MRI at diagnostic versus confirmatory biopsy during MRI-based active surveillance of prostate cancer.

OBJECTIVES: Active surveillance (AS) is a management strategy for patients with favorable risk prostate cancer. Multi-parametric magnetic resonance imaging (mpMRI) may impact upgrading rates, but there is mixed evidence on the appropriate timing to introduce mpMRI. We evaluated timing of initial mpMRI use for patients on AS and compared upgrading and intervention rates for AS candidates who received initial mpMRI before diagnostic biopsy vs. confirmatory biopsy. SUBJECTS AND METHODS: Patients enrolled in AS captured by the Prospective Loyola Urology mpMRI (PLUM) Prostate Biopsy Cohort which captures men undergoing MRI-fusion prostate biopsy. We included patients enrolled in AS between January 2014 and October 2022. We conducted a retrospective analysis of patients who underwent MRI-fusion prostate biopsy while on AS at our institution. The cohort was stratified by men who underwent first mpMRI prior to diagnostic biopsy (MRI-DBx), confirmatory biopsy (MRI-CBx), or a subsequent surveillance biopsy. Oncologic outcomes including pathologic reclassification, intervention-free survival, progression-free survival, and overall survival were evaluated. RESULTS: Of 346 patients identified on AS, 94 (27.2%) received mpMRI at the time of diagnostic biopsy, 182 (52.6%) at confirmatory biopsy, and 70 (20.2%) at a later biopsy. At confirmatory biopsy (median 14 months), there was no difference in upgrading (HR 0.95, P = 0.78) or intervention rates (HR 0.97, P = 0.88) between MRI-DBx and MRI-CBx. PI-RADS score on initial mpMRI was associated with upgrading during AS follow-up relative to men with negative mpMRI (HR 4.20 (P = 0.04), 3.24 (P < 0.001), and 1.99 (P < 0.001) for PI-RADS 5, 4, and 3, respectively), and PSA density was associated with intervention (HR 1.52, P = 0.03). CONCLUSION: mpMRI can serve as a prognostic tool to select and monitor AS patients, but there was no difference in upgrading or intervention rates based on initial timing of MRI.

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

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

Neoadjuvant Chemotherapy Before Radical Cystectomy for Muscle-Invasive Bladder Cancer: Elective and Eligibility Factors Impacting Utilization.

INTRODUCTION: We aimed to assess utilization of neoadjuvant chemotherapy (NAC) and etiologies for lack of NAC receipt among patients with muscle-invasive bladder cancer (MIBC). METHODS: Patients diagnosed with MIBC undergoing radical cystectomy at a single institution (2005-2021) were included. Patients were categorized by receipt of NAC, and reasons for no NAC were categorized into eligibility and elective factors. Overall survival was analyzed using univariable and multivariable Cox proportional hazards regression models and modeled with Kaplan-Meier curves. RESULTS: Three hundred eighty patients with MIBC were included; 154 (40.5%) received NAC. Patients were not candidates for NAC due to renal dysfunction (16.6%), clinical contraindications (4.7%), salvage setting (2.1%), and histology (5.3%; total N = 109). Among 271 (71.3%) who were eligible, utilization increased from early (2005-2016) to recent (2016-2021) time periods (34.2% to 85.7% among NAC-eligible, P < .001; 22.8% vs 67.1% among all MIBC, P < .001). Elective factors for not receiving NAC included patient symptoms (7.8%), disease progression concern (7.0%), patient preference/refusal (20.3%) and provider discretion (8.1%) among 271 NAC-eligible patients. Notably, patient preference/refusal decreased from 33.6% to 3.4% in recent years (P < .001). On multivariable analysis, lack of NAC utilization due to renal dysfunction (HR 2.18, P = .002), clinical contraindications (HR 2.62, P = .01), and elective factors (HR 1.88, P = .01) were associated with worse overall survival. CONCLUSIONS: NAC utilization increased over time with 85.7% of eligible patients with MIBC receiving NAC in recent years. Renal dysfunction, patient preference, and clinical contraindications were primary etiologies for lack of NAC. Fewer patients refused NAC in recent years leading to a potential ceiling for NAC utilization.

