Heresy - Is there a role for ultrasound in management of the non-palpable testicle?

INTRODUCTION: AUA Guidelines do not support the routine use of ultrasound (US) in evaluation of boys with an undescended testicle (UDT) prior to urology referral. Multiple studies have demonstrated that real time US is inferior to a physical examination by a pediatric urologist in detecting an UDT. However, improved US technology, which now permits detection of the non-palpable testis located just proximal to the internal ring, may aid in guiding the surgical approach to the non-palpable testis. We evaluated US findings of boys deemed to have a non-palpable UDT and compared them to surgical findings. OBJECTIVE: To assess the role of pre-operative ultrasonography in guiding surgical management in boys deemed to have a non-palpable testis by a pediatric urologist. STUDY DESIGN: US of boys with a non-palpable UDT, as reported by a pediatric urologist on physical exam, during a 3-year period, were reviewed. All US were performed jointly by a technician and pediatric radiologist. Patient demographics, laterality, and intra-operative findings were assessed. RESULTS: Thirty-one boys with a non-palpable testicle on physical exam underwent scrotal/inguinal/pelvis US at a median age of 7.5 months (IQR 2.5-12.3 months). Two patients had bilateral non-palpable testicles, 21 had a non-palpable left sided testicle and 8 had a non-palpable right sided testicle. Of the 33 non-palpable testes, 5 (15.2%) were identified in the inguinal canal. Sixteen (48.5%) were visualized in the lower pelvis just proximal to the internal ring and graded as intra-abdominal. Four (12.1%) nubbins or very atrophic testes were identified in the inguinal region or scrotum and 5 (15.2%) testes were not identified on US. Three (9.1%) testes were observed to be mobile between the lower pelvis just proximal to the internal ring and the inguinal canal. Of the 8 patients with testes that were identified in the inguinal canal, or mobile between the lower pelvis and inguinal canal, 7 avoided a diagnostic laparoscopy and underwent an inguinal orchiopexy. Of the 16 testicles located in the lower pelvis proximal to the internal ring, only 2 underwent laparoscopy/laparoscopic orchiopexy. DISCUSSION: In cases of a non-palpable testicle following a physical examination by a urologist, an ultrasound can impact the operative plan, and allow for patients to avoid laparoscopy. In our cohort, 87.5% of non-palpable testes avoided laparoscopic surgery after ultrasound identification of a viable testis. CONCLUSIONS: US in the evaluation of cryptorchidism can guide surgical management in select cases in which a testis is non-palpable following careful examination by a urologist.

Prostate cancer risk stratification using magnetic resonance imaging-ultrasound fusion vs systematic prostate biopsy.

BACKGROUND: Image-guided approaches improve the diagnostic yield of prostate biopsy and frequently modify estimates of clinical risk. To better understand the impact of magnetic resonance imaging-ultrasound fusion targeted biopsy (MRF-TB) on risk assessment, we compared the distribution of National Comprehensive Cancer Network (NCCN) risk groupings, as calculated from MRF-TB vs systematic biopsy alone. METHODS: We performed a retrospective analysis of 713 patients who underwent MRF-TB from January 2017 to July 2021. The primary study objective was to compare the distribution of National Comprehensive Cancer Network risk groupings obtained using MRF-TB (systematic + targeted) vs systematic biopsy. RESULTS: Systematic biopsy alone classified 10% of samples as very low risk and 18.7% of samples as low risk, while MRF-TB classified 10.5% of samples as very low risk and 16.1% of samples as low risk. Among patients with benign findings, low-risk disease, and favorable/intermediate-risk disease on systematic biopsy alone, 4.6% of biopsies were reclassified as high risk or very high risk on MRF-TB. Of 207 patients choosing active surveillance, 64 (31%), 91 (44%), 42 (20.2%), and 10 (4.8%) patients were classified as having very low-risk, low-risk, and favorable/intermediate-risk and unfavorable/intermediate-risk criteria, respectively. When using systematic biopsy alone, 204 patients (28.7%) were classified as having either very low-risk and low-risk disease per NCCN guidelines, while 190 men (26.6%) received this classification when using MRF-TB. CONCLUSION: The addition of MRF-TB to systematic biopsy may change eligibility for active surveillance in only a small proportion of patients with prostate cancer. Our findings support the need for routine use of quantitative risk assessment over risk groupings to promote more nuanced decision making for localized cancer.

