Building a Roadmap for Surveillance of Renal Masses Using a Modified Delphi Method to Help Achieve Consensus.

OBJECTIVE: To establish a consensus for initial evaluation and follow-up of patients on active surveillance (AS) for T1 renal masses (T1RM). METHODS: A modified Delphi method was used to gather information about AS of T1RM, with a focus on patient selection, timing/type of imaging modality, and triggers for intervention. A consensus panel of Michigan Urological Surgery Improvement Collaborative-affiliated urologists who routinely manage renal masses was formed. Areas of consensus (defined >80% agreement) about T1RM AS were established iteratively via 3 rounds of online questionnaires. RESULTS: Twenty-six Michigan Urological Surgery Improvement Collaborative urologists formed the panel. Consensus was achieved for 321/587 scenarios (54.7%) administered through 124 questions. Life expectancy, age, comorbidity, and renal function were most important for patient selection, with life expectancy ranking first. All tumors <3 cm and all patients with life expectancy <1 year were considered appropriate for AS. Appropriateness also increased with elevated perioperative risk, increasing tumor complexity, and/or declining renal function. Consensus was for multiphasic axial imaging initially (contrast CT for GFR >60 or MRI for GFR >30) with first repeat imaging at 3-6 months and subsequent imaging timing determined by tumor size. Consensus was for chest imaging for tumors >3 cm initially and >5 cm at follow up. Renal biopsy was not felt to be a requirement for entering AS, but useful in several scenarios. Consensus indicated rapid tumor growth as an appropriate trigger for intervention. CONCLUSION: Our consensus panel was able to achieve areas of consensus to help define a clinically useful and specific roadmap for AS of T1RM and areas for further discussion where consensus was not achieved.

Exploring Variation in the Receipt of Recommended Active Surveillance for Men with Favorable-Risk Prostate Cancer.

PURPOSE: Men on active surveillance for favorable-risk prostate cancer do not receive all the recommended testing. Reasons for variation in receipt are unknown. MATERIALS AND METHODS: We combined prospective registry data from the Michigan Urological Surgery Improvement Collaborative, a collaborative of 46 academic and community urology practices across Michigan, with insurance claims from 2014 to 2018 for men on active surveillance for favorable-risk prostate cancer. We defined receipt of recommended surveillance according to the collaborative's low-intensity criteria as: annual prostate specific antigen testing and either magnetic resonance imaging or prostate biopsy every 3 years. We assessed receipt of recommended surveillance among men with ≥36 months of followup (246). We conducted multilevel analyses to examine the influence of the urologist, urologist and primary care provider visits, and patient demographic and clinical factors on variation in receipt. RESULTS: During 3 years of active surveillance, just over half of men (56.5%) received all recommended surveillance testing (69.9% annual prostate specific antigen testing, 72.8% magnetic resonance imaging/biopsy). We found 19% of the variation in receipt was attributed to individual urologists. While increasing provider visits were not significantly associated with receipt, older men were less likely to receive magnetic resonance imaging/biopsy (≥75 vs <55 years, adjusted odds ratio 0.07; 95% confidence interval 0.01-0.81). CONCLUSIONS: Nearly half of men on active surveillance for favorable-risk prostate cancer did not receive all recommended surveillance. While urologists substantially influenced receipt of recommended testing, exploring how to leverage patients and their visits with their primary care providers to positively influence receipt appears warranted.

Overtreatment and Underutilization of Watchful Waiting in Men With Limited Life Expectancy: An Analysis of the Michigan Urological Surgery Improvement Collaborative Registry.

OBJECTIVE: To determine rates of watchful waiting (WW) vs treatment in prostate cancer (PCa) and limited life expectancy (LE) and assess determinants of management. MATERIALS AND METHODS: Patients diagnosed with PCa between 2012 and 2018 with <10 years LE were identified from the Michigan Urologic Surgery Improvement Collaborative registry. Multinomial logistic regression models were used to identify factors associated with management choice among NCCN low-risk PCa patients. Data from high-volume practices were analyzed to understand practice variation. RESULTS: Total 2393 patients were included. Overall, WW was performed in 8.1% compared to 23.3%, 25%, 11.2%, and 3.6% who underwent AS, radiation (XRT), prostatectomy (RP), and brachytherapy (BT), respectively. In men with NCCN low-risk disease (n = 358), WW was performed in 15.1%, compared to AS (69.3%), XRT (4.2%), RP (6.7%), and BT (2.5%). There was wide variation in management among practices in low-risk men; WW (6%-35%), AS (44%-81%), and definitive treatment (0%-30%). Older age was associated with less likelihood of undergoing AS vs WW (odds ratio [OR] 0.88, P < .001) or treatment vs WW (OR 0.83, P < .0001). Presence of ≥cT2 disease (OR 8.55, P = .014) and greater number of positive biopsy cores (OR 1.41, P = .014) was associated with greater likelihood of treatment vs WW and Charlson comorbidity score of 1 vs 0 (OR 0.23, P = .043) was associated with less likelihood of treatment vs WW. CONCLUSION: Wide practice level variation exists in management for patients with low- and favorable-risk PCa and <10-year LE. Utilization of WW is poor, suggesting overtreatment in men who will experience little benefit.

