Evaluation of Educational Feedback in Urology Training: A Survey-Based Assessment of Trainees and Program Directors.

OBJECTIVE: Our objective was to evaluate current satisfaction with the feedback provided during post-graduate urological training, including the quality and frequency of feedback, with participants consisting of both trainees and program directors. Additionally, we aimed to identify areas for future improvement in resident and fellow-level urological training. METHODS: Graduating residents, fellows, and program directors from accredited residency/fellowship programs in the United States were surveyed. A total of 575 surveys were sent out. Information on feedback frequency, quality, form, and satisfaction was collected using applicable multiple-choice responses and a five-point Likert scale. An open-ended question gathered suggestions for improving current feedback processes. A chi-square test of independence was used to compare the responses to individual questions. RESULTS: Ninety-two respondents answered our survey: 22 residents, 18 fellows, 25 residency program directors (PDs), and 27 fellowship PDs. The distribution of age, race, and gender categories was not significantly different between PDs and trainees. However, there was a significant difference in their subspecialties and American Urological Association (AUA) sections. The majority of fellowship PDs, residency PDs, fellows, and residents (88 total) reported verbal feedback as the predominant method within their practice. This was followed by written (68 total), electronic (54 total), and app-based feedback (19 total). CONCLUSION: Our study suggests that there may be a need for ongoing improvement or standardization of feedback mechanisms in the field of urological training and highlights the perceived discrepancies between learners and educators.

Primary Chemoablation of Low-Grade Intermediate-Risk Nonmuscle-Invasive Bladder Cancer Using UGN-102, a Mitomycin-Containing Reverse Thermal Gel (Optima II): A Phase 2b, Open-Label, Single-Arm Trial.

PURPOSE: Low-grade intermediate-risk nonmuscle-invasive bladder cancer (LG IR NMIBC) is a recurrent disease, thus requiring repeated transurethral resection of bladder tumor under general anesthesia. We evaluated the efficacy and safety of UGN-102, a mitomycin-containing reverse thermal gel, as a primary chemoablative therapeutic alternative to transurethral resection of bladder tumor for patients with LG IR NMIBC. MATERIALS AND METHODS: This prospective, phase 2b, open-label, single-arm trial recruited patients with biopsy-proven LG IR NMIBC to receive 6 once-weekly instillations of UGN-102. The primary end point was complete response (CR) rate, defined as the proportion of patients with negative endoscopic examination, negative cytology and negative for-cause biopsy 3 months after treatment initiation. Patients with CR were followed quarterly up to 12 months to assess durability of treatment effect. Safety and adverse events were monitored throughout the trial. RESULTS: A total of 63 patients (38 males and 25 females 33-96 years old) enrolled and received ≥1 instillation of UGN-102. Among the patients 41 (65%) achieved CR at 3 months, of whom 39 (95%), 30 (73%) and 25 (61%) remained disease-free at 6, 9 and 12 months after treatment initiation, respectively. A total of 13 patients had documented recurrences. The probability of durable response 9 months after CR (12 months after treatment initiation) was estimated to be 73% by Kaplan-Meier analysis. Common adverse events (incidence ≥10%) included dysuria, urinary frequency, hematuria, micturition urgency, urinary tract infection and fatigue. CONCLUSIONS: Nonsurgical primary chemoablation of LG IR NMIBC using UGN-102 resulted in significant treatment response with sustained durability. UGN-102 may provide an alternative to repetitive surgery for patients with LG IR NMIBC.

PCA3-based nomogram for predicting prostate cancer and high grade cancer on initial transrectal guided biopsy.

BACKGROUND: To develop a validated prostate cancer antigen 3 (PCA3) based nomogram that predicts likelihood of overall prostate cancer (PCa) and intermediate/high grade prostate cancer (HGPCa) in men pursuing initial transrectal prostate biopsy (TRUS-PBx). METHODS: Data were collected on 3,675 men with serum prostate specific antigen level (PSA) ≤ 20 ng/ml who underwent initial prostate biopsy with at least 10 cores sampling at time of the biopsy. Two logistic regression models were constructed to predict overall PCa and HGPCa incorporating age, race, family history (FH) of PCa, PSA at diagnosis, PCA3, total prostate volume (TPV), and digital rectal exam (DRE). RESULTS: One thousand six hundred twenty (44%) patients had biopsy confirmed PCa with 701 men (19.1%) showing HGPCa. Statistically significant predictors of overall PCa were age (P < 0.0001, OR. 1.51), PSA at diagnosis (P < 0.0001, OR.1.95), PCA3 (P < 0.0001, OR.3.06), TPV (P < 0.0001, OR.0.47), FH (P = 0.003, OR.1.32), and abnormal DRE (P = 0.001, OR. 1.32). While for HGPCa, predictors were age (P < 0.0001, OR.1.77), PSA (P < 0.0001, OR.2.73), PCA3 (P < 0.0001, OR.2.26), TPV (P < 0.0001, OR.0.4), and DRE (P < 0.0001, OR.1.53). Two nomograms were reconstructed for predicted overall PCa probability at time of initial biopsy with a concordance index of 0.742 (Fig. 1), and HGPCa with a concordance index of 0.768 (Fig. 2). CONCLUSIONS: Our internally validated initial biopsy PCA3 based nomogram is reconstructed based on a large dataset. The c-index indicates high predictive accuracy, especially for high grade PCa and improves the ability to predict biopsy outcomes.

