Novel Prostate Biopsy Technique Using Imaging Fusion in a Patient With Absent Rectum.

INTRODUCTION: A 70-year-old male with prior total colectomy for ulcerative colitis was referred for elevated prostate specific antigen (PSA) (8.01) with PIRADS 4 lesion on magnetic resonance imaging (MRI). Described is a novel technique using pre-operative multi-parametric prostate MRI and intraoperative computed tomography (CT) 3D/3D fusion for systematic and targeted prostate biopsy in a patient lacking a rectum. TECHNICAL CONSIDERATIONS: Under general anesthesia, an ultra-low-dose (ULD) cone beam CT was performed in supine position using a robotic-armed fluoroscopy system (Artis Zeego Care+Clear, Siemens). 3D/3D auto-registration of the femoral heads and prostate from the MRI and ULD CT was performed. The prostate edges and two areas of concern were marked. Then, reduced-dose fluoroscopy-guided prostate biopsy was performed transperineally using triangulation technique. 27 prostate biopsy cores were obtained. Grade group 5 (Gleason 4+5=9) prostate cancer was identified in two cores from the targeted lesion and one core from the prostate base. The remaining twenty-four biopsies were negative for malignancy. Surgical time was 81 minutes. PSMA scan demonstrated no metastasis or lymphadenopathy. Robotic-assisted laparoscopic radical prostatectomy was performed without complications. Final pathology demonstrated T3a, grade group 5 prostate adenocarcinoma involving 10% of the prostate volume with negative surgical margins. CONCLUSION: This is the initial report of fluoroscopy-guided prostate biopsy using imaging fusion techniques in a patient without a rectum. This technique allowed precise identification of localized, very high-risk prostate cancer with over three times the number of cores, and much lower radiation dose, than typical CT-guided biopsies. Our technique could provide a new paradigm in targeted prostate biopsy.

Age-Dependent Effects of Voluntary Wheel Running Exercise on Voiding Behavior and Potential Age-Related Molecular Mechanisms in Mice.

BACKGROUND: Older men frequently develop lower urinary tract symptoms attributed to benign prostatic hyperplasia (LUTS/BPH). Risk factors for LUTS/BPH include sedentary lifestyle, anxiety/depression, obesity, and frailty, which all increase with age. Although physical exercise may reduce the progression and/or severity of LUTS/BPH, the age-related mechanisms responsible remain unknown. METHODS: Voiding symptoms, body mass, and frailty were assessed after 4-weeks of voluntary wheel running in 2-month (n = 10) and 24-month (n = 8) old C57Bl/6J male mice. In addition, various social and individual behaviors were examined in these cohorts. Finally, cellular and molecular markers of inflammation and mitochondrial protein expression were assessed in prostate tissue and systemically. RESULTS: Despite running less (aged vs young X¯ = 12.3 vs 30.6 km/week; p = .04), aged mice had reduced voiding symptoms (X¯ = 67.3 vs 23.7; p < .0001) after 1 week of exercise, which was sustained through week 4 (X¯ = 67.3 vs 21.5; p < .0001). Exercise did not affect voiding symptoms in young mice. Exercise also increased mobility and decreased anxiety in both young and aged mice (p < .05). Exercise decreased expression of a key mitochondrial protein (PINK1; p < .05) and inflammation within the prostate (CD68; p < .05 and plasminogen activator inhibitor-1; p < .05) and in the serum (p < .05). However, a frailty index (X¯ = 0.17 vs 0.15; p = .46) and grip strength (X¯ = 1.10 vs 1.19; p = .24) were unchanged after 4 weeks of exercise in aged mice. CONCLUSIONS: Voluntary aerobic exercise improves voiding behavior and mobility, and decreases prostatic mitochondrial protein expression and inflammation in aged mice. This promising model could be used to evaluate molecular mechanisms of aerobic exercise as a novel lifestyle intervention for older men with LUTS/BPH.

A Novel Technique of Robotic-Assisted Simple Cystectomy During Urinary Diversion for Benign Indications.

