Targeted focal therapy for the management of organ confined prostate cancer.

PURPOSE: Patients currently diagnosed with low risk prostate cancer are often overtreated and experience complications, resulting in detriment to quality of life. Targeted focal therapy is a minimally invasive procedure designed to ablate tumor foci while minimizing collateral damage to maintain quality of life. MATERIALS AND METHODS: This institutional review board approved, prospective study was done to assess the safety and efficacy of targeted focal therapy using cryotherapy in men 40 to 85 years old diagnosed with low risk, organ confined prostate cancer at our institution between 2006 and 2009. Low risk, organ confined prostate cancer was defined as Gleason score 7 or less (3 + 4) on transrectal ultrasound biopsy, tumor burden 50% or less and prostate specific antigen less than 10 ng/dl. Patients were evaluated for eligibility after undergoing 3-dimensional mapping biopsy. Median followup was 28 months (IQR 26-31). RESULTS: A total of 62 men with low risk disease met study inclusion criteria. At 1 year biopsy was negative in 50 of 62 patients (81%). All 12 men who tested positive on repeat biopsy had a Gleason score of 3 + 3 = 6 with 1 or 2 positive cores. The median prostate specific antigen change was a 3.0 ng/dl decrease (p <0.01). The median American Urological Association symptom score change was a 1.5-point decrease (p <0.01). No significant change was observed in Sexual Health Inventory for Men score (p = 0.6). No urinary incontinence episodes and no severe side effects were noted. CONCLUSIONS: Targeted focal therapy in carefully selected patients provides a feasible, practical option for treating low risk prostate cancer with minimal impact on quality of life.

A Description and Safety Overview of Irreversible Electroporation for Prostate Tissue Ablation in Intermediate-Risk Prostate Cancer Patients: Preliminary Results from the PRESERVE Trial.

The PRESERVE study (NCT04972097) aims to evaluate the safety and effectiveness of the NanoKnife System to ablate prostate tissue in patients with intermediate-risk prostate cancer (PCa). The NanoKnife uses irreversible electroporation (IRE) to deliver high-voltage electrical pulses to change the permeability of cell membranes, leading to cell death. A total of 121 subjects with organ-confined PCa ≤ T2c, prostate-specific antigens (PSAs) ≤ 15 ng/mL, and a Gleason score of 3 + 4 or 4 + 3 underwent focal ablation of the index lesion. The primary endpoints included negative in-field biopsy and adverse event incidence, type, and severity through 12 months. At the time of analysis, the trial had completed accrual with preliminary follow-up available. Demographics, disease characteristics, procedural details, PSA responses, and adverse events (AEs) are presented. The median (IQR) age at screening was 67.0 (61.0-72.0) years and Gleason distribution 3 + 4 (80.2%) and 4 + 3 (19.8%). At 6 months, all patients with available data (n = 74) experienced a median (IQR) percent reduction in PSA of 67.6% (52.3-82.2%). Only ten subjects (8.3%) experienced a Grade 3 adverse event; five were procedure-related. No Grade ≥ 4 AEs were reported. This study supports prior findings that IRE prostate ablation with the NanoKnife System can be performed safely. Final results are required to fully assess oncological, functional, and safety outcomes.

Clinical-pathologic correlation between transperineal mapping biopsies of the prostate and three-dimensional reconstruction of prostatectomy specimens.

BACKGROUND: Extended transrectal ultrasound guided biopsies (TRUSB) of the prostate may not accurately convey true morphometric information and Gleason score (GS) of prostate cancer (PCa) and the clinical use of template-guided (5-mm grid) transperineal mapping biopsies (TPMBs) remains controversial. METHODS: We correlated the clinical-pathologic results of 1,403 TPMB cores obtained from 25 men diagnosed with PCa with 64 cancer lesions found in their corresponding radical prostatectomy (RP) specimens. Special computer models of three-dimensional, whole-mounted radical prostatectomy (3D-WMRP) specimens were generated and used as gold standard to determine tumor morphometric data. Between-sample rates of upgrade and downgrade (highest GS and a novel cumulative GS) and upstage and downstage (laterality) were determined. Lesions ≥ 0.5 cm(3) or GS ≥ 7 were considered clinically significant. RESULTS: From 64 separate 3D-WMRP lesions, 25 had significant volume (mean 1.13 cm(3)) and 39 were insignificant (mean 0.09 cm(3)) (P < 0.0001); 18/64 lesions were missed by TPMB, but only one was clinically significant with GS-8 (0.02 cm(3)). When comparing the cumulative GS of TPMB versus RP, 72% (n = 18) had identical scores, 12% (n = 3) were upgraded, and only 16% (n = 4) were downgraded. Laterality of TPMB and RP was strongly correlated, 80% same laterality, 4% were up-staged, and 16% down-staged. CONCLUSIONS: Our clinical-pathology correlation showed very high accuracy of TPMB with a 5-mm grid template to detect clinically significant PCa lesions as compared with 3D-WMRP, providing physicians and patients with a reliable assessment of grade and stage of disease and the opportunity to choose the most appropriate therapeutic options.