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.

The Interaction of Diabetic Peripheral Neuropathy and Carpal Tunnel Syndrome.

BACKGROUND: Diabetes mellitus (DM) increases the risk for carpal tunnel syndrome (CTS) and is associated with its own neuropathic complications. Diabetic peripheral neuropathy (DPN) is a common complication seen in diabetic patients. In this study, we examine the relationship between the severity of DPN and CTS. METHODS: Type 2 diabetic and control patients (n = 292) were recruited at a clinic visit. The Michigan Neuropathy Screening Instrument (MNSI) questionnaire was used to collect data related to peripheral neuropathy. The MNSI scores were compared for patients with CTS with and without DM in univariable and multivariable analyses. χ2 analyses were performed to quantitatively measure the associations between peripheral neuropathy and the presence of CTS. RESULTS: Of the 292 patients, 41 had CTS, and 19 of these had both CTS and DM. Of the 138 diabetic patients, 85 had peripheral neuropathy. There was no association between a diagnosis of CTS and an MNSI score indicative of peripheral neuropathy. In the diabetic population, CTS was inversely associated with DPN (P = .017). The MNSI scores between diabetic and control patients with CTS were comparable. CONCLUSION: The severity of peripheral neuropathy in diabetic patients with and without CTS is comparable. Diabetic patients without peripheral neuropathy have an association with higher incidence of CTS in this study, suggesting that there are disparate mechanisms causing DPN and CTS. Nevertheless, diabetes and CTS are risk factors for developing the other, and future studies should further explore how DPN and CTS differ to tailor patient interventions based on their comorbidities.

Outcomes of penile inversion vaginoplasty and robotic-assisted peritoneal flap vaginoplasty in obese and nonobese patients.

AIM: To explore the impact of body mass index (BMI) on the outcomes of gender-affirming vaginoplasty. METHODS: A cohort consisting of all gender-affirming vaginoplasties in our practice between September 27th, 2018, and September 1st, 2022 were identified, and data were retrospectively collected. Patients were classified as obese if their BMI was ≥30 kg/m2 at the time of surgery and nonobese if their BMI was <30 kg/m2 . Complications were assigned a Clavien-Dindo grade and grouped as Grade ≥2 versus Grade ≤1. Patient-reported functional outcomes of intact erogenous sensation, tactile sensation, ability to achieve penetrative vaginal intercourse, and cosmetic satisfaction were assessed. RESULTS: A total of 58 patients with a mean follow-up time of 6.9 months were included. Seventeen patients (mean BMI = 36.8 kg/m2 ) were classified as obese and 41 patients (mean BMI = 25.1 kg/m2 ) were classified as nonobese. No significant differences in outcomes were identified in the obese versus nonobese groups in terms of the incidence of complications. Patient-reported functional outcomes did not differ significantly between the two groups. CONCLUSIONS: Similar results can be achieved with gender-affirming vaginoplasty in obese patients when compared to their nonobese counterparts. Eligibility for this procedure should not be restricted based on BMI alone.

Neonatal circumcision availability in the United States: a physician survey.

BACKGROUND: A significant proportion of boys present to surgical specialists later in infancy/early childhood for elective operative circumcision despite the higher procedural risks. This study aims to assess physician perspectives on access to neonatal circumcision across the United States and identify potential reasons contributing to disparities in access. METHODS: A cross-sectional survey was electronically distributed to physician members of the Societies for Pediatric Urology and the American Academy of Pediatrics Section on Hospital Medicine. Hospital characteristics and circumcision practices were assessed. Associations between NC availability and institutional characteristics were evaluated using chi-squared testing and multivariable logistic regression. Qualitative analyses of free-text comments were performed. RESULTS: A total of 367 physicians responded (129 urologists [41%], 188 pediatric hospitalists [59%]). Neonatal circumcision was available at 86% of hospitals represented. On univariate and multivariate analysis, the 50 hospitals that did not offer neonatal circumcision were more likely to be located in the Western region (odds ratio [OR] = 8.33; 95% confidence interval [CI] 3.1-25 vs. Midwest) and in an urban area (OR = 4.2; 95% CI 1.6-10 vs. suburban/rural) compared with hospitals that offered neonatal circumcision. Most common reasons for lack of availability included not a birth hospital (N = 22, 47%), lack of insurance coverage (N = 8, 17%), and low insurance reimbursement (N = 7, 15%). Institutional, regional, or provider availability (68%), insurance/payment (12.4%), and ethics (12.4%) were common themes in the qualitative comments. CONCLUSIONS: Overall availability of neonatal circumcision varied based on hospital characteristics, including geography. Information from this survey will inform development of interventions designed to offer neonatal circumcision equitably and comprehensively.