Reduction in hospital admissions with the addition of prophylactic intramuscular ceftriaxone before transrectal ultrasonography-guided prostate biopsies.

OBJECTIVE: To evaluate the hospitalization rates in 2 pre-prostate biopsy antibiotic protocols. METHODS: Two prebiopsy protocols were compared. CiproAlone required ciprofloxacin 500 mg twice daily starting 1 day before biopsy and continuing for 3 days after biopsy (4 days total). Diabetic patients were prescribed ciprofloxacin for 4 days after biopsy. CiproCeft required 1 dose of oral ciprofloxacin 500 mg 1 hour before the biopsy and ceftriaxone 1 g intramuscular at the time of the biopsy. Hospitalization rates between the CiproAlone vs CiproCeft protocols were examined. RESULTS: A total of 4134 biopsies were identified-2093 in the CiproAlone cohort and 2041 in the CiproCeft cohort. The post-prostate biopsy infection hospitalization rate was 0.6% (14 patients) in the CiproAlone group vs 0.0% (0 patients) in the CiproCeft group (P <.0001). Of the patients hospitalized, 12 fit systemic inflammatory response syndrome (SIRS) criteria. Eight of 14 hospitalized patients fit the sepsis (SIRS and source of infection) criteria. Positive cultures (urine and/or blood) resulted from 71% (n = 10) of hospitalized patients. Antibiotic resistance was analyzed. Diabetes mellitus was associated with hospitalization after prostate biopsy (P = .01) in our population, but there was no difference between the 2 groups in the rates of diabetes mellitus (P = .46). Patient age, prostate-specific antigen level, number of biopsy cores obtained, race, and previous antibiotics exposure were not found to be independent predictors of post-transrectal ultrasonography biopsy hospitalization for infection using a multivariate regression analysis. CONCLUSION: A prophylactic prebiopsy protocol including 2 classes of antibiotics, single-dose ciprofloxacin, and single-dose intramuscular ceftriaxone reduced post-transrectal ultrasonography biopsy rates of hospitalizations compared to oral ciprofloxacin alone.

Urinary PCA3 as a predictor of prostate cancer in a cohort of 3,073 men undergoing initial prostate biopsy.

PURPOSE: PCA3 is a urinary marker that has shown promise in predicting the presence of prostate cancer in men undergoing repeat prostate biopsy. We studied PCA3 before initial prostate biopsy. MATERIALS AND METHODS: Records from a single organization were retrospectively reviewed. The predictive value of PCA3 was explored using nonparametric receiver operating characteristic curve analysis (ROC) and multivariable logistic regression analysis. RESULTS: A total of 3,073 men underwent PCA3 analysis before initial prostate biopsy sampling of 12 to 14 areas. Mean PCA3 was 27.2 and 52.5 for patients without and with cancer, respectively. Prostate cancer was identified in 1,341 (43.6%) men. Overall 54.5% had Gleason 6 disease and 45.5% had Gleason 7 or greater (high grade prostate cancer). Mean PCA3 was 47.5 and 58.5 for the patients with Gleason 6 and 7 or greater disease, respectively. On multivariable logistic analysis PCA3 was statistically significantly associated with prostate cancer and high grade prostate cancer after adjusting for prostate specific antigen (p<0.001 for both), free prostate specific antigen (p=0.04 and p=0.01, respectively), age (p<0.001 for both), family history (p<0.001 and p=0.59, respectively), abnormal digital rectal examination (p=0.31 and p<0.001, respectively), prostate volume (p<0.001 for both) and body mass index (p<0.001 for both). Using ROC analysis PCA3 outperformed prostate specific antigen in the prediction of prostate cancer (AUC 0.697 vs 0.599, p<0.01) but not for high grade prostate cancer (AUC 0.682 vs 0.679, p=0.702). CONCLUSIONS: PCA3 proved a useful tool in identifying patients at risk for prostate cancer before initial prostate biopsy. To our knowledge this is the largest PCA3 study in the initial biopsy population. These results suggest that further exploration of the value of PCA3 is warranted.

Effect of pretreatment prostate volume on urinary quality of life following intensity-modulated radiation therapy for localized prostate cancer.

