Radiation-induced Sarcoma of the Prostate After Treatment for Rhabdomyosarcoma.

Rhabdomyosarcoma (RMS) is among the most common pediatric solid malignancies. Fusion-negative, embryonal RMS is the predominant histology among prostate and bladder lesions. Management strategies depend on the clinical stage and risk group. Although the optimal strategy continues to evolve, the field has transitioned from radical upfront resection to organ preservation strategies with multi-modal therapy, including chemotherapy, radiation, and surgery. Survivors frequently develop late complications, including impaired fertility and sexual function, bladder dysfunction, and secondary malignancies. Our case describes an 11-year-old male who developed a radiation-induced prostatic sarcoma. We present a novel surgical technique and highlight the importance of multidisciplinary care.

NCCN Guidelines® Insights: Bladder Cancer, Version 3.2024.

Bladder cancer, the sixth most common cancer in the United States, is most commonly of the urothelial carcinoma histologic subtype. The clinical spectrum of bladder cancer is divided into 3 categories that differ in prognosis, management, and therapeutic aims: (1) non-muscle-invasive bladder cancer (NMIBC); (2) muscle invasive, nonmetastatic disease; and (3) metastatic bladder cancer. These NCCN Guidelines Insights detail recent updates to the NCCN Guidelines for Bladder Cancer, including changes in the fifth edition of the WHO Classification of Tumours: Urinary and Male Genital Tumours and how the NCCN Guidelines aligned with these updates; new and emerging treatment options for bacillus Calmette-Guérin (BCG)-unresponsive NMIBC; and updates to systemic therapy recommendations for advanced or metastatic disease.

Surveillance of non-muscle-invasive bladder cancer with blue-light cystoscopy: a meta-analysis.

OBJECTIVE: To compare the value of flexible blue-light cystoscopy (BLC) vs flexible white-light cystoscopy (WLC) in the surveillance setting of non-muscle-invasive bladder cancer (NMIBC). METHODS: All major databases were searched for articles published before May 2023 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The primary outcome was the accuracy of flexible BLC vs WLC in detecting bladder cancer recurrence among suspicious bladder lesions. RESULTS: A total of 10 articles, comprising 1634 patients, were deemed eligible for the quantitative synthesis. In the meta-analysis focusing on the detection of disease recurrence, there was no difference between flexible BLC and WLC (odds ratio [OR] 1.08, 95% confidence interval [CI] 0.82-1.41)]; the risk difference (RD) showed 1% of flexible BLC, corresponding to a number needed to treat (NNT) of 100. In the subgroup meta-analysis of detection of carcinoma in situ (CIS) only, there was again no significant difference between flexible BLC and WLC (OR 1.19, 95% CI 0.82-1.69), BLC was associated with a RD of 2% (NNT = 50). The positive predictive values for flexible BLC and WLC in detecting all types of recurrence were 72% and 66%, respectively, and for CIS they were 39% and 29%, respectively. CONCLUSION: Surveillance of NMIBC with flexible BLC could detect more suspicious lesions and consequently more tumour recurrences compared to flexible WLC, with a increase in the rate of false positives leading to overtreatment. A total of 100 and 50 flexible BLC procedures would need to be performed to find on additional tumor and CIS recurences, respectively. A risk-stratified strategy for patient selection could be considered when using flexible BLC for the surveillance of NMIBC patients.

Robotic single-port multiquadrant surgery to treat renal tumors and benign abdominal conditions.

BACKGROUND: Multiquadrant procedures are technically more demanding than sequential operations. The new single port (SP) system allows to work in every abdominal quadrant maintaining an adequate triangulation without the need for changes in the port positioning. METHODS: In February 2020, two patients underwent a robotic SP partial nephrectomy for malignancy combined with a cholecystectomy and a left inguinal hernia repair respectively. RESULTS: Both procedures were successfully completed with one robotic docking and without the need for conversion. The operative time was 213 minutes for the right partial nephrectomy (126 min) with cholecystectomy (18 min), and 257 minutes for the left partial nephrectomy (161 min) with inguinal hernia repair (35 min). Estimated blood loss was 200 (150-250) mL, while the total warm ischemia time was 15 minutes for the right partial nephrectomy and 53 minutes for the left partial nephrectomy. There were no intraoperative complications or perioperative transfusions. The postoperative course was uneventful, and the postoperative hospital stay was 1 and 2 days. Both resections had free margins and the median tumor size was 2.5 (1.5-3.5) cm. Histopathology analysis revealed chronic cholecystitis and renal cell carcinomas with free margins and a median tumor size of 2.5 (1.5-3.5) cm. After a mean follow-up of 24 months, no surgical-related complications or recurrence were detected. CONCLUSIONS: The robotic SP approach facilitates the completion of combined surgical procedures in multiple abdominal quadrants through a single 25mm incision.