Personalizing approaches to the management of metastatic hormone sensitive prostate cancer: role of advanced imaging, genetics and therapeutics.

PURPOSE: To summarize contemporary and emerging strategies for the diagnosis and management of metastatic hormone sensitive prostate cancer (mHSPC), focusing on diagnostic testing and therapeutics. METHODS: Literature review using PUBMED-Medline databases as well as clinicaltrials.gov to include reported or ongoing clinical trials on treatment for mHSPC. We prioritized the findings from phase III randomized clinical trials, systematic reviews, meta-analyses and clinical practice guidelines. RESULTS: There have been significant changes to the diagnosis and staging evaluation of mHSPC with the integration of increasingly accurate positron emission tomography (PET) imaging tracers that exceed the performance of conventional computerized tomography (CT) and bone scan. Germline multigene testing is recommended for the evaluation of patients newly diagnosed with mHSPC given the prevalence of actionable alterations that may create candidacy for specific therapies. Although androgen deprivation therapy (ADT) remains the backbone of treatment for mHSPC, approaches to first-line treatment include the integration of multiple agents including androgen receptor synthesis inhibitors (ARSI; abiraterone) Androgen Receptor antagonists (enzalutamide, darolutamide, apalautamide), and docetaxel chemotherapy. The combination of ADT, ARSI, and docetaxel chemotherapy has recently been evaluated in a randomized trial and was associated with significantly improved overall survival including in patients with a high burden of disease. The role of local treatment to the prostate with radiation has been evaluated in randomized trials with additional studies underway evaluating the role of cytoreductive radical prostatectomy. CONCLUSION: The staging and initial management of patients with mHSPC has undergone significant advances in the last decade with advancements in the diagnosis, treatment and sequencing of therapies.

Ejaculatory Preserving Holmium Laser Enucleation of the Median Lobe: Preserving Sexual Function While Improving Urinary Outcomes.

OBJECTIVE: To evaluate perioperative outcomes related to sexual and urinary function in patients who underwent a holmium laser enucleation of the prostate (HoLEP) with selective laser enucleation of the median lobe. MATERIALS AND METHODS: We retrospectively reviewed the first 450 HoLEP cases by a single surgeon from April 2019 to March 2022. Fifty-five patients with intravesical-prostatic protrusion or high bladder neck without obstructing lateral lobes underwent selective enucleation of the median lobe of the prostate. Patients were asked to comment on whether they had retrograde ejaculation during their follow-up appointment. Urinary function was assessed using the American Urological Association Symptom Score and subjective evaluation of urinary incontinence. RESULTS: Median age of the cohort was 65 years (range: 44-91). Compared to preoperative, there was significant improvement in mean postoperative American Urological Association Symptom Score (22.5 vs 6.9, P < .001), mean postoperative quality of life scores (4 vs 1.2, P < .001), and mean postoperative post void residual volumes (244.1 vs 69.3 cc, P < .001). No patients reported stress urinary incontinence. Of the 55 patients who underwent selective enucleation of the median lobe, 40 were sexually active. Of those men, 35 reported normal ejaculation, 3 had retrograde ejaculation that was unchanged from pre-op, and 2 had new ejaculatory dysfunction. CONCLUSION: In this case series of selective laser enucleation of the median lobe, urinary function significantly improved in short-term follow-up with preservation of ejaculation in approximately 90% of men.

Oncologic outcomes of neoadjuvant chemotherapy in patients with micropapillary variant urothelial carcinoma of the bladder.