BACKGROUND: The aim of this study was to describe the effect of pretreatment prostate volume on urinary quality of life after intensity-modulated radiation therapy (IMRT) for clinically localized prostate cancer. METHODS: A total of 368 men treated with prostate IMRT (77.4-81 Gy) were stratified into three gland volume groups, ie, <30 g (group 1), 30-60 g (group 2), and >60 g (group 3). Post-IMRT urinary function was evaluated by National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 genitourinary guidelines at one year post-IMRT, and surveyed by the International Prostate Symptom Score (IPSS) before treatment, and then at one month and one year post-IMRT. RESULTS: Late (one year post-IMRT) CTCAE version 4.0 genitourinary toxicity occurred in 11/368 (3.0%) men, but was not severe (grade ≥ 3); total toxicity was similar between the prostate volume groups (P = 0.86). Continuous prostate volume neither correlated with (P = 0.50) nor predicted late genitourinary toxicity (univariate odds ratio 0.99, 95% confidence interval 0.96-1.02). The total IPSS cohort, group 1 (<30 g) and 2 (30-60 g), showed a similar IPSS trend of elevation from pretreatment baseline to one month post-IMRT (each P < 0.01), then a reduction to baseline at one year (each P < 0.01). Group 3 (>60 g) had the highest pretreatment IPSS, but uniquely showed a better urinary symptom trend than the smaller volume groups, with similar IPSS from baseline to one month post-IMRT (P = 0.88) and improved post-treatment IPSS from baseline at one year (P = 0.003). CONCLUSION: Pretreatment prostate volume and initial IPSS scores were not associated with increased late genitourinary toxicity after IMRT in our series. Patients with smaller prostates had an initial increase in urinary symptoms, but returned to baseline at one year. Larger prostate glands (>60 g) had comparatively worse pretreatment symptoms, but at one year showed an overall improvement in IPSS versus baseline.

Sensorimotor polyneuropathy and foot-drop as result of a prostate cancer paraneoplastic syndrome.

Paraneoplastic syndromes (PNS) vary in incidence and manifestation based on tumor histology. PNS secondary to urologic malignancies have an extremely low incidence. Most reported cases of PNS from urologic malignancies are associated with adenocarcinoma. Peripheral neuropathy-associated PNS from urologic malignancy are exceedingly rare. An 80-year-old male developed a paraneoplastic sensorimotor polyneuropathy and foot-drop after a diagnosis of clinical stage T2cN0M0, Gleason grade 5+4 prostate cancer. A thorough workup is needed in order to adequately assess and treat PNS. Careful analysis must be used to determine the root cause of a patient's symptoms.

Use of PCA3 in detecting prostate cancer in initial and repeat prostate biopsy patients.

BACKGROUND: The PCA3 urinary assay has shown promise in predicting the presence of prostate cancer. We evaluated the value of this test in patients undergoing initial and repeat prostate biopsy. METHODS: PCA3 and PSA levels were obtained from 456 men with no known personal history of prostate cancer prior to prostate biopsy. Two hundred eighty-nine men underwent an initial prostate biopsy and 167 underwent a repeat prostate biopsy. PCA3 and PSA levels were compared to the prostate biopsy results. RESULTS: PCA3 score was shown to be independent of prostate volume (P = 0.162) and PSA level (P = 0.959). PCA3 scores were significantly higher in patients with cancer on prostate biopsy compared to patients with negative biopsy results (P < 0.0001). In logistic regression, PCA3 showed a significantly higher AUC than PSA (0.726 vs. 0.512, P = 0.0001). This difference persisted when examining the initial biopsy subgroup, with PCA3 out-performing PSA (AUC 0.772 vs. AUC = 0.552, P < 0.0001), but not in the repeat biopsy subgroup (AUC = 0.605 vs. AUC = 0.500, P = 0.2488). CONCLUSIONS: PCA3 was found to be a better predictor of prostate cancer than PSA in the total population as well as the initial biopsy population, but was not superior to PSA in the repeat biopsy population. Prostate 73: 48-53, 2013. © 2012 Wiley Periodicals, Inc.

Low incidence of prostate cancer identified in the transition and anterior zones with transperineal biopsy.

PURPOSE: Determine the incidence of anterior (AZ) and transition (TZ) zone prostate cancers using a transperineal mapping approach. METHODS: A retrospective review of 137 patients with history of previous negative biopsy undergoing transperineal saturation biopsy for an elevated prostate-specific antigen (PSA), high-grade prostate intraepithelial neoplasia, atypical small acinar proliferation history, or abnormal digital rectal exam. The number of biopsy cores was determined by prostate volume and obtained using a predefined template. The electronic medical records were reviewed for patients' clinical and pathological characteristics. RESULTS: Forty-one of 137 patients (31.4%) had positive biopsy for prostate adenocarcinoma; 11 were from 24-core, 19 from 36-core, and 11 from 48-core sampling. Glands > 45 mL had a mean of 1.7 previous biopsies and a PSA of 9.1 ng/mL. Glands < 30 mL were 1.3 and 6.3 ng/mL and glands 30-45 mL were 1.4 and 6.5 ng/mL. Glands < 45 mL had a higher number of positive biopsies per total cores. Seven patients chose active surveillance while 34 chose treatment. Of the 36- and 48-cores biopsies, 2.2% and 1.5%, respectively, were positive in the TZ. One patient was AZ-positive, 1 was TZ-positive, and 18 were peripheral zone (PZ)-positive alone. Twelve patients had cancer detected in PZ and TZ. Two patients developed urinary retention and one had a urine infection. CONCLUSION: Transperineal saturation biopsy is a safe and efficacious method of prostate cancer detection in patients with previous negative biopsy and high suspicion for cancer. Few cancers were found to originate in the TZ or AZ alone. We recommend that initial biopsy templates should sample PZ with less focus on the TZ.