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.

Biparametric Quantitative MRI for Prostate Cancer Detection.

OBJECTIVES: This study sought to prospectively investigate a novel quantitative biparametric prostate magnetic resonance imaging (MRI) protocol to detect prostate cancer (PCa) in biopsy-naïve men. Secondarily, this study reports the accuracy of fractional order calculus (FROC) diffusion and quantitative T2 compared with the Prostate Imaging Reporting & Data System (PI-RADS). METHODS: This prospective pilot study (NCT04175730) enrolled 50 prostate biopsy-naïve men who met eligibility criteria. All men received 3T MRI with T2 and diffusion-weighted imaging (DWI) (b-values: 50-4,000 s/mm2). Men with PI-RADS lesions ≥3 underwent targeted and systematic prostate biopsy, omitting systematic biopsy cores in peripheral zone lesions. DWI series images were fit to signal decay to calculate ADC (mm2/s) and the FROC model for coefficient DF (mm2/s). The primary end point was detection of Gleason grade group ≥2 (GG≥2) PCa. Receiver operating characteristic regression and area under the curve (AUC) were reported. RESULTS: Forty-eight men underwent MRI and biopsy. Mean age was 61.5 years (56-68), 29% were White, 52% were African American, mean PSA was 6.0 ng/mL (4.9-8.0), and mean PSA density was 0.14 ng/mL2. In total, 61 PI-RADS ≥3 lesions were targeted for biopsy. GG≥2 PC was found in 7% (1/14) of PI-RADS 3 lesions, 28% (10/36) of PI-RADS 4 lesions, and 36% (4/11) of PI-RADS 5 lesions. The AUC for detection of GG≥2 PC was 0.63 (0.5-0.76) for PI-RADS, 0.82 (0.68-0.96) for ADC, and 0.87 (0.77-0.97) for the FROC model. CONCLUSION: This small prospective pilot study demonstrates the feasibility of a novel quantitative biparametic MRI protocol to detect prostate cancer in biopsy-naïve men.

Perioperative outcomes in male patients undergoing cystectomy, radical colorectal procedure or total pelvic exenteration.

Background: Total pelvic exenteration (TPE) in men is a surgical procedure to treat genitourinary and colorectal malignancies. Despite improvement in multimodal strategies and technology, mortality is still high and literature is limited about perioperative outcomes comparison to other radical procedures. Methods: We analyzed National Surgical Quality Improvement Program (NSQIP) baseline database of all male patients undergoing cystectomy, low anterior resection/abdominoperineal resection (LAR/APR) or TPE from January 1, 2005 to December 31, 2016. Postoperative complications within 30 days after surgery were measured including: Wound infection, septic complications, deep vein thrombosis, cardiovascular events, and return to the operating room or mortality, etc. Differences between groups were analyzed using analysis of variance (ANOVA) tests. Results: A total of 7,375 patients underwent radical cystectomy, 49,762 underwent LAR/APR and 792 underwent TPE. Cystectomy patients were on average older compared to TPE or LAR/APR patients (P<0.001). In univariable and multivariable analysis, patients undergoing TPE had greater infectious and septic complications compared to cystectomy (odds ratio =1.09; 95% confidence interval (CI): 1.06-1.12) and LAR/APR (odds ratio =1.08; 95% CI: 1.05-1.11). Moreover, TPE had a slightly higher mortality within the 30-day postoperatively than those who underwent LAR/APR (odds ratio =1.01; 95% CI: 1.00-1.02) and cystectomy (odds ratio =1.01; 95% CI: 1.00-1.01). Conclusions: Men undergoing TPE had greater rates of infections and postoperative complications compared to those undergoing radical cystectomy and LAR/APR. From a clinical standpoint, TPE has high morbidity that could provide opportunity for quality improvement projects with the goal of mitigating high complication rates.

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.

The diagnosis and treatment of castrate-sensitive oligometastatic prostate cancer: A review.