Acquired von Willebrand Disease Secondary to Clear Cell Renal Cell Carcinoma.

Background: Acquired von Willebrand disease (AvWD) is a rare and often underdiagnosed disease that typically is associated with lymphoproliferative, cardiovascular disease, and myeloproliferative disease. It is challenging to diagnose as it requires a hemostatic challenge to present itself. Case Presentation: This is a 46-year-old male with a history of multiple sclerosis complicated by neurogenic bladder who presented with intermittent gross painless hematuria. He underwent a gross hematuria workup. Cystoscopy demonstrated active bleeding from the right ureteral orifice. CT Urogram showed a filling defect in the right renal pelvis and endophytic 3 cm solid, enhancing left kidney mass. The patient underwent diagnostic cystourethroscopy, bilateral retrograde pyelogram demonstrating no filling defects bilaterally. Right ureteropyeloscopy demonstrated diffuse patchy erythema of the infrarenal collecting system with biopsies obtained. His postoperative course was complicated by gross hematuria requiring cystoscopy which demonstrated no upper tract bleeding and small pulsatile bleeding vessel in the bladder requiring cauterization. Hematology was consulted to rule out bleeding diathesis with workup demonstrating a von Willebrand deficiency (vWD). He had no family history of vWD and an AvWD was suspected. Hematologic workup was consistent with AvWD, type 2B vWD also known as a platelet-type von Willebrand disease. Renal pelvis biopsies were negative for pathology. Further investigation of the left renal mass confirmed a biopsy-proven clear cell renal cell carcinoma (ccRCC). He underwent a laparoscopic left radical nephrectomy with final pathology demonstrating pT1 ccRCC with negative margins. Postoperatively his repeat laboratories demonstrated normal factor VIII activity, ristocetin cofactor, and vWF antigen with normalized activated partial thromboplastin time. Follow-up imaging demonstrated no further evidence of disease supporting the hypothesis of a paraneoplastic syndrome from his ccRCC that caused an AvWD. Conclusion: This is the first case report to our knowledge of a paraneoplastic AvWD secondary to ccRCC. This should be on your differential when there is abnormal bleeding in the setting of renal masses.

Appropriateness Criteria for Active Surveillance of Prostate Cancer.

PURPOSE: The adoption of active surveillance varies widely across urological communities, which suggests a need for more consistency in the counseling of patients. To address this need we used the RAND/UCLA Appropriateness Method to develop appropriateness criteria and counseling statements for active surveillance. MATERIALS AND METHODS: Panelists were recruited from MUSIC urology practices. Combinations of parameters thought to influence decision making were used to create and score 160 theoretical clinical scenarios for appropriateness of active surveillance. Recent rates of active surveillance among real patients across the state were assessed using the MUSIC registry. RESULTS: Low volume Gleason 6 was deemed highly appropriate for active surveillance whereas high volume Gleason 6 and low volume Gleason 3+4 were deemed appropriate to uncertain. No scenario was deemed inappropriate or highly inappropriate. Prostate specific antigen density, race and life expectancy impacted scores for intermediate and high volume Gleason 6 and low volume Gleason 3+4. The greatest degree of score dispersion (disagreement) occurred in scenarios with long life expectancy, high volume Gleason 6 and low volume Gleason 3+4. Recent rates of active surveillance use among real patients ranged from 0% to 100% at the provider level for low or intermediate biopsy volume Gleason 6, demonstrating a clear opportunity for quality improvement. CONCLUSIONS: By virtue of this work urologists have the opportunity to present specific recommendations from the panel to their individual patients. Community-wide efforts aimed at increasing rates of active surveillance and reducing practice and physician level variation in the choice of active surveillance vs treatment are warranted.

