Impact of Fellowship-Trained Andrology and Sexual Medicine Specialists on Performance on the Annual American Urological Association In-Service Examination.

OBJECTIVE: To demonstrate the distribution and impact of fellowship-trained andrology and/or sexual medicine urological specialists (FTAUS) on resident in-service examination (ISE) performance. METHODS: Residency program websites were accessed to create a database of FTAUS in the United States between 2007 and 2017. This database was reviewed by three separate FTAUS and cross referenced with membership lists to the Sexual Medicine of North America Society and the Society for the Study of Male Reproduction. De-identified ISE scores were obtained from the American Urological Association from 2007-2017 and scores from trainees at programs with a FTAUS were identified for comparison. Resident performance was analyzed using a linear model of the effect of a resident being at a program with an FTAUS, adjusting for post-graduate year. RESULTS: ISE data from 13,757 residents were obtained for the years 2007-2017. The number of FTAUS in the United States increased from 40-102 during this study period. Mean raw scores on the "Sexual Dysfunction, Endocrinopathy, Fertility Problems" (SDEFP) section of the ISE ranged from 52.1% ± 17.7% to 65.7% ± 16% (mean ± SD). Throughout the study period, there was no difference in performance within the SDEFP section (P < .01). Residents at a program with a FTAUS answered 0.95% more questions correctly in the SDEFP than those without a FTAUS (P < .001). For these residents, there was an improvement of approximately 0.66% on the percentage of questions answered correctly on the ISE overall (P < .001). Performance improved significantly as residents progressed from PGY-2-PGY-5. CONCLUSION: There is a small but statistically significant improvement in overall ISE and SDEFP sub-section performance.

Perceived barriers to the adoption of active surveillance in low-risk prostate cancer: a qualitative analysis of community and academic urologists.

BACKGROUND: Clinical practice guidelines recommend active surveillance as the preferred treatment option for low-risk prostate cancer, but only a minority of eligible men receive active surveillance, and practice variation is substantial. The aim of this study is to describe barriers to urologists' recommendation of active surveillance in low-risk prostate cancer and explore variation of barriers by setting. METHODS: We conducted semi-structured interviews among 22 practicing urologists, evenly distributed between academic and community practice. We coded barriers to active surveillance according to a conceptual model of determinants of treatment quality to identify potential opportunities for intervention. RESULTS: Community and academic urologists were generally in agreement on factors influencing active surveillance. Urologists perceived patient-level factors to have the greatest influence on recommendations, particularly tumor pathology, patient age, and judgements about the patient's ability to adhere to follow-up protocols. They also noted cross-cutting clinical barriers, including concerns about the adequacy of biopsy samples, inconsistent protocols to guide active surveillance, and side effects of biopsy procedures. Urologists had differing opinions on the impact of environmental factors, such as financial disincentives and fear of litigation. CONCLUSIONS: Despite national and international recommendations, both academic and community urologists note a variety of barriers to implementing active surveillance in low risk prostate cancer. These barriers will need to be specifically addressed in efforts to help urologists offer active surveillance more consistently.

Exploration of biomarkers from a pilot weight management study for men undergoing radical prostatectomy.