The association of cancer-specific anxiety with disease aggressiveness in men on active surveillance of prostate cancer.

BACKGROUND: Active surveillance (AS) provides appropriate prostate cancer (PCa)-specific survival while minimizing morbidity, but underlying worry of PCa can generate anxiety. The aim of the study is to evaluate anxiety levels in men on AS and how anxiety relates to disease characteristics and treatment decision-making. METHODS: A retrospective analysis was conducted using all 302 subjects from the Reduction by Dutasteride of clinical progression Events in Expectant Management (REDEEM) study. Prostate biopsies were obtained at 18 and 36 months. Anxiety was measured at baseline and 3, 6, 12, 18, and 36 months post-randomization using the MAX-PC (Memorial general anxiety scale for PCa) questionnaire. Univariable and multivariable analysis of the association of disease aggressiveness (PSA levels, percentage of positive cores, and maximum core involvement) and anxiety levels were performed. Cox regression was used to analyze time to progression to discontinuation of active surveillance as a function of baseline anxiety. RESULTS: Overall, MAX-PC scores decreased from moderate at baseline with slight increases after receiving PSA results at 18 months, followed by more decline. Percentage of positive cores was associated with baseline anxiety (P = 0.02). The association remained when controlling for age, race, number of cores sampled, body mass index, prostate volume, and maximum core length (P = 0.003). In univariable and multivariable analysis, baseline anxiety was not significantly associated with time to progression to discontinuation of active surveillance. CONCLUSIONS: In evaluating the natural history of anxiety levels among patients with prostate cancer undergoing active surveillance, there was a decline of anxiety levels over time, with increases after receiving PSA results. Moreover, we found that disease aggressiveness measured by percentage of positive biopsy cores was associated with baseline levels of anxiety. However, anxiety had no impact on clinical or therapeutic progression.

Chronic Baseline Prostate Inflammation is Associated with Lower Tumor Grade in Men with Prostate Cancer on Repeat Biopsy: Results from the REDUCE Study.

PURPOSE: We investigated whether baseline acute or chronic prostate inflammation among men with initial negative biopsies for prostate cancer was associated with cancer grade in 2-year repeat biopsies. MATERIALS AND METHODS: Retrospective analyses were conducted of 889 men aged 50 to 75 years old with negative baseline prostate biopsy and 2-year repeat biopsy positive for prostate cancer in the Reduction by Dutasteride of Prostate Cancer Events (REDUCE) study. Acute and chronic prostate inflammation and cancer grade were determined by central pathology during the REDUCE study. The association of inflammation in baseline and 2-year repeat biopsy and prostate cancer grade in 2-year repeat biopsy was evaluated with Student's t-test, chi-squared test and multivariable logistic regression. RESULTS: Chronic, acute inflammation and both were detected in 533 (60%), 12 (1%) and 85 (10%) baseline biopsies, respectively. Presence of acute and chronic inflammation were significantly associated with each other (p <0.001). Both types of inflammation were unrelated to race, body mass index, prostate specific antigen or digital rectal exam. At the 2-year biopsy, 621 (70%) tumors were low grade (Gleason scores 2-6) and 268 (30%) were high grade (Gleason scores 7-10). In univariable and multivariable analyses, men with baseline chronic inflammation had significantly fewer high grade tumors (univariable OR 0.64, 95% CI 0.47-0.87, p=0.004; multivariable OR=0.68, 95% CI0.50-0.93, p=0.016) than those without baseline chronic inflammation. Baseline acute inflammation was not associated with tumor grade (univariable OR 0.74, 95% CI 0.45-1.20, p=0.22; multivariable OR 0.78, 95% CI 0.48-1.29, p=0.34). CONCLUSIONS: Chronic inflammation in a negative biopsy was associated with lower prostate cancer grade among men with cancer on follow-up 2-year biopsy.