Comparison of Pathological Outcomes for Men with Low Risk Prostate Cancer from Diverse Practice Settings: Similar Results from Immediate Prostatectomy or Initial Surveillance with Delayed Prostatectomy.

PURPOSE: We compared pathological outcomes after radical prostatectomy for a population based sample of men with low risk prostate cancer initially on active surveillance and undergoing delayed prostatectomy vs those treated with immediate surgery in order to better understand this expectant management approach outside of the context of academic cohorts. We hypothesized that delays in surgery due to initial surveillance would not impact surgical pathological outcomes. MATERIALS AND METHODS: We performed a prospective cohort study of 2 groups of patients with NCCN low risk prostate cancer from practices in the Michigan Urological Surgery Improvement Collaborative, that is 1) men who chose initial active surveillance and went on to delayed prostatectomy and 2) men who chose immediate prostatectomy. Diagnoses occurred from January 2011 through August 2015. For these 2 groups we compared radical prostatectomy Gleason scores, and rates of extraprostatic disease, positive surgical margins, seminal vesicle invasion and lymph node metastases. RESULTS: During a median followup of 506 days 79 (6%) of 1,359 low risk men choosing initial surveillance transitioned to prostatectomy. Compared to those treated with immediate prostatectomy (778), men undergoing delayed surgery were more likely to have Gleason score 7 or greater disease (69.2% vs 48.8%, respectively, p=0.004), but were no more likely to have positive margins, extraprostatic extension, seminal vesicle invasion or lymph node metastases. CONCLUSIONS: Patients with low risk prostate cancer who enter active surveillance have higher grade disease at prostatectomy compared to those undergoing immediate surgery. However, the lack of difference in other adverse pathological outcomes suggests preservation of the window of curability.

Urologists' personal feelings on PSA screening and prostate cancer treatment.

RATIONALE, AIMS AND OBJECTIVE: This study aimed to determine if urologists' feelings on prostate cancer screening with prostate-specific antigen (PSA) and treatment on themselves are consistent with what they recommend to patients. METHODS: A survey regarding prostate cancer screening and treatment was assembled using the SurveyMonkey web site. The link to the survey was then emailed to urologists. Participation was voluntary. RESULTS: The survey was sent to 2672 American urologists and completed by 215 urologists; response rate was 8%. One hundred ninety-eight (92%) were male. Most (56%) urologists recommend PSA screening beginning at age 50 for patients, and this corresponded with the age at which survey responders began their PSA screening. Two urologists did not recommend screening, and 10% were 'not sure' if screening saves lives. Of those that had not had their PSA checked, 34% plan to begin screening at 40-44 with 11% stating they 'never' plan to be screened. One hundred thirty-eight (70%) men completing the survey had their PSA checked. The majority (86%) had it drawn for screening. Nineteen respondents had an elevated PSA with nine men diagnosed with prostate cancer. Eight of these had radical prostatectomy. When faced with the hypothetical diagnosis of an elevated PSA and low-grade prostate cancer, respondents favoured repeat PSA (94%) and surveillance (48%), respectively, than any other option. CONCLUSION: Despite recommendations from the American Urologic Association to screen men for prostate cancer, a significant percentage of urologists do not wish to be screened with PSA. Almost all, however, continue to recommend prostate cancer screening for their patients. Treatment recommendations also varied among the respondents.

Cystectomy for ulcerative interstitial cystitis: sequelae and patients' perceptions of improvement.

OBJECTIVE: To evaluate the outcomes after cystectomy for ulcerative interstitial cystitis (IC). METHODS: Medical records were reviewed for history, operative data, and postoperative events. A mailed survey assessed preoperative symptom severity/duration, providers seen, and symptom changes on 7-point scaled global response assessments. Descriptive statistics were performed. RESULTS: Of 10 women (mean age 64 ± 12.5 years), 9 had cystectomy with ileal conduit and 1 had a neobladder. All had previous cautery of Hunner's ulcer (median 3.0 cautery procedures). Maximum bladder capacity at first and last cautery was median 325 and 188 mL, respectively. Median operative time was 321 minutes, blood loss was 200 mL (range, 100-900), 4 of 10 were transfused, and length of stay was 8 days. During a mean follow-up of 3.9 years, 6 patients required 1 or more reoperations, including hernia repair (2), urostomy revision (2), revision of ureteroileal anastomosis (1), small bowel resection (1), and neobladder cutaneous fistula repair (1). Survey respondents (n = 9) reported having seen (mean) 5.4 ± 3.8 providers before cystectomy. Median duration of symptoms was 5 years, and day and nighttime urinary frequencies were 30 and 15 times, respectively. Postoperatively, IC pain had resolved in all patients except for one. On the global response assessments, patients had moderate/marked improvement in overall symptoms (8 of 8), pain (9 of 9), sexual function (4 of 6), and quality of life (8 of 9), 7 of 9 were very satisfied with the treatment, and 8 of 9 would make the same decision again. CONCLUSION: Despite subsequent reoperations, symptom improvements lead to high levels of satisfaction with cystectomy for IC.