BACKGROUND: Several biologic mechanisms, including inflammation and immune changes, have been proposed to explain the role of obesity in prostate cancer (CaP) progression. Compared to men of a healthy weight, overweight and obese men are more likely to have CaP recurrence post-prostatectomy. Obesity is related to inflammation and immune dysregulation; thus, weight loss may be an avenue to reduce inflammation and reverse these immune processes. OBJECTIVES: This study explores the reversibility of the biological mechanisms through intentional weight loss using a comprehensive weight management program in men undergoing prostatectomy. Outcomes include blood and tissue biomarkers, microtumor environment gene expression, inflammation markers and Dietary Inflammatory Index (DII) scores. METHODS: Twenty overweight men undergoing prostatectomy participated in this study. Fifteen men chose the intervention and 5 men chose the nonintervention group. The intervention consisted of a comprehensive weight loss program prior to prostatectomy and a weight maintenance program following surgery. Prostate tissue samples were obtained from diagnostic biopsies before the intervention and prostatectomy samples after weight loss. Blood samples and diet records were collected at baseline, pre-surgery after weight loss and at study end after weight maintenance. Immunohistochemistry and NanoString analysis were used to analyze the tissue samples. Flow cytometry was used to assess circulating immune markers. Inflammation markers were measured using Luminex panels. RESULTS: The intervention group lost >5% body weight prior to surgery. DII scores improved during the weight loss intervention from baseline to pre-surgery (P = 0.002); and between group differences were significant (P = 0.02). DII scores were not associated with IL-6 nor hsCRP. In the intervention, CXCL12, CXCR7, and CXCR4 (C-X-C motif chemokine ligand/receptor) and Ki67 expression decreased in the prostate tissue from biopsy to surgery (P = 0.06), yet plasma CXCL12 increased during the same timeframe (P = 0.009). The downregulation of several genes (FDR<0.001) was observed in the intervention compared to the non-intervention. Changes in immune cells were not significant in either group. CONCLUSION: This feasibility study demonstrates that in overweight men with localized CaP, weight loss alters blood, and tissue biomarkers, as well as tumor gene expression. More research is needed to determine the biological and clinical significance of these findings.

The American Board of Urology: In Pursuit of Diversity, Equity, and Inclusion.

INTRODUCTION: The purpose of this manuscript is to describe the methods we employ to build a foundation of diversity, quality and inclusion within the American Board of Urology and its certifying processes. METHODS: The American Board of Urology consists of 3 major committees: the Trustees of the Board and the Written and Oral Exam Committees. Yearly, before selecting new members to these committees, a Gap analysis is performed to evaluate discrepancies between the committee structure and the constituents we serve. The selection of new committee members is based on both the individual's merit and an attempt to match or supersede the diversity ratios described within the most current national census conducted by the American Urological Association. RESULTS: This year's evaluation revealed our committee structure consisting of 85% (98/115) male and 15% (17/115) women: National Census 90% and 10% respectively. Regarding race and ethnicity, White nonHispanic: 74% (85/115) compared to 81% (National Census); Hispanic: 1% (1/115) compared to 4%; Asian: 22% (25/115) compared to 12%; Black/African American 3% (4/115) compared to 2%. CONCLUSIONS: The American Board of Urology recognizes that the evaluation of ratios is an excellent initial step to establish diversity; however, ratios alone may not change behavior or attitudes. To reach our eventual goal, we must include educational efforts that inform our diplomates and committee members regarding the benefits of diversity. We also acknowledge that establishing and maintaining diversity within any governing board is an imperative that requires continuous and structural processes to be sustained.

Feasibility of a Weight Management Program Tailored for Overweight Men with Localized Prostate Cancer - A Pilot Study.

BACKGROUND: Overweight men with prostate cancer are more likely to suffer from recurrence and death following prostatectomy compared with healthy weight men. This study tested the feasibility of delivering a comprehensive program to foster weight loss before and weight maintenance after surgery in overweight men with localized prostate cancer. METHODS: Twenty overweight men scheduled for prostatectomy elected either the intervention (n = 15) or the nonintervention (n = 5). Anthropometrics, biomarkers, diet quality, nutrition literacy, quality of life, and long-term follow-up were assessed in both groups. RESULTS: The intervention led to 5.55 kg of weight loss including 3.88 kg of fat loss from baseline to surgery (mean = 8.3 weeks). The intervention significantly increased fiber, protein, fruit, nut, and vegetable intake; and decreased trans fats intake during weight loss. The intervention significantly reduced insulin, C-peptide, systolic blood pressure, leptin:adiponectin ratio, and visceral adiposity compared to the nonintervention. Post-surgically, weight loss was maintained. Changes in lipid profiles, nutrition literacy, and follow-up were not statistically significant in either group. CONCLUSION: Significant weight loss (≥5%) is feasible with a coaching intervention in overweight men preparing for prostatectomy and is associated with favorable cardiometabolic effects. This study is registered under NCT02252484 (www.clinicaltrials.gov).

Medical Professionalism Is Like Pornography: You Know it When You See it.