BACKGROUND: There is lack of consensus about the effectiveness of neoadjuvant platinum-based chemotherapy in patients with micropapillary variant urothelial carcinoma (MVUC) prior to radical cystectomy. We studied the association between neoadjuvant chemotherapy (NAC) and pathologic response (PR) among patients with micropapillary versus non-variant bladder urothelial carcinoma (UC). METHODS: We queried the National Cancer Database to identify patients with localized UC and MVUC from 2004 to 2017. We restricted our analysis to patients who underwent radical cystectomy with or without NAC. We compared clinical, demographic, and pathologic characteristics associated with NAC. We used multivariable logistic regression and propensity score matching to examine the association between NAC and the occurrence of a pathologic complete response (pT0) and pathologic lymph node positivity (pN+). Kaplan Meier analyses and Cox proportional hazards models were used to assess overall survival (OS). We performed analyses among subsets of patients with clinical stage II (cT2) disease, as well as the entire cohort (cT2-T4). RESULTS: We identified 18,761 patients, including 18,027 with non-variant UC and 734 patients with MVUC. Multivariable analysis revealed that NAC use was associated with greater odds of pT0 (9.64[7.62-12.82], P<0.001), and the association did not differ significantly between MVUC and non-variant UC. In a propensity matched analysis of patients with MVUC, NAC use was associated with higher odds of pT0 (OR 4.93 [2.43-13.18] P<0.001), lower odds of pN+ (OR 0.52 [0.26-0.92] P=0.047) and pathologic upstaging (OR 0.63 [0.34-0.97] P=0.042) in all stages. Similar findings were observed with cT2 disease. No significant association was seen between NAC and OS with MVUC (HR 0.89 [0.46-1.10] P=0.63), including the subset of patients with cT2 (HR 0.83 [0.49-1.06] P=0.58). CONCLUSIONS: NAC is associated with similar pathologic and nodal responses in patients with localized MVUC and non-variant UC. Improvements in pathologic findings did not translate into OS in this retrospective hospital-based registry study.

Association Between a 22-feature Genomic Classifier and Biopsy Gleason Upgrade During Active Surveillance for Prostate Cancer.

BACKGROUND: Although the Decipher genomic classifier has been validated as a prognostic tool for several prostate cancer endpoints, little is known about its role in assessing the risk of biopsy reclassification for patients on active surveillance, a key event that often triggers treatment. OBJECTIVE: To evaluate the association between Decipher genomic classifier scores and biopsy Gleason upgrading among patients on active surveillance. DESIGN SETTING AND PARTICIPANTS: This was a retrospective cohort study among patients with low- and favorable intermediate-risk prostate cancer on active surveillance who underwent biopsy-based Decipher testing as part of their clinical care. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We evaluated the association between the Decipher score and any increase in biopsy Gleason grade group (GG) using univariable and multivariable logistic regression. We compared the area under the receiver operating characteristic curve (AUC) for models comprising baseline clinical variables with or without the Decipher score. RESULTS AND LIMITATIONS: We identified 133 patients for inclusion with a median age of 67.7 yr and median prostate-specific of 5.6 ng/ml. At enrollment, 75.9% had GG1 and 24.1% had GG2 disease. Forty-three patients experienced biopsy upgrading. On multivariable logistic regression, the Decipher score was significantly associated with biopsy upgrading (odds ratio 1.37 per 0.10 unit increase, 95% confidence interval [CI] 1.05-1.79; p = 0.02). The Decipher score was associated with upgrading among patients with biopsy GG 1 disease, but not GG2 disease. The discriminative ability of a clinical model (AUC 0.63, 95% CI 0.51-0.74) was improved by integration of the Decipher score (AUC 0.69, 95% CI 0.58-0.80). CONCLUSIONS: The Decipher genomic classifier score was associated with short-term biopsy Gleason upgrading among patients on active surveillance. PATIENT SUMMARY: The results from this study indicate that among patients with prostate cancer undergoing active surveillance, those with higher Decipher scores were more likely to have higher-grade disease found over time. These findings indicate that the Decipher test might be useful for guiding the intensity of monitoring during active surveillance, such as more frequent biopsy for patients with higher scores.

The Medical Community's Evolving Focus on Physician and Surgeon Pregnancy: Thematic Trends From a Scoping Review.