BACKGROUND: When urinary diversion is necessary for benign indications, the defunctionalized bladder is at risk of a number of severe complications such as bleeding, pain, pyocystis and secondary urothelial carcinoma. These complications occur in 54%-80% of patients left with native bladder after diversion, and these patients go on to require completion cystectomy 20%-25% of the time. Rowley et al. at the University of Michigan reported their experience in open simple cystectomy in 2011 in a series of 23 patients. This operation, to our knowledge, has not been previously adapted to the robotic platform despite the growing prevalence of robotic surgery including for complex reconstruction and urinary diversion. Here we report our novel adapted technique of performing robotic simple cystectomy in 2 index patients. OBJECTIVE: To visually demonstrate and report our technique of simple cystectomy, utilizing the robotic platform, including outcomes in 2 index patients. METHODS: Two index patients are presented, including outcomes: One female with spinal cord injury, smoking and chronic infections in the setting of suprapubic catheter diversion, and one male with multiply failed local treatments including radiation and cryotherapy for prostate cancer that have resulted in chronic fistula, prior Fournier's gangrene, and sympheseal osteomyelitis. RESULTS: he operations were completed without difficulty, in an expedient fashion (35-48 minutes) and without significant blood loss (10cc or less). The technique is illustrated in the accompanying video. CONCLUSION: This novel adapted robotically-assisted operation appears to be a rapid and reproducible operation that recapitulates the principles of open surgery with little time or blood loss, thus avoiding the morbidity of radical cystectomy or of delayed secondary operations, while at the same time providing all the benefits inherent to a robotic operation. Outcomes appear excellent. Further study is needed.

The relationship of depression, alcohol and marijuana with treatment for LUTS/BPH.

INTRODUCTION: Despite widespread usage, research on the relationship of marijuana use to disease is sorely lacking. We sought to test the relationship of LUTS/BPH treatment and endocannabinoid agonist usage, as well as alcohol usage and depression, with treatment for LUTS/BPH in our health system. MATERIALS AND METHODS: We queried our hospital system database of nearly three million patients in a marijuana-legalized region for data from the electronic medical record between January 2011 and October 2018. Men over the age of 45 on medical therapy for LUTS (selective alpha blockade and/or finasteride) were included. Exclusions were diagnosis of bladder or prostate malignancy and men with only one visit. Alcohol and marijuana (MJ) use were found from diagnosis code and/or social history text. Medical diagnoses were based on ICD-9/10 codes. Multiple logistic regression was used to control for confounders. We considered all men over the age of 45 who had any of these features: depression, obesity or metabolic syndrome (MetS), hypertension (HTN), erectile dysfunction (ED), hypogonadism, diabetes (DM) and calculated the odds ratio of also receiving medical therapy for LUTS. Univariable and multivariable analyses were employed, multiple logistic regression was used to control for confounders. RESULTS: A total of 173,469 patients were identified meeting criteria with 20,548 (11.9%) on medical treatment for LUTS. After adjusting for confounding variables, MJ and depression remained associated with an increased risk of LUTS medication, within the context of verifying previously established relationships of ED, Obesity/MetS, DM, HTN and hypogonadism. CONCLUSIONS: Men with depression and MJ usage were more likely to be treated for LUTS/BPH in our system. Better understanding of the causality of this relationship and potential interaction of LUTS/BPH with the endocannabinoid system is desirable.

Geographic Variation of Infectious Complications Following Prostate Biopsy in The United States: Results From a Population-Based Cohort of Privately Insured Patients.