Addressing professionalism is a key role of Certification Boards, but how best to do this is not clear. This article describes a 360° approach to monitoring and enhancing professionalism taken by the American Board of Urology (ABU). In addition to monitoring full and active medical licenses, ABU has identified ethical issues specific to Urology, includes a position article on ethics in Urology on its Web site, and requires a completion of modules on ethics. As a part of its 10-year cycle, the Board requires peer evaluations from other urologists in the community. Finally, and most importantly, ABU uses a portfolio practice log to evaluate the candidates' use of procedures appropriate to their stated subspecialty area of expertise, evaluation of potential overuse or inappropriate use of procedures and a narrative that details any major complications associated with their procedures.

Eighteen-Year Review of Resident Performance on the American Urological Association In-Service Examination.

OBJECTIVE: To analyze national performance trends of urology residents on the American Urological Association In-Service Examination (ISE) over the last 18 years. METHODS: Trends in the national averages on the in-service examination for each year of residency training were collected and analyzed between the years 2000 and 2017. Mean and standard error were calculated for examination performance for each year of residency. Subject-specific performance was also determined for each given year of residency. Regression analysis was used to model trends in performance as a function of residency year. RESULTS: There was no significant difference in examination performance over 18 years with respect to each specific residency year. While there was an overall improvement in total scores with each advancing training year, year-over-year improvement in total examination performance began to plateau after Uro-2. Largest absolute performance improvement from Pre-Uro to Uro-4 were in subjects of "Urinary Diversion," "Obstructive Uropathy" and "Neoplasm." Scores in "Sexual Dysfunction, Endocrinopathy, Fertility Problems", and "Congenital Anomalies, Embryology, Anatomy" were consistently the lowest regardless of year of training. CONCLUSION: No significant change in performance was seen in each given year of residency over the 18-year period. There was improvement in overall scores as residents progressed through training, but scores plateaued after Uro-2 with minimal improvement between Uro-3 and Uro-4 years. Difference in subject scores suggests a disparity in educational focus in residency curricula and a potential need to improve the teaching strategies for subjects that tested less well throughout residency training.

Science in the Heartland: Exploring determinants of offering cancer clinical trials in rural-serving community urology practices.

OBJECTIVE: Engaging community urologists in referring patients to clinical trials could increase the reach of cancer trials and, ultimately, alleviate cancer disparities. We sought to identify determinants of referring patients to clinical trials among urology practices serving rural communities. METHODS: We conducted semistructured qualitative interviews based on the Theoretical Domains Framework at nonmetropolitan urology practices located in communities offering urological cancer trials. Participants were asked to consider barriers and strategies that might support engaging their patients in discussions about urological cancer clinical trials and referring them appropriately. Recorded interviews were transcribed and coded using template analysis. RESULTS: Most participants were not aware of available trials and had no experience with trial referral. Overall, participants held positive attitudes toward clinical trials and recognized their potential roles in accrual, but limited local resources reduced opportunities for offering trials. Most participants expressed a need for increased human, financial, and other resources to support this role. Many participants requested information and training to increase their knowledge of clinical trials and confidence in offering them to patients. Participants highlighted the need to build efficient pathways to identify available trials, match eligible patients, and facilitate communication and collaboration with cancer centers for patient follow-up and continuity of care. CONCLUSIONS: With adequate logistical and informational support, community urology practices could play an important role in clinical trial accrual, advancing cancer research and increasing treatment options for rural cancer patients. Future studies should explore the effectiveness of strategies to optimize urology practices' role in clinical trial accrual.

Patient Factors That Influence How Physicians Discuss Active Surveillance With Low-Risk Prostate Cancer Patients: A Qualitative Study.

For men diagnosed with prostate cancer, making treatment decisions can be overwhelming. Navigating treatment options, along with potential treatment side effects, can be difficult, and patients often rely heavily on the advice of their physicians. This study was aimed at understanding more about the way urologists talk with their patients about one treatment option: active surveillance (AS), a recognized management strategy for men with low-risk prostate cancer that includes close observation and monitoring of the cancer. This study reports, through 22 interviews with urologists, that urologists believe patients are hesitant about AS for a number of reasons, including misperceptions about cancer severity, anxiety, aversion to repeated biopsies that accompany AS, or family member preferences. Because urologists play an influential role in educating patients about treatment options, the discussion around AS can be impacted by barriers that physicians believe matter for their patients. Improving awareness among urologists about what factors impact their patient education about low-risk prostate cancer is important. Identifying tools to improve shared decision making in this area could result in treatment decisions that are increasingly concordant with patients' values, concerns, and goals.