PURPOSE: The authors aimed to chronicle the evolution of the medical community's study of physician and surgeon pregnancy by investigating thematic trends in the literature in the context of pertinent sociopolitical events. METHOD: A scoping review was conducted in Cochrane Library, Google Scholar, Ovid MEDLINE, Ovid Embase, Scopus, and Web of Science Core Collection from inception through August 11, 2020, using vocabulary and terms for physicians (including surgeons), pregnancy, and family leave. Study populations were categorized by all physician specialties or exclusively surgical specialties as well as by all career levels or exclusively trainees. Subthemes and themes were based on a priori assumptions of physician pregnancy and extrapolated from previously published reviews, respectively. Thematic trends were analyzed by plotting the total number of publications and the frequency of themes and subthemes by publication year. RESULTS: After title and abstract and full-text reviews, 407 manuscripts met inclusion criteria. Publications on physician pregnancy first emerged in the 1960s and surged from 1988 to 1996 and again from 2010 to 2019. The first known manuscript exclusively on surgeon pregnancy was published in 1991; subsequent publication frequency trends for surgeon pregnancy generally paralleled those for all physician pregnancy publications albeit in reduced quantities. Four major themes were found: impact of pregnancy on the physician and her colleagues, pregnant physician work productivity, physician maternity leave policies, and physician maternal-fetal health outcomes. CONCLUSIONS: As the number of women physicians increased and the sociopolitical environment progressed, the thematic focus of the literature on physician pregnancy evolved. Multi-institutional prospective observational studies are needed to develop definitive evidence-based recommendations that will positively impact physician pregnancy.

"En-Bloc" Enucleation With Early Apical Release Compared to Standard Holmium Laser Enucleation of the Prostate: A Retrospective Pilot Study During the Initial Learning Curve of a Single Surgeon.

OBJECTIVE: To compare operative efficiency of Holmium laser enucleation of the prostate (HoLEP) using both the standard multi-incisional approach and en-bloc enucleation with early apical release during the initial learning curve. MATERIALS AND METHODS: We retrospectively reviewed the initial 95 consecutive men who underwent HoLEP between April 2019 and September 2020 by a single surgeon. We compared patient demographics, and pre-, intra-, and post-operative metrics between both groups. Differences between groups were evaluated with Mann-Whitney U and Kruskal-Wallis tests. RESULTS: Forty-nine patients underwent the standard HoLEP approach, and 46 patients underwent the en-bloc approach. Compared to a standard HoLEP, the en-bloc approach was associated with decreased operative time (131.11 minutes vs 153.59 minutes, P = .007) with similar weights of tissue removed. Operative efficiency, as measured by grams of prostate tissue removed per minute, was greater for the en-bloc approach (0.49 g/min vs 0.36 g/min, P = .005). There was no difference in length of stay (0.91 days vs 0.96 days, P = .383), laser efficiency (4.41 kJ/g vs 4.83 kJ/g, P = .200), or number of post-operative complications (10 vs 6, P = .236) between the groups. CONCLUSION: Utilization of the en-bloc technique during the initial learning curve allows for a faster, more efficient operation without any difference in functional outcomes or major complications compared to a standard HoLEP.

Pregnancy in physicians: A scoping review.

BACKGROUND: The personal health and professional impact of physician pregnancy requires further study. We performed a comprehensive scoping review of physician pregnancy to synthesize and assess the evidence to aid decision-making for relevant stakeholders. METHODS: A search of 7 databases resulted in 3733 citations. 407 manuscripts were included and scored for evidence level. Data were extracted into themes using template analysis. RESULTS: Physician pregnancy impacted colleagues through perceived increased workload and resulted in persistent stigmatization and discrimination despite work productivity and academic metrics being independent of pregnancy events. Maternity leave policies were inconsistent and largely unsatisfactory. Women physicians incurred occupational hazard risk and had high rates of childbearing delay, abortion, and fertility treatment; obstetric and fetal complication rates compared to controls are conflicting. CONCLUSIONS: Comprehensive literature review found that physician pregnancy impacts colleagues, elicits negative perceptions of productivity, and is inadequately addressed by current parental leave policies. Data are poor and insufficient to definitively determine the impact of physician pregnancy on maternal and fetal health. Prospective risk-matched observational studies of physician pregnancy should be pursued.

Diffuse large B-cell lymphoma presenting as LUTS: Clinical practice points.