OBJECTIVE: To elucidate regional trends of infectious complications following transrectal ultrasound prostate biopsy (TRUS-PB) from a national, privately-insured database. MATEREIAL AND METHODS: Using Market Scan, we identified all men who underwent TRUS-PB from 2010 to 2015. Infectious complications (UTI, prostatitis, sepsis) occurring 30 days after the prostate biopsy from emergency room (ER) visits or hospital admissions constituted the primary outcomes. We analyzed unadjusted and adjusted rates of infectious complications from ER visits and hospital admissions per 100 prostate biopsies by state. Multivariable logistic regression analyses were used to identify patient covariates associated with infectious complications. RESULTS: During the study interval, we identified 193,490 patients who underwent TRUS-PB. The mean age was 57.6 years (SD: 5.0). Over time the unadjusted national rates of infectious complications remained similar from 0.4 ER visits per 100 prostate biopsies in 2010 -0.2 in 2015 (P = 0.83), and 1.2 hospital admissions per 100 prostate biopsies in 2010 to 1.1 in 2015 (P= 0.58). Connecticut had the lowest unadjusted infectious complication rate per 100 biopsies at 0.64, whereas West Virginia had the highest at 2.34. Multivariable analysis revealed higher Elixhauser status and patient age were associated with higher odds of infectious complications (P<0.05). CONCLUSIONS: While rates of infectious complications attributable to prostate biopsies remain relatively stable, significant variation exists at the state level regarding this adverse outcome.

High-risk Disease and Poor Follow-up: The Importance of Renal Mass Biopsy in a Cohort of Veterans.

OBJECTIVE: To assess the clinical utility of renal mass biopsy (RMB) in our multistate system. RMB is useful in the management of masses ≤4 cm (T1a), but evaluation of RMB in the uniquely vulnerable Veteran population is lacking. METHODS: About 136 RMB in 130 patients performed between 06/2015 and 11/2020 were identified in this Quality Improvement analysis. Demographics, size, pathology, treatment, and biopsy complications were analyzed. Of 101 T1a masses, 89 were either diagnostic or not decompressed cysts and 77 met inclusion criteria for follow-up imaging compliance analysis. RESULTS: The median age was 66 years. The diagnostic rate was 94.1% (128/136) for all masses and 94.1% (95/101) for T1a renal masses, with a complication rate of 2.2%. Among solid T1a masses, unexpectedly aggressive lesions (Fuhrman Grade 4, Type 2 papillary or sarcomatoid features) were identified in 8/89 (9.0%). Fifty-seven (64%) patients were treated with cryoablation or surgery and 32 (36%) patients elected active surveillance (AS). A neoplastic finding (oncocytoma or renal cell carcinoma (RCC)) was present in 16 patients choosing AS (50%) compared to 52 patients choosing treatment (91%). Compliance with National Comprehensive Cancer Network-recommended imaging was 50% and 47% for AS and treatment groups, respectively. CONCLUSION: In this VA cohort, we found a significant incidence of high-risk lesions and poor compliance with follow-up imaging. Aggressive biopsy protocols with high consideration of treatment may be appropriate to limit risk in those lost to follow-up. Given that 9% of our small renal masses were highly aggressive, biopsy may be critical in the selection of AS candidates.

The Impact of Race, Ethnicity and Insurance Status on Surgery Rates for Benign Prostatic Hyperplasia.

OBJECTIVE: To determine whether patient race/ethnicity are associated with differences in likelihood of undergoing surgical treatment for LUTS/BPH. METHODS: Queried hospital network database between 1/2011 and 10/2018. Men over age 40 on medical therapy for LUTS (selective alpha blockade and/or 5-alpha-reductase inhibitor), with 2+ provider visits, and without bladder/prostate malignancy were included. Ethnicity/race determined by self-identification. Insurance status classified as public (Medicare/Medicaid/Tricare), private, self-pay, or other. Multivariable backwards step-wise logistic regression was performed to compare odds of undergoing a surgical procedure by race/ethnicity, controlling for patient age, insurance status, comorbidities, and type of medical therapy. RESULTS: 30,466 patients included, with White (n=24,443, 80.2%), Hispanic (n=2,715, 8.9%), Black (n=1,245, 4.1%), and other race/ethnicity (2,073, 6.8%) identified within the study population. After adjusting for age, insurance status, major comorbidities, and type of medical therapy, Black patients were less likely to undergo surgery than White patients (OR 0.57, 95% CI 0.37 - 0.88, P = .011), as were patients of other race/ethnicity (OR 0.67, 95% CI 0.49 - 0.92, P = .013). CONCLUSIONS: Adjusting for age, insurance status, major comorbidities and type of LUTS medication, men categorized as Black were significantly less likely to undergo surgical treatment for LUTS/BPH than White patients. It is unknown whether this difference results from differences in counseling, access, or other bias in therapy. Efforts to understand and respond to this disparity are necessary. Limitations include lack of IPSS data, additional comorbidity data, limited geographic area, and retrospective nature.