Use of Nonprostate Ultrasound in Urology Practice.

INTRODUCTION: Ultrasound imaging is necessary for the care of urology patients, and urology residents are encouraged to learn ultrasound technique and interpretation. However, there is limited mandated education in this field. Currently the only ultrasound procedure considered an index case is transrectal ultrasound for prostate biopsy. We investigated the current use of nonprostate ultrasound in urological practice. METHODS: We reviewed ABU (American Board of Urology) certification and recertification logs of practicing urologists from 2012 to 2014. We obtained data for the codes 76700-76776 (kidney), 76870 (scrotal), 76999 (unlisted) and 93975-93981 (Doppler including penile). Codes 51798 (post-void residual) and 76950 (ultrasound for interstitial radiotherapy) were excluded from the study. We analyzed the results based on self-identified demographic information provided by the urologists. RESULTS: The practices of 2,427 urologists were reviewed and of these, 43% billed for at least 1 renal, scrotal or penile ultrasound. General and subspecialist urologists perform similar percentages of ultrasound studies, except for pediatrics (0% penile) and andrology (40% penile). Of those who reported on practice type (2,067) 82% self-identify as in private practice and performed more ultrasound studies than academic urologists, including renal 42% vs 23%, scrotal 33% vs 15% and penile 8% vs 6%, respectively. Men performed more nonprostate ultrasounds than women (44% vs 36%, p <0.001). CONCLUSIONS: In addition to prostate ultrasound, renal and scrotal ultrasound is relevant to all urologists regardless of practice model or subspecialty. Graduating residents can expect to perform ultrasound examinations in their practices and, therefore, in addition to prostate ultrasound we should train residents in renal and scrotal ultrasound.

Weight Management to Reduce Prostate Cancer Risk: A Survey of Men's Needs and Interests.

Obese men have a higher rate of prostate cancer-related death than non-obese men, and obesity increases the risk of prostate cancer progression and biochemical recurrence. The purpose of this study was to assess needs and interests of men for a technology-driven weight loss intervention to reduce prostate cancer risk. We distributed a survey collecting demographic characteristics, health history, exercise and eating habits (and perception of those habits), current and prior attempts of health behavior change, and technology use. Survey answers were summarized by count and percent of total respondents. Completed surveys (N = 109) described men with a family history of prostate cancer (25%), a history of elevated prostate specific antigen (26%), and prostate cancer survivors (22%). We compared body mass index (BMI) to perception of weight; overweight and obese men perceived their weight as more normal than their BMI category suggests. Most men reported their diet needed minor improvement (74%), and 65% of men reported they are either currently trying to lose weight or interested in weight loss. Most respondents access the internet (92%), while text messaging (60%) and smartphone application use (40%) are less frequent, especially in men over 60. Our results revealed a need and willingness for lifestyle modification and suggest a need for evidence-based weight loss strategies and for addressing the misperception of weight status. A male-tailored intervention that implements technology could improve energy balance, hold men accountable to healthy behavior change, and promote dietary patterns in order to reduce prostate cancer risk.

Enhancing DPYSL3 gene expression via a promoter-targeted small activating RNA approach suppresses cancer cell motility and metastasis.