Factors contributing to healthcare professional burnout during the COVID-19 pandemic: A rapid turnaround global survey.

BACKGROUND: Healthcare professionals (HCPs) on the front lines against COVID-19 may face increased workload and stress. Understanding HCPs' risk for burnout is critical to supporting HCPs and maintaining the quality of healthcare during the pandemic. METHODS: To assess exposure, perceptions, workload, and possible burnout of HCPs during the COVID-19 pandemic we conducted a cross-sectional survey. The main outcomes and measures were HCPs' self-assessment of burnout, indicated by a single item measure of emotional exhaustion, and other experiences and attitudes associated with working during the COVID-19 pandemic. FINDINGS: A total of 2,707 HCPs from 60 countries participated in this study. Fifty-one percent of HCPs reported burnout. Burnout was associated with work impacting household activities (RR = 1·57, 95% CI = 1·39-1·78, P<0·001), feeling pushed beyond training (RR = 1·32, 95% CI = 1·20-1·47, P<0·001), exposure to COVID-19 patients (RR = 1·18, 95% CI = 1·05-1·32, P = 0·005), and making life prioritizing decisions (RR = 1·16, 95% CI = 1·02-1·31, P = 0·03). Adequate personal protective equipment (PPE) was protective against burnout (RR = 0·88, 95% CI = 0·79-0·97, P = 0·01). Burnout was higher in high-income countries (HICs) compared to low- and middle-income countries (LMICs) (RR = 1·18; 95% CI = 1·02-1·36, P = 0·018). INTERPRETATION: Burnout is present at higher than previously reported rates among HCPs working during the COVID-19 pandemic and is related to high workload, job stress, and time pressure, and limited organizational support. Current and future burnout among HCPs could be mitigated by actions from healthcare institutions and other governmental and non-governmental stakeholders aimed at potentially modifiable factors, including providing additional training, organizational support, and support for family, PPE, and mental health resources.

Factors Contributing to Healthcare Professional Burnout During the COVID-19 Pandemic: A Rapid Turnaround Global Survey.

BACKGROUND: Healthcare professionals (HCPs) on the front lines against COVID-19 may face increased workload, and stress. Understanding HCPs risk for burnout is critical to supporting HCPs and maintaining the quality of healthcare during the pandemic. METHODS: To assess exposure, perceptions, workload, and possible burnout of HCPs during the COVID-19 pandemic we conducted a cross-sectional survey. The main outcomes and measures were HCPs self-assessment of burnout and other experiences and attitudes associated with working during the COVID-19 pandemic. FINDINGS: A total of 2,707 HCPs from 60 countries participated in this study. Fifty-one percent of HCPs reported burnout. Burnout was associated with work impacting household activities (RR=1.57, 95% CI=1.39-1.78, P<0.001), feeling pushed beyond training (RR=1.32, 95% CI=1.20-1.47, P<0.001), exposure to COVID-19 patients (RR=1.18, 95% CI=1.05-1.32, P=0.005), making life prioritizing decisions (RR=1.16, 95% CI=1.02-1.31, P=0.03). Adequate personal protective equipment (PPE) was protective against burnout (RR=0.88, 95% CI=0.79-0.97, P=0.01). Burnout was higher in high-income countries (HICs) compared to low- and middle-income countries (LMICs) (RR=1.18; 95% CI=1.02-1.36, P=0.018). INTERPRETATION: Burnout is prevalent at higher than previously reported rates among HCPs working during the COVID-19 pandemic and is related to high workload, job stress, and time pressure, and limited organizational support. Current and future burnout among HCPs could be mitigated by actions from healthcare institutions and other governmental and non-governmental stakeholders aimed at potentially modifiable factors, including providing additional training, organizational support, support for family, PPE, and mental health resources. FUNDING: N/A.