI) in 21.1%. Areas of discrepancy with respect to guideline recommendations included underuse of MRI and infrequent follow-up examinations for changes in the cardiovascular, endocrine, neurological, and pulmonary systems, in addition to psychological burden. Further deviations of reported routine procedures from guideline recommendations were identified in the fields of active surveillance in Stage I seminoma, contralateral biopsies (63.1% overuse) and cryopreservation (19.2% underuse). Moreover, we found that hospital-based clinicians and younger specialists, with ≤5 years of practice following board certification, perform a more accurate and thorough follow-up. German urologists show relatively strong guideline adherence in staging patterns. Significant improvements are necessary in the following areas: recommending cryopreservation, imaging modalities and accurate follow-up examinations with a focus on late toxicities.

Racial disparity in quality of care and overall survival among black vs. white patients with muscle-invasive bladder cancer treated with radical cystectomy: A national cancer database analysis.

OBJECTIVES: To examine the impact of race on quality of care and overall survival (OS) among patients with muscle invasive bladder cancer (MIBC) treated with radical cystectomy (RC) in the U.S. MATERIALS & METHODS: Our cohort consisted of 12,652 patients receiving RC for MIBC within the National Cancer Database from 2004 to 2012. Patients were stratified by race (Black non-Hispanic vs. White non-Hispanic) and imbalances in patient characteristics mitigated using propensity score weighting. Logistic and Cox regressions examined the impact of race on quality of care metrics (receipt of pelvic lymph node dissection (PLND), lymph node count, hospital volume, length of stay, delay of treatment) and on OS. The difference in OS was expressed as Delta, and stratified by facility-type, hospital volume, and region. RESULTS: Blacks were less likely to receive PLND (odds ratio [OR] 0.70, 95% confidence interval [CI]: 0.55-0.91), or to have a greater number of lymph nodes removed (OR 0.76, 95%CI: 0.64-0.90). They exhibited greater length of stay (OR 1.34, 95%CI: 1.13-1.59), and delay of RC among recipients of neoadjuvant chemotherapy (OR 2.59, 95%CI: 1.77-3.85) (all P ≤ 0.001). Notably, utilization of neoadjuvant chemotherapy in advanced disease stages was more common in blacks (OR 2.82, 95%CI: 1.93-4.13, P < 0.001). Additionally, Black race was associated with inferior OS (Hazard ratio 0.87, 95%CI: 0.79-0.97, P < 0.014). Disparities in OS varied based on facility type and geographical region, but not hospital volume. Specifically, Blacks had worse OS when treated in a community cancer program (Delta 0.42, 95%CI: 0.28-0.57,P < 0.001), or within New England/Middle Atlantic region (Delta 0.16, 95% CI: 0.07-0.24,P < 0.001). CONCLUSION: Black race is an independent predictor of inferior quality of care and OS in patients undergoing RC for MIBC. Survival disparities vary based on geographical region and facility type. Notably, the OS disparity appears to have narrowed in comparison to previous studies.

Short-term external ureter stenting shows significant benefit in comparison to routine double-J stent placement after ureterorenoscopic stone extraction: A prospective randomized trial - the Fast track stent study (FaST).

OBJECTIVES: To determine whether short-term stenting using an external ureter catheter following ureterorenoscopic stone extraction provides a better outcome in comparison to double-J stent ureteral stenting. METHODS: Between August 2014 and August 2015, 141 patients initially managed with a double-J stent insertion were prospectively randomized to ureter catheter for 6 h vs double-J stent insertion for 5 days after stone extraction via ureteroscopy retrograde surgery (including flexible ureteroscopy retrograde surgery) in a single academic center. Endoscopic procedures were performed by nine surgeons. Exclusion criteria were acute urinary tract infection, a solitary kidney, or a stone mass more than 25 mm. Study endpoints were ureter-stent related symptoms and pain assessed by a validated questionnaire (ureteral stent symptom questionnaire) and visual analogue scale before and 4 weeks after surgery. RESULTS: Overall stone-free rate was more than 90%. Mean operative time was 24 min (range 5-63). Groups did not differ in terms of age, body mass index, and stone size. Patients who received short-term ureter catheter showed a significantly higher quality of life. In the ureter catheter group, the urinary index score (16.8 vs 27.8; P < 0.0001), the pain score (9.7 ± 1.3 vs 20.2 ± 1.5; P < 0.0001), and general health index (15.3 ± 0.7 vs 8.5 ± 0.6; P < 0.0001) were significantly lower. Consultation of a physician and antibiotic treatment were rarely needed (1.3 ± 0.1 vs 1.6 ± 0.1; P = 0.017). CONCLUSION: A short-term ureter catheter insertion for 6 h following ureteroscopy retrograde surgery stone removal is a safe procedure and superior to double-J stent insertion with regard to urinary symptoms, pain, quality of life, and stent related symptoms. Patients treated with a short-term ureter catheter recover more quickly, return to work earlier, and need less doctor visits. Most patients would recommend a ureter catheter, and would prefer this strategy in case of future stone treatments.