To explore a novel strategy in suppressing tumor metastasis, we took the advantage of a recent RNA activation (RNAa) theory and used small double-strand RNA molecules, termed as small activating RNAs (saRNA) that are complimentary to target gene promoter, to enhance transcription of metastasis suppressor gene. The target gene in this study is Dihydro-pyrimidinase-like 3 (DPYSL3, protein name CRMP4), which was identified as a metastatic suppressor in prostate cancers. There are two transcriptional variants of DPYSL3 gene in human genome, of which the variant 2 is the dominant transcript (DPYSL3v2, CRMP4a) but is also significantly down-regulated in primary prostate cancers. A total of 8 saRNAs for DPYSL3v1 and 14 saRNAs for DPYSL3v2 were tested in multiple prostate cancer cell lines. While none of the saRNAs significantly altered DPYSL3v1 expression, 4 saRNAs showed a strong enhancing effect on DPYSL3v2 expression, resulting in reduced cell mobility in vitro. To achieve a prostate cancer-specific delivery for in vivo testing, we conjugated the most potent saV2-9 RNA molecule with the prostate-specific membrane antigen (PSMA)-targeting aptamer A10-3.2. The conjugates successful increased DPYSL3v2 gene expression in PSMA-positive but not PSMA-negative prostate cancer cells. In nude mice bearing orthotopic xenograft of prostate cancer, a 10-day consecutive treatment with the saV2-9 conjugates significantly suppress distal metastasis compared to the control saRNAs. Analysis of xenograft tissues revealed that DPYSL3v2 expression was largely increased in saV2-9 conjugate-treated group compared to the control group. In conclusion, DPYSL3v2 promoter-targeted saRNA molecules might be used as an adjunctive therapy to suppress prostate cancer metastasis.

The Need for Survivorship Care in Genitourinary Cancers: Considerations from SUO and LUGPA.

INTRODUCTION: A quarter of American cancer survivors have genitourinary malignancies that are largely managed by urologists. We explored urologist perceptions about survivorship care for genitourinary malignancies. METHODS: A total of 701 SUO (Society of Urologic Oncology) and 1,746 LUGPA (Large Urology Group Practice Association) members were invited to complete a web based survey composed of 5 domains, including 1) demographics, 2) current survivorship care practices, 3) perceived barriers, 4) accessibility to survivorship resources and 5) perceptions of advocacy groups. RESULTS: Of 191 respondents 137 (72%) had no training in survivorship care. Of the 174 respondents 129 (74%) practiced shared care models while 45 (26%) preferred pure specialized followup care. Only 39 of 129 respondents (30%) with a shared care model always provided a written care plan. These plans infrequently included information on lifestyle modifications and educational resources. Routine patient referral to advocacy organizations was highest for prostate cancer at 40% followed by bladder, testicular and kidney cancers at 17%, 10% and 8%, respectively. Lack of time/resources and practice guidelines were considered the 2 most important barriers to survivorship care by 31% and 30% of participants, respectively. Web based information on advocacy groups and best practice guidelines were selected as the most important initiatives to promote survivorship care. CONCLUSIONS: Despite the low response rate this study highlights important practice gaps in survivorship care for patients with genitourinary malignancies. In collaboration with advocacy organizations professional societies should initiate programs to better educate and train their members in survivorship care guidelines and consensus best practices.

GSK-3ß controls autophagy by modulating LKB1-AMPK pathway in prostate cancer cells.

BACKGROUND: Glycogen synthase kinase 3ß (GSK3B, GSK-3ß) is a multi-functional protein kinase involved in various cellular processes and its activity elevates after serum deprivation. We have shown that inhibition of GSK-3ß activity triggered a profound autophagic response and subsequent necrotic cell death after serum deprivation in prostate cancer cells. In this study, we dissected the mechanisms involved in GSK-3ß inhibition-triggered autophagy. METHODS: Prostate cancer PC-3 and DU145 cells were used in the study. Multiple GSK-3ß specific inhibitors were used including small chemicals TDZD8, Tideglusib, TWS119, and peptide L803-mts. Western blot assay coupled with phospho-specific antibodies were used in detecting signal pathway activation. ATP levels were assessed with ATPLite kit and HPLC methods. Autophagy response was determined by evaluating Microtubule-associated proteins 1A/1B light chain 3B (LC3B) processing and p62 protein stability in Western blot assays. Immunofluorescent microscopy was used to detect LKB1 translocation. RESULTS: Inhibition of GSK-3ß activity resulted in a significant decline of cellular ATP production, leading to a significant increase of AMP/ATP ratio, a strong trigger of AMP-activated protein kinase (AMPK) activation in prostate cancer PC-3 cells. In parallel with increased LC-3B biosynthesis and p62 protein reduction, the classical sign of autophagy induction, AMPK was activated after inhibition of GSK-3ß activity. Further analysis revealed that Liver kinase B1 (LKB1) but not Calcium/calmodulin-dependent protein kinase kinase ß (CaMKKß) is involved in AMPK activation and autophagy induction triggered by GSK-3ß inhibition. Meanwhile, GSK-3ß inhibition promoted LKB1 translocation from nuclear to cytoplasmic compartment and enhanced LKB1 interaction with its regulatory partners Mouse protein-25 (MO25) and STE20-related adaptor (STRAD). CONCLUSIONS: In conclusion, our data suggest that GSK-3ß plays an important role in controlling autophagy induction by modulating the activation of LKB1-AMPK pathway after serum deprivation.