There is a paucity of management recommendations for patients with aggressive Diffuse large B cell lymphoma (DLBCL) of the bladder. A 57-year-old male patient presented with lower urinary tract symptoms underwent flexible cystoscopy and then bladder tumor biopsy. Through immediate staging CT scan, tumor and bone biopsies he was diagnosed with a 16 cm Stage IVa high-grade DLBCL. He was treated with DA EPOCH with only a partial response and was transitioned to R-ICE. For rarer presentations of bladder cancer during diagnostic cystoscopy there should be no delay in tumor imaging and involving medical oncology in early treatment decision making.

The Intraoperative Use of a Portable Cone-Beam Computed Tomography System for the Diagnosis of Intraperitoneal Bladder Perforation.

BACKGROUND: Intraoperative imaging for endourologic procedures is generally limited to single-plane fluoroscopic X-ray. The O-arm™ is a mobile cone-bean CT scanner that may have applications in urologic surgeries. Case Presentation. We present a case of an 85-year-old male with radiation cystitis and recurrent gross hematuria who was identified to have a bladder perforation on cystoscopy during emergent clot evacuation. Single-view fluoroscopic evaluation was inconclusive as to whether an intraperitoneal bladder perforation occurred. A portable cone-beam CT scan was used to acquire a 3-D CT cystogram, which demonstrated intraperitoneal contrast extravasation, confirming the diagnosis of an intraperitoneal bladder perforation. CONCLUSION: We report the first use of a portable cone-beam CT scanner to perform an intraoperative CT cystogram to diagnose an intraperitoneal bladder perforation and guide surgical management.

Cachexia and bladder cancer: clinical impact and management.

PURPOSE OF REVIEW: The purpose of this review is to describe the causes, management, and clinical outcomes associated with cachexia and related components including sarcopenia, among patients with bladder cancer (BCa). RECENT FINDINGS: Cachexia in patients with BCa is associated with poorer outcomes after radical cystectomy (RC), radiation, and chemotherapy. Nutritional supplements and novel pharmaceutical agents including magnolol, flucoidan and Anamorelin are currently undergoing investigation for their potential use in BCa patients with cachexia. SUMMARY: Cachexia is a hypercatabolic state thought to be caused by an immune-regulated release of cytokines and disruptions of molecular pathways within the tumor microenvironment and systemically. Nutritional deficiencies in patients with BCa also contribute to cachexia and sarcopenia. Patients with BCa -related cachexia and sarcopenia experience worse survival and therapeutic outcomes after RC, chemotherapy, and radiation therapy. Patients with cachexia also experience more postoperative complications after RC. The management of cachexia in patients with BCa remains challenging and requires timely identification, and multidisciplinary management including nutritional supplementation, physical therapy, palliative care, and pharmacological agents. Clinical trials and human studies are still required to determine which pharmacological agents are optimal for BCa cachexia.

Utility of PSA Density in Predicting Upgraded Gleason Score in Men on Active Surveillance With Negative MRI.

OBJECTIVES: To determine whether PSA density (PSAD), can sub-stratify risk of biopsy upgrade among men on active surveillance (AS) with normal baseline MRI. METHODS: We identified a cohort of patients with low and favorable intermediate-risk prostate cancer on AS at two large academic centers from February 2013 - December 2017. Analysis was restricted to patients with GG1 cancer on initial biopsy and a negative baseline or surveillance mpMRI, defined by the absence of PI-RADS 2 or greater lesions. We assessed ability of PSA, prostate volume and PSAD to predict upgrading on confirmatory biopsy. RESULTS: We identified 98 patients on AS with negative baseline or surveillance mpMRI. Median PSA at diagnosis was 5.8 ng/mL and median PSAD was 0.08 ng/mL/mL. Fourteen men (14.3%) experienced Gleason upgrade at confirmatory biopsy. Patients who were upgraded had higher PSA (7.9 vs 5.4 ng/mL, P = .04), PSAD (0.20 vs 0.07 ng/mL/mL, P < .001), and lower prostate volumes (42.5 vs 65.8 mL, P = .01). On multivariate analysis, PSAD was associated with pathologic upgrade (OR 2.23 per 0.1-increase, P = .007). A PSAD cutoff at 0.08 generated a NPV of 98% for detection of pathologic upgrade. CONCLUSION: PSAD reliably discriminated the risk of Gleason upgrade at confirmatory biopsy among men with low-grade prostate cancer with negative MRI. PSAD could be clinically implemented to reduce the intensity of surveillance for a subset of patients.