Association of Surgical Approach and Urinary Diversion in Radical Cystectomy for Bladder Cancer With Costs and Readmission: Results From a Large Private Health Insurance Cohort.

INTRODUCTION: We sought to assess the comparative hospital outcomes and costs among a population-based cohort of bladder cancer patients by surgical approach and diversion. METHODS: From a privately insured national database, we identified all bladder cancer patients who underwent open or robotic radical cystectomy and ileal conduit or neobladder from 2010 to 2015. The primary outcomes were length of stay, readmissions, and total health care costs at 90 days from surgery. We used multivariable logistic regression and generalized estimating equations to assess for 90-day readmission and health care costs, respectively. RESULTS: Most patients underwent open radical cystectomy with ileal conduit (56.7%; n = 1,680) followed by open radical cystectomy with neobladder (22.7%; n = 672), robotic radical cystectomy with ileal conduit (17.4%; n = 516), and robotic radical cystectomy with neobladder (3.1%; n = 93). On multivariable analysis, patients had higher odds of 90-day readmissions for open radical cystectomy and neobladder (OR: 1.36; P = .002) and robotic radical cystectomy with neobladder (OR 1.60; P = .03) relative to open radical cystectomy with ileal conduit. After adjusting for patient covariates, we also found lower adjusted total 90-day health care costs for open radical cystectomy with ileal conduit ($67,915) and open radical cystectomy with neobladder ($67,371) compared to robotic radical cystectomy with ileal conduit ($70,677) and neobladder ($70,818; P < .05). CONCLUSIONS: In our study, neobladder diversion was associated with higher odds of 90-day readmission, while robotic surgery increased total 90-day health care costs.

Perioperative Clerkship Design for Students with Physical Disabilities: A Model for Implementation.

OBJECTIVE: Disability inclusion is an important and growing area of focus for medical education that may be stymied by stereotypes about disabilities, lack of knowledge about accommodations for students with physical disabilities, or outdated technical standards that preclude participation of people with mobility disabilities. To support the inclusion of students with physical disability in surgical clerkships, we describe a proactive, progressive approach to the accommodations process for a student with a thoracic spinal cord injury entering a surgical clerkship. DESIGN: Working proactively, medical school leadership, disability professionals and the clerkship team collaborated on the development of reasonable accommodations for a student with a thoracic spinal cord injury entering a surgical clerkship. SETTING: University of Colorado, Department of Surgery and Department of Medical Education, Aurora, CO. PARTICIPANTS: A third-year medical student and faculty from the medical school and surgical clerkship leaders. RESULTS: An M3 student with a thoracic spinal cord injury successfully completed an 8-week surgical clerkship completing all required procedural and clinical skills utilizing reasonable accommodation. The student achieved a grade of honors for the rotation. CONCLUSIONS: Early communication and planning for disability-related adjustments are critical to ensure an accessible experience for students with physical disabilities. The addition of a student with a disability adds to a better understanding of inclusive practices for surgical education and adds to the diversity of thought and experience for the medical education community.

Sociodemographic index and global trends in prostate cancer: 1990-2017.