Nanomicellar TGX221 blocks xenograft tumor growth of prostate cancer in nude mice.

BACKGROUND: Combination of androgen ablation along with early detection and surgery has made prostate cancer highly treatable at the initial stage. However, this cancer remains the second leading cause of cancer death among American men due to castration-resistant progression, suggesting that novel therapeutic agents are urgently needed for this life-threatening condition. Phosphatidylinositol 3-kinase p110ß is a major cellular signaling molecule and has been identified as a critical factor in prostate cancer progression. In a recent report, we established a nanomicelle-based strategy to deliver p110ß-specific inhibitor TGX221 to prostate cancer cells by conjugating the surface of nanomicelles with a RNA aptamer against prostate specific membrane antigen (PSMA) present in all clinical prostate cancers. In this study, we tested this nanomicellar TGX221 for its in vivo anti-tumor effect in mouse xenograft models. METHODS: Prostate cancer cell lines LAPC-4, LNCaP, C4-2 and 22RV1 were used to establish subcutaneous xenograft tumors in nude mice. Paraffin sections from xenograft tumor specimens were used in immunohistochemistry assays to detect AKT phosphorylation, cell proliferation marker Ki67 and proliferating cell nuclear antigen (PCNA), as well as 5-bromo-2-deoxyuridine (BrdU) incorporation. Quantitative PCR assay was conducted to determine prostate-specific antigen (PSA) gene expression in xenograft tumors. RESULTS: Although systemic delivery of unconjugated TGX221 significantly reduced xenograft tumor growth in nude mice compared to solvent control, the nanomicellar TGX221 conjugates completely blocked tumor growth of xenografts derived from multiple prostate cancer cell lines. Further analyses revealed that AKT phosphorylation and cell proliferation indexes were dramatically reduced in xenograft tumors received nanomicellar TGX221 compared to xenograft tumors received unconjugated TGX221 treatment. There was no noticeable side effect by gross observation or at microscopic level of organ tissue section. CONCLUSION: These data strongly suggest that prostate cancer cell-targeted nanomicellar TGX221 is an effective anti-cancer agent for prostate cancer.

A prospective study of erectile function after transrectal ultrasonography-guided prostate biopsy.

OBJECTIVE: To prospectively evaluate the effect of transrectal ultrasonography (TRUS)-guided prostate biopsy on erectile and voiding function at multiple time-points after biopsy. PATIENTS AND METHODS: All men who underwent TRUS-guided prostate biopsy completed a five-item version of the International Index of Erectile Function (IIEF-5) and the International Prostate Symptom Score (IPSS) before and at 1, 4 and 12 weeks after TRUS-guided biopsy. Statistical analyses used were a general descriptive analysis, continuous variables using a t-test and categorical data using chi-square analysis. A paired t-test was used to compare each patient's baseline score to their own follow-up survey scores. RESULTS: In all, 220 patients were enrolled with a mean age of 64.1 years and PSA level of 6.7 ng/dL. At initial presentation, 38.6% reported no erectile dysfunction (ED), 22.3% mild ED, 15.5% mild-to-moderate ED, 10% moderate ED, and 13.6% severe ED. On paired t-test there was a statistically significant reduction in IIEF-5 score at 1 week after biopsy compared with before biopsy (18.2 vs 15.5; P < 0.001). This remained significantly reduced at 4 (18.4 vs 17.3; P = 0.008) and 12 weeks (18.4 vs 16.9, P = 0.004) after biopsy. CONCLUSIONS: The effects of TRUS-guided prostate biopsy on erectile function have probably been underestimated. It is important to be aware of these transient effects so patients can be appropriately counselled. The exact cause of this effect is yet to be determined.

PI-3 kinase p110ß: a therapeutic target in advanced prostate cancers.