Postoperative Complications After Robotic Partial Nephrectomy.

Objectives: To assess the incidence of postoperative arterial malformation (AM) and urine leak/urinoma (UL) after robotic partial nephrectomy (RPN) in a contemporary series and to evaluate risk factors for these complications. Materials and Methods: All RPNs were queried from Institutional Review Board-approved retrospective and prospective nephrectomy databases. Demographics, perioperative variables, and postoperative complications were collected. Differences between cohorts were analyzed using univariate analysis. Postoperative complications were graded using the Clavien-Dindo system. UL was defined in the context of signs and symptoms of a collection with supporting evidence of urine collection through drainage or aspiration. AM was identified based on postoperative imaging indicative of arteriovenous fistula or pseudoaneurysm and/or requirement for selective embolization. Predictors of AM and UL were assessed by univariate analysis. Results: A total of 395 RPNs were performed by four urologists between January 2014 and October 2018. Tumor complexity, defined by nephrometry score, was significantly greater in the prospective cohort (p = 0.01). Overall incidence of postoperative complications was 5.6% with cohort-specific incidences of 5.3% and 5.8%. The retrospective cohort had a greater percentage of complications classified as ≥IIIa: 8/13 (61.5%) vs 2/8 (25%). Overall incidence of AM was 2.3% with cohort-specific incidence of 3.1% (7/225) vs 1.1% (2/170). Overall incidence of UL was 0.25% with cohort-specific incidence of 0.55% (1/225) and 0.0% (0/170). The difference in incidence of both complications between cohorts was significant (p < 0.05). No significant predictors for AM were identified. Conclusions: The incidence of postoperative complications after RPN remains low (5.3% vs 5.8%, overall: 5.6%). UL and AM are becoming rarer with experience, despite increasing surgical complexity (0.55% vs 0%, 3.1% vs 1.1%).

The ultrasound characteristics of regions identified as suspicious by magnetic resonance imaging (MRI) predict the likelihood of clinically significant cancer on MRI-ultrasound fusion-targeted biopsy.

OBJECTIVE: To determine whether the presence of an ultrasound hypoechoic region at the site of a region of interest (ROI) on magnetic resonance imaging (MRI) results in improved prostate cancer (PCa) detection and predicts clinically significant PCa on MRI-ultrasonography fusion-targeted prostate biopsy (MRF-TB). MATERIALS AND METHODS: Between July 2011 and June 2017, 1058 men who underwent MRF-TB, with or without systematic biopsy, by a single surgeon were prospectively entered into an institutional review board-approved database. Each MRI ROI was identified and scored for suspicion by a single radiologist, and was prospectively evaluated for presence of a hypoechoic region at the site by the surgeon and graded as 0, 1 or 2, representing none, a poorly demarcated ROI-HyR, or a well demarcated ROI-HyR, respectively. The interaction of MRI suspicion score (mSS) and ultrasonography grade (USG), and the prediction of cancer detection rate by USG, were evaluated through univariate and multivariate analysis. RESULTS: For 672 men, the overall and Gleason score (GS) ≥7 cancer detection rates were 61.2% and 39.6%, respectively. The cancer detection rates for USGs 0, 1 and 2 were 46.2%, 58.6% and 76.0% (P < 0.001) for any cancer, and 18.7%, 35.2% and 61.1% (P < 0.001) for GS ≥7 cancer, respectively. For MRF-TB only, the GS ≥7 cancer detection rates for USG 0, 1 and 2 were 12.8%, 25.7% and 52.0%, respectively (P < 0.001). On univariate analysis, in men with mSS 2-4, USG was predictive of GS ≥7 cancer detection rate. Multivariable regression analysis showed that USG, prostate-specific antigen density and mSS were predictive of GS ≥7 PCa on MRF-TB. CONCLUSIONS: Ultrasonography findings at the site of an MRI ROI independently predict the likelihood of GS ≥7 PCa, as men with a well-demarcated ROI-HyR at the time of MRF-TB have a higher risk than men without.