BACKGROUND: Oligometastatic prostate cancer (OMPCa) is emerging as a transitional disease state between localized and polymetastatic disease. This review will assess the current knowledge of castrate-sensitive OMPCa. METHODS: A review of the current literature was performed to summarize the definition and classification of OMPCa, assess the diagnostic methods and imaging modalities utilized, and to review the treatment options and outcomes. We further identify gaps in knowledge and areas for future research. RESULTS: Currently there is no unified definition of OMPCa. National guidelines mostly recommend systemic therapies without distinguishing oligometastatic and polymetastatic disease. Next generation imaging is more sensitive than conventional imaging and has led to early detection of metastases at initial diagnosis or recurrence. While mostly retrospective in nature, recent studies suggest that treatment (surgical or radiation) of the primary tumor and/or metastatic sites might delay initiation of androgen deprivation therapy while increasing survival in selected patients. CONCLUSIONS: Prospective data are required to better assess the incremental improvement in survival and quality of life achieved with various treatment strategies in patients with OMPCa.

Prostate-derived circulating microRNAs add prognostic value to prostate cancer risk calculators.

Prostate cancer is the second leading cause of malignancy-related deaths among American men. Active surveillance is a safe option for many men with less aggressive disease, yet definitively determining low-risk cancer is challenging with biopsy alone. Herein, we sought to identify prostate-derived microRNAs in patient sera and serum extracellular vesicles, and determine if those microRNAs improve upon the current clinical risk calculators for prostate cancer prognosis before and after biopsy. Prostate-derived intracellular and extracellular vesicle-contained microRNAs were identified by small RNA sequencing of prostate cancer patient explants and primary cells. Abundant microRNAs were included in a custom microRNA PCR panel that was queried in whole serum and serum extracellular vesicles from a diverse cohort of men diagnosed with prostate cancer. The levels of these circulating microRNAs significantly differed between indolent and aggressive disease and improved the area under the curve for pretreatment nomograms of prostate cancer disease risk. The microRNAs within the extracellular vesicles had improved prognostic value compared to the microRNAs in the whole serum. In summary, quantifying microRNAs circulating in extracellular vesicles is a clinically feasible assay that may provide additional information for assessing prostate cancer risk stratification.

Advanced chronic kidney disease; A comparison between nephroureterectomy and nephron-sparing surgery for upper tract urothelial carcinoma.

PURPOSE: Renal function outcomes between radical nephroureterectomy (RNU) and nephron-sparing surgery (NSS) for upper tract urothelial carcinoma (UTUC) patients are not well established. We sought to compare the incidence and factors associated with development of advanced chronic kidney disease (CKD) between RNU and NSS and examine the role of acute kidney injury (AKI) on renal function outcomes. METHODS: We retrospectively analyzed an institutional database for patients who underwent either RNU or NSS for UTUC. Cumulative incidence of postoperative advanced CKD, defined as eGFR < 30 ml/min/1.73 m2, was compared between groups. Fine-Gray competing risk regression was used to identify predictors of advanced CKD. Locally weight scatterplot smoothing was used to assess postoperative eGFR trends. AKI events were counted, staged, and assessed for influence of progression to advanced CKD. RESULTS: Four hundred and twenty-six patients were included in analysis, with a median follow up of 6.68 years (IQR 3.4-12.2). Median preoperative eGFR was similar between the groups (NSS: 68 ml/min/1.73 m2, RNU: 65 ml/min/1.73 m2,P = 0.220). Cumulative incidence of advanced CKD was significantly lower in the NSS cohort (P = 0.009). Factors associated with advanced CKD included age, diabetes, recurrent AKI and RNU. Percent of patients with an AKI event differed between the groups (51.5% NSS, 72.7% RNU, P = <0.001), there was no between group difference in percentage of patients with recurrent AKI (25.6% NSS, 25.9% RNU, P =1). CONCLUSION: NSS provides a renal function benefit in UTUC. AKI is common among UTUC patients and recurrent AKI is a risk factor for development of advanced CKD.

Prostate-derived circulating microRNAs add prognostic value to prostate cancer risk calculators.