Prostate cancers in the castration-resistant stage are life-threatening because they are not curable in clinic. The novel androgen receptor inhibitor Xandi (Enzalutamide) and the new CYP17 inhibitor Zytiga (Abiraterone) prolonged patient survival only a few months in advanced prostate cancers. Therefore, novel therapeutic agents for advanced prostate cancers are urgently needed. PI-3 kinases are major intracellular signaling molecules that regulate multiple signal pathways related to cellular metabolism, cytokinesis, growth and survival. Accumulating evidence in the literature indicates that some isoforms of this kinase family are oncogenic and abnormally expressed in various human cancers, including prostate cancers. Recent extensive studies from our group and others showed that PI-3 kinase p110ß is aberrantly overexpressed in advanced prostate cancers and is critical for prostate cancer development and progression as demonstrated in cell-based and animal models. Importantly, novel p110ß-specific inhibitors have been developed and are currently been testing in clinical trials. In this article, we will briefly summarize recent developments in this regard.

Modifier 22 on perioperative outcomes of robotic assisted laparoscopic prostatectomy.

INTRODUCTION: Robotic assisted laparoscopic prostatectomy (RALP) is a mainstay in the treatment of prostate cancer. Current procedure terminology (CPT) identifies a case that requires substantially greater effort than usual by using the modifier 22 code (M22). Our objective was to identify the most common etiologies leading to M22 at our institution and determine the effect on perioperative outcomes. MATERIALS AND METHODS: We retrospectively reviewed our prostatectomy database from 2009-2012 to identify patients who underwent RALP with and without M22. Reasons for M22 were determined by review of operative reports. Comparisons were made using Chi-square analysis and independent t-tests for continuous data. RESULTS: Of 579 patients identified from our database, 208 (36%) had a M22. Eighty-six (41%) patients had ≥ 2 documented reasons for M22. Adhesiolysis was the most common reason for M22 followed by large prostate and previous hernia mesh. Body mass index (BMI) (29.8 versus 28), prostate volume (53 g versus 44 g), operative time (259 minutes versus 234 minutes), and discharge from hospital with pelvic drain in place (6.7% versus 3%) were all significantly higher in the M22 group. Final pathological stage and positive margin rate were not increased in those with a M22. Complications were not different between those with and without M22. CONCLUSION: The M22 code is associated with longer operative times, larger prostates, and higher BMI. Adverse effects on final pathological stage, margin status and complications were not found in those with M22. Many patients with a M22 have more than one reason documented as for the explanation of the modifier.

Prostate-specific antigen and prostate-specific antigen velocity as threshold indicators in 11C-acetate PET/CTAC scanning for prostate cancer recurrence.

PURPOSE: The aim of this study was to identify which patient characteristics are associated with the highest likelihood of positive findings on 11C-acetate PET/computed tomography attenuation correction (CTAC) (PET/CTAC) scan when imaging for recurrent prostate cancer. METHODS: From 2007 to 2011, 250 11C-acetate PET/CTAC scans were performed at a single institution on patients with prostate cancer recurrence after surgery, brachytherapy, or external beam radiation. Of these patients, 120 met our inclusion criteria. Logistic regression analysis was used to examine the relationship between predictability of positive findings and patients' characteristics, such as prostate-specific antigen (PSA) level at the time of scan, PSA kinetics, Gleason score, staging, and type of treatment before scan. RESULTS: In total, 68.3% of the 120 11C-acetate PET/CTAC scans were positive. The percentage of positive scans and PSA at the time of scanning and PSA velocity (PSAV) had positive correlations. The putative sensitivity and specificity were 86.6% and 65.8%, respectively, when a PSA level greater than 1.24 ng/mL was used as the threshold for scanning. The putative sensitivity and specificity were 74% and 75%, respectively, when a PSAV level greater than 1.32 ng/mL/y was used as the threshold. No significant associations were found between scan positivity and age, PSA doubling time, Gleason score, staging, or type of treatment before scanning. CONCLUSIONS: This retrospective study suggests that threshold models of PSA greater than 1.24 ng/mL or PSAV greater than 1.32 ng/mL per year are independent predictors of positive findings in 11C-acetate PET/CTAC imaging of recurrent prostate cancer.