Development of a Novel Prognostic Risk Score for Predicting Complications of Penectomy in the Surgical Management of Penile Cancer.

INTRODUCTION: Penectomy for PC is useful in staging, disease prognosis, and treatment. Limited studies have evaluated its surgical complications. We sought to assess these complications and determine predictive models to create a novel risk score for penectomy complications. PATIENTS AND METHODS: A retrospective review of patients undergoing PC surgical management from the 2005-2016 American College of Surgeons National Surgical Quality Improvement Program was performed. Data were queried for partial and total penectomy among those with PC. To develop predictive models of complications, we fit LASSO logistic, random forest, and stepwise logistic models to training data using cross-validation, demographic, comorbidity, laboratory, and wound characteristics as candidate predictors. Each model was evaluated on the test data using receiver operating characteristic curves. A novel risk score was created by rounding coefficients from the LASSO logistic model. RESULTS: A total of 304 cases met the inclusion criteria. Overall incidence of penectomy complications was 19.7%, where urinary tract infection (3.0%), superficial surgical site infection (3.0%), and bleeding requiring transfusion (3.9%) were most common. LASSO logistic, random forest, and stepwise logistic models for predicting complications had area under the curve (AUC) [95% confidence interval] values of 0.66 [0.52-0.81], 0.73 [0.63-0.83], and 0.59 [0.45-0.74], respectively. Eleven variables were included in the risk score. The LASSO model-derived risk score had moderately good performance (area under the curve [95% confidence interval] 0.74 [0.66-0.82]). Using a cutoff point of 6, the score attains sensitivity 0.58, specificity 0.74, and kappa 0.26. CONCLUSION: PC management through penectomy is associated with appreciable complications rates. Predictive models of penectomy complications performed moderately well. Our novel prognostic risk score may allow for improved preoperative counseling and risk stratification of men undergoing surgical management of PC.

Differentiating Molecular Risk Assessments for Prostate Cancer.

It is critically important to the evolving goals of prostate biopsy to find clinically significant cancer with lethal potential and avoid detection of indolent disease. Better tests and markers are required for improved detection of clinically significant prostate cancer and avoidance of biopsies in men with indolent disease. Currently, there are myriad alternative prostate cancer risk-assessment tests available derived from serum and urine that are designed to improve the specificity for detection of "significant" prostate cancer. Herein we discuss these tests and their clinical implications.

Discriminative Ability of Commonly Used Indexes to Predict Adverse Outcomes After Radical Cystectomy: Comparison of Demographic Data, American Society of Anesthesiologists, Modified Charlson Comorbidity Index, and Modified Frailty Index.

BACKGROUND: The American Society of Anesthesiologists physical status classification system, modified Charlson Comorbidity Index (mCCI), and modified Frailty Index have been associated with complications after urologic surgery. No study has compared the predictive performance of these indexes for postoperative complications after radical cystectomy (RC) for bladder cancer. MATERIALS AND METHODS: Data from 1516 patients undergoing elective RC for bladder cancer were extracted from the 2005 to 2011 American College of Surgeons National Surgical Quality Improvement Program for a retrospective review. The perioperative outcome variables assessed were occurrence of minor adverse events, severe adverse events, infectious adverse events, any adverse event, extended length of hospital stay, discharge to a higher level of care, and mortality. Patient comorbidity indexes and demographic data were assessed for their discriminative ability in predicting perioperative adverse outcomes using an area under the curve (AUC) analysis from the receiver operating characteristic curves. RESULTS: The most predictive comorbidity index for any adverse event was the mCCI (AUC, 0.511). The demographic factors were the body mass index (BMI; AUC, 0.519) and sex (AUC, 0.519). However, the overall performance for all predictive indexes was poor for any adverse event (AUC < 0.52). Combining the most predictive demographic factor (BMI) and comorbidity index (mCCI) resulted in incremental improvements in discriminative ability compared with that for the individual outcome variables. CONCLUSION: For RC, easily obtained patient mCCI, BMI, and sex have overall similar discriminative abilities for perioperative adverse outcomes compared with the tabulated indexes, which are more difficult to implement in clinical practice. However, both the demographic factors and the comorbidity indexes had poor discriminative ability for adverse events.