Prostate cancer is the second leading cause of malignancy-related deaths among American men. Active surveillance is a safe option for many men with less aggressive disease, yet definitively determining low-risk cancer is challenging with biopsy alone. Herein, we sought to identify prostate-derived microRNAs in patient sera and serum extracellular vesicles, and determine if those microRNAs improve upon the current clinical risk calculators for prostate cancer prognosis before and after biopsy. Prostate-derived intracellular and extracellular vesicle-contained microRNAs were identified by small RNA sequencing of prostate cancer patient explants and primary cells. Abundant microRNAs were included in a custom microRNA PCR panel that was queried in whole serum and serum extracellular vesicles from a diverse cohort of men diagnosed with prostate cancer. The levels of these circulating microRNAs significantly differed between indolent and aggressive disease and improved the area under the curve for pretreatment nomograms of prostate cancer disease risk. The microRNAs within the extracellular vesicles were the most informative and improved the AUC to 0.739 compared to the existing nomogram alone, which has an AUC of 0.561. The microRNAs in the whole serum improved it to AUC 0.675. In summary, quantifying microRNAs circulating in extracellular vesicles is a clinically feasible assay that may provide additional information for assessing prostate cancer risk stratification.

Retroperitoneal dermoid cyst presenting with radiculopathy symptoms: a case report.

Dermoid cysts rarely present in the retroperitoneal space or during adulthood. In this case report, we describe the clinical presentation, operative and post-operative course of a 31-year old with a retroperitoneal dermoid cyst. The patient presented with buttock and leg pain/paresthesia found to have a retroperitoneal mass between the psoas muscle and L5/S1 disk space. We describe the operative approach, including intra-operative images, of the resection by a team of urologists and neurosurgeons. The histology is also presented. Finally, we discuss the benefits of use of intra-operative ultrasound and neuromonitoring.

NCCN Guidelines® Insights: Bladder Cancer, Version 2.2022.

The NCCN Guidelines for Bladder Cancer provide recommendations for the diagnosis, evaluation, treatment, and follow-up of patients with bladder cancer and other urinary tract cancers (upper tract tumors, urothelial carcinoma of the prostate, primary carcinoma of the urethra). These NCCN Guidelines Insights summarize the panel discussion behind recent important updates to the guidelines regarding the treatment of non-muscle-invasive bladder cancer, including how to treat in the event of a bacillus Calmette-Guérin (BCG) shortage; new roles for immune checkpoint inhibitors in non-muscle invasive, muscle-invasive, and metastatic bladder cancer; and the addition of antibody-drug conjugates for metastatic bladder cancer.

Reconciling Discordance Between Prostate Biopsy Histology and Magnetic Resonance Imaging Suspicion - Implementation of a Quality Improvement Protocol of Imaging Re-review and Reverse-fusion Target Analysis.

There is uncertainty with how to proceed when targeted prostate biopsy of suspicious multiparametric magnetic resonance imaging (mpMRI) lesions return without clinically significant prostate cancer (csPCa). While possible, there are error sources that could contribute to such discordance including the mpMRI read, mpMRI-ultrasound fusion, biopsy technique, and histologic classification. Consequences are potentially significant; mistakenly missing csPCa can lead to delays in curative treatment. Conversely, in cases of incorrect mpMRI interpretation, the patient may be subjected to unnecessary workup/burden. At our institution, we implemented a quality improvement (QI) initiative triggered after a discordant case occurs. This multidisciplinary review process incorporates mpMRI re-review and assessment of accurate lesion-sampling, termed "reverse-fusion." Herein, we describe the protocol, present sample cases, and discuss clinical implications.

Comparison of Perioperative Outcomes Between Retroperitoneal Single-Port and Multiport Robot-Assisted Partial Nephrectomies.

Objective: To report early institutional experience with the single-port robotic platform and compare perioperative outcomes between single-port robot-assisted partial nephrectomies (SP-RAPN) and multiport robot-assisted partial nephrectomies (MP-RAPN) when utilizing a retroperitoneal approach. Methods: A retrospective chart review of patients who underwent SP-RAPN or MP-RAPN at our institution between November 1, 2013 and May 30, 2021 was performed. Surgical platforms were compared through univariate analysis using the Kruskal-Wallis test for continuous variables and χ2 test for categorical variables. Results: A total of 20 SP-RAPN and 42 MP-RAPN were performed utilizing a retroperitoneal approach. Patients who underwent SP-RAPN were more likely to have a lower radius, endophytic/exophytic, nearness, anterior/posterior, location score (4 vs 6; p = 0.0084) and their masses tended to be more exophytic, although this was not statistically significant (p = 0.0535). Patients undergoing SP-RAPN had a shorter postoperative length of hospital stay (1 vs 2 days; p < 0.0001). There were no significant differences in operative time, estimated blood loss, ischemia time, positive margin rate, malignant histology, postoperative complication rate, or Clavien-Dindo complication grade. Conclusion: Retroperitoneal SP-RAPN appear to be safe without compromising perioperative outcomes when compared with MP-RAPN for low-complexity renal masses. Further studies are recommended to assess the role of the SP for higher-complexity renal masses and to characterize variables that influence the observed difference in length of hospital stay.