BACKGROUND: Considered globally, prostate cancer is a disease of the aging male that increases in prevalence with exposure to screening and diagnostic testing, and which requires a population with the health and longevity to encounter it. The Global Burden of Disease (GBD) dataset is an aggregation of worldwide registries and health data systems that reports global and regional assessment of disease impact. METHODS: Using the GBD database, 1171 worldwide registries and health registration systems from 1990 to 2016 were aggregated for prostate cancer disease codes and outcomes. Disease-Adjusted Life Years (DALYs) were calculated and segregated by sociodemographic index (SDI) quintile, and compared to other urologic diseases and tuberculosis (TB). RESULTS: Prostate cancer exerts a burden of disease that is vastly higher in the top quintile of SDI. The three lowest SDI quintiles represent the majority of global population but are currently less impacted by prostate cancer. Conversely, TB has its highest impact on the lowest SDI levels, although these rates are declining. CONCLUSIONS: As a global disease, prostate cancer predominantly affects high SDI men who enjoy a longer life expectancy in which to suffer from this disease and a greater exposure to screening and diagnosis. As lower SDI men are elevated in health and income, reallocation of DALYs will occur, and a greater burden of prostate cancer can be expected. These epidemiologic trends have great implications for the allocation of resources, as the population of men affected by prostate cancer outpaces urologic workforce growth.

Solitary brain metastasis after recurrent adenocarcinoma of the prostate.

Prostate cancer is rarely metastatic to visceral organs, and even less commonly to the brain. Recent data suggests brain metastasis from prostatic adenocarcinoma occur in 0.16% of patients, and almost universally in the setting of very high-volume disease. We present a man with an abruptly symptomatic brain lesion that developed at a PSA value of 1.5 ng/mL with no other known metastatic disease and required emergent neurosurgical resection. The patient had been initially treated with radiotherapy for Grade Group 4 prostate cancer in 2005 with a long period of PSA suppression.

Marijuana, Alcohol, and ED: Correlations with LUTS/BPH.

PURPOSE OF REVIEW: Benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) is a disease complex with enormous societal burden and yet the pathogenesis of LUTS/BPH is poorly understood. We set out to review the literature on the relationship between depression, marijuana usage, and erectile dysfunction (ED) to LUTS/BPH. RECENT FINDINGS: LUTS/BPH has independent associations with depression as well as with ED. In each case, the causality and mechanistic relationship is unknown. The impact of marijuana, as it increasingly pervades the general population, on the disease complex of LUTS/BPH is not well studied but recent results support short-term benefit and long-term caution. Depression, a form of central nervous dysfunction, and ED, which is likely mediated via endothelial dysfunction, are independently associated with LUTS/BPH. The presence of cannabinoid receptors in urologic organs, coupled with recent population studies, supports a modulatory effect of marijuana on voiding although an enormous knowledge gap remains.

The rising worldwide impact of benign prostatic hyperplasia.

OBJECTIVES: To describe the trend in the impact of lower urinary tract symptoms attributed to benign prostatic hyperplasia (LUTS/BPH) on a global scale using the Global Burden of Disease (GBD) database. MATERIALS AND METHODS: Using the GBD database, worldwide data aggregated from registries and health systems from 1990 to 2017 were filtered for LUTS/BPH diagnoses. Calculation of years lived with disability (YLD) were compared with other urological diseases. YLD were calculated by a standardized method using assigned disability weights. The GBD-defined sociodemographic index (SDI) was used to assess impact of LUTS/BPH by global SDI quintile. RESULTS: Global Burden of Disease data over the 1990-2017 study period were summarized and global numbers and trends noted with other urological diseases for comparison. A total of 2 427 334 YLD were attributed to BPH in 2017 alone, almost three times more than those attributed to the next highest urological disease, prostate cancer (843 227 YLD). When stratified by SDI quintile, a much lower impact of BPH was found in the bottom three quintiles, despite this subset representing 66.9% of the 2017 world population. CONCLUSIONS: Lower urinary tract symptoms attributed to benign prostatic hyperplasia exert a rapidly rising human burden far exceeding other urological diseases. As the population ages and men in a lower SDI enjoy increased life expectancy and decreased competing mortalities, a continually accelerating wave of LUTS/BPH can be forecast. These epidemiological trends have serious implications for the future allocation of resources and the global urological workforce.