Can video games be used to predict or improve laparoscopic skills?

BACKGROUND AND PURPOSE: Performance of laparoscopic surgery requires adequate hand-eye coordination. Video games are an effective way to judge one's hand-eye coordination, and practicing these games may improve one's skills. Our goal was to see if there is a correlation between skill in video games and skill in laparoscopy. Also, we hoped to demonstrate that practicing video games can improve one's laparoscopic skills. SUBJECTS AND METHODS: Eleven medical students (nine male, two female) volunteered to participate. On day 1, each student played three commercially available video games (Top Spin, XSN Sports; Project Gotham Racing 2, Bizarre Creations; and Amped 2, XSN Sports) for 30 minutes on an X-box (Microsoft, Seattle, WA) and was judged both objectively and subjectively. Next, the students performed four laparoscopic tasks (object transfer, tracing a figure-of-eight, suture placement, and knot-tying) in a swine model and were assessed for time to complete the task, number of errors committed, and hand-eye coordination. The students were then randomized to control (group A) or "training" (i.e., video game practicing; group B) arms. Two weeks later, all students repeated the laparoscopic skills laboratory and were reassessed. RESULTS: Spearman correlation coefficients demonstrated a significant relation between many of the parameters, particularly time to complete each task and hand-eye coordination at the different games. There was a weaker association between video game performance and both laparoscopic errors committed and hand-eye coordination. Group B subjects did not improve significantly over those in group A in any measure (P >0.05 for all). CONCLUSION: Video game aptitude appears to predict the level of laparoscopic skill in the novice surgeon. In this study, practicing video games did not improve one's laparoscopic skill significantly, but a larger study with more practice time could prove games to be helpful.

Stent-change therapy in advanced malignancies with ureteral obstruction.

BACKGROUND AND PURPOSE: To determine if patients with advanced malignancies and resultant ureteral obstruction who are managed with chronic ureteral stent changes have adequate preservation of renal function and an acceptable rate of complications. PATIENTS AND METHODS: A retrospective review was conducted on 28 patients who had a stent to relieve ureteral obstruction caused by cancer. RESULTS: During the study period, 201 stents were placed, a median of 4 (range 1-34) per patient. The mean time from cancer diagnosis to first stent placement was 34 months (range 1-109 months). The median survival after the first stent insertion was 15.3 months (95% CI 15.1, 15.6). Seven patients had worsening renal function and hydronephrosis despite indwelling stents. In these patients, the median time from the first stent to a rising serum creatinine concentration was 17 months (range 1-66 months). No patient required dialysis. Eighteen patients developed a total of 69 urinary tract infections (mean 2.5). Eight patients had a total of 13 episodes of urosepsis. The median infection-free survival was 11.9 months (range 7.7-16.9 months). The median urosepsis-free survival was 28.5 months (range 9.7-47.1 months). Fourteen patients died from their malignancies during the study. CONCLUSIONS: Stent-change therapy is an efficacious way to treat patients with advanced malignancies and ureteral obstruction, many of whom have a short life expectancy. All patients maintained adequate renal function to obviate dialysis. Most patients with stents in place will die before their renal function deteriorates. They may also benefit from treatment strategies designed to avoid the occurrence of frequent urinary infections.

Ancillary instrumentation for ureteroscopy.

As the quality of ureteroscopy continues to improve, ancillary instrumentation will advance. The endourologist now has a vast supply of specially designed guidewires, stents, balloons, and baskets. These technologies have expanded the realm of cases that may be managed endoscopically. As the urologist becomes more familiar with the options at his or her disposal, patient care will improve.