Genomic Sequencing Should Not be Part of the Standard of Care for Most Urologic Cancers.

There are currently few situations in which genomic testing is actionable for genitourinary tumors. Without clear indications or treatment paradigms, genomic sequencing cannot be recommended as a standard of care for genitourinary tumors.

Prostate Cancer Disparities in Hispanics Using the National Cancer Database.

OBJECTIVES: To evaluate the differences in prostate cancer characteristics and treatment between Hispanic Americans with different countries of origin using the National Cancer Database. METHODS: We performed a retrospective analysis of 54,947 adult Hispanic Americans diagnosed with prostate cancer between 2004 and 2015. Origin was Mexican (N = 7844; 14.3%), South/Central American (N = 4010; 7.3%), Puerto Rican (N = 2938; 5.4%), Cuban (N = 2549; 4.6%), Dominican (N = 1535; 2.8%), Hispanic not specified (N = 36,269; 65.7%). Comparison between characteristics among Hispanic American sub-groups' categories was performed using chi-square and Kruskal-Wallis tests for categorical and continuous variables respectively. RESULTS: Mexicans had overall worse disease at presentation including highest median PSA (7.8 ng/mL), most prevalent T3/T4 stage (6.7%), M1 stage (8.9%), and high-grade Gleason scores (24.0%) when compared to all other Hispanic American groups. Cubans were most likely to receive hormone therapy and radiation therapy and least likely to receive surgical treatment. Compared to Mexicans, Cubans (hazards ratio [HR] = 1.30, 95% confidence interval = [1.16-1.44]) had worse overall survival, while Puerto Ricans (HR = 1.08 [0.95-1.19] had similar overall survival, and Dominicans (HR = 0.63 [0 0.53-0.75]), South/Central Americans (HR = 0.75, [0.66-0.84]) and not specified (HR = 0.84 [0.79-0.91]) had better survival. CONCLUSION: Among Hispanic Americans with different countries of origin, disparities in prostate cancer characteristics, treatment choice, and survival do exist. Mexicans had the least favorable prostate cancer characteristics at presentation. Cubans had the worst overall survival while they were also most likely to receive hormone and/or radiation as first-line treatment. Our analysis demonstrates significant heterogeneity in the Hispanic American population.

Investigating the heterogeneity of viscoelastic properties in prostate cancer using MR elastography at 9.4T in fresh prostatectomy specimens.

PURPOSE: To quantify the heterogeneity of viscoelastic tissue properties in prostatectomy specimens from men with prostate cancer (PC) using MR elastography (MRE) with histopathology as reference. METHODS: Twelve fresh prostatectomy specimens were examined in a preclinical 9.4T MRI scanner. Maps of the complex shear modulus (|G*| in kPa) with its real and imaginary part (G' and G" in kPa) were calculated at 500 Hz. Prostates were divided into 12 segments for segment-wise measurement of viscoelastic properties and histopathology. Coefficients of variation (CVs in %) were calculated for quantification of heterogeneity. RESULTS: Group-averaged values of cancerous vs. benign segments were significantly increased: |G*| of 12.13 kPa vs. 6.14 kPa, G' of 10.84 kPa vs. 5.44 kPa and G" of 5.45 kPa vs. 2.92 kPa, all p < 0.001. In contrast, CVs were significantly increased for benign segments: 23.59% vs. 26.32% (p = 0.014) for |G*|, 27.05% vs. 37.84% (p < 0.003) for G', and 36.51% vs. 50.37% (p = 0.008) for G". DISCUSSION: PC is characterized by a stiff yet homogeneous biomechanical signature, which may be due to the unique nondestructive growth pattern of PC with intervening stroma, providing a rigid scaffold in the affected area. In turn, increased heterogeneity in benign prostate segments may be attributable to the presence of different prostate zones with involvement by specific nonmalignant pathology.