Association of testosterone therapy with mortality, myocardial infarction, and stroke in men with low testosterone levels.

IMPORTANCE: Rates of testosterone therapy are increasing and the effects of testosterone therapy on cardiovascular outcomes and mortality are unknown. A recent randomized clinical trial of testosterone therapy in men with a high prevalence of cardiovascular diseases was stopped prematurely due to adverse cardiovascular events raising concerns about testosterone therapy safety. OBJECTIVES: To assess the association between testosterone therapy and all-cause mortality, myocardial infarction (MI), or stroke among male veterans and to determine whether this association is modified by underlying coronary artery disease. DESIGN, SETTING, AND PATIENTS: A retrospective national cohort study of men with low testosterone levels (<300 ng/dL) who underwent coronary angiography in the Veterans Affairs (VA) system between 2005 and 2011. MAIN OUTCOMES AND MEASURES: Primary outcome was a composite of all-cause mortality, MI, and ischemic stroke. RESULTS: Of the 8709 men with a total testosterone level lower than 300 ng/dL, 1223 patients started testosterone therapy after a median of 531 days following coronary angiography. Of the 1710 outcome events, 748 men died, 443 had MIs, and 519 had strokes. Of 7486 patients not receiving testosterone therapy, 681 died, 420 had MIs, and 486 had strokes. Among 1223 patients receiving testosterone therapy, 67 died, 23 had MIs, and 33 had strokes. At 3 years after coronary angiography, the Kaplan-Meier estimated cumulative percentages with events were 19.9%in the no testosterone therapy group vs 25.7%in the testosterone therapy group,with an absolute risk difference of 5.8%(95%CI, -1.4%to 13.1%) [corrected].The Kaplan-Meier estimated cumulative percentages with events among the no testosterone therapy group vs testosterone therapy group at 1 year after coronary angiography were 10.1% vs 11.3%; at 2 years, 15.4% vs 18.5%; and at 3 years, 19.9% vs 25.7 [corrected].There was no significant difference in the effect size of testosterone therapy among those with and without coronary artery disease (test for interaction, P = .41). CONCLUSIONS AND RELEVANCE: Among a cohort of men in the VA health care system who underwent coronary angiography and had a low serum testosterone level, the use of testosterone therapy was associated with increased risk of adverse outcomes. These findings may inform the discussion about the potential risks of testosterone therapy.

Cardiovascular/Stroke Risk Assessment in Patients with Erectile Dysfunction-A Role of Carotid Wall Arterial Imaging and Plaque Tissue Characterization Using Artificial Intelligence Paradigm: A Narrative Review.

PURPOSE: The role of erectile dysfunction (ED) has recently shown an association with the risk of stroke and coronary heart disease (CHD) via the atherosclerotic pathway. Cardiovascular disease (CVD)/stroke risk has been widely understood with the help of carotid artery disease (CTAD), a surrogate biomarker for CHD. The proposed study emphasizes artificial intelligence-based frameworks such as machine learning (ML) and deep learning (DL) that can accurately predict the severity of CVD/stroke risk using carotid wall arterial imaging in ED patients. METHODS: Using the PRISMA model, 231 of the best studies were selected. The proposed study mainly consists of two components: (i) the pathophysiology of ED and its link with coronary artery disease (COAD) and CHD in the ED framework and (ii) the ultrasonic-image morphological changes in the carotid arterial walls by quantifying the wall parameters and the characterization of the wall tissue by adapting the ML/DL-based methods, both for the prediction of the severity of CVD risk. The proposed study analyzes the hypothesis that ML/DL can lead to an accurate and early diagnosis of the CVD/stroke risk in ED patients. Our finding suggests that the routine ED patient practice can be amended for ML/DL-based CVD/stroke risk assessment using carotid wall arterial imaging leading to fast, reliable, and accurate CVD/stroke risk stratification. SUMMARY: We conclude that ML and DL methods are very powerful tools for the characterization of CVD/stroke in patients with varying ED conditions. We anticipate a rapid growth of these tools for early and better CVD/stroke risk management in ED patients.

The role of 3-dimensional mapping biopsy in decision making for treatment of apparent early stage prostate cancer.

PURPOSE: We determined the impact of a grid based, transperineal 3-dimensional mapping biopsy on decision making for primary management of early stage prostate cancer. MATERIALS AND METHODS: We prospectively performed 3-dimensional mapping biopsy on 180 consecutive men who presented to our clinic between 2006 and 2009 with early stage, organ confined prostate cancer based on transrectal ultrasound guided 10 to 12-core biopsy, and on 35 with prior negative transrectal ultrasound biopsies. RESULTS: At presentation median patient age was 60.5 years (range 43 to 77), median prostate specific antigen was 4.8 ng/ml (range 0.5 to 72.4) and median prostate volume was 35 cc (range 9 to 95). The median number of cores acquired by transrectal ultrasound and 3-dimensional mapping biopsy was 12 and 56, and the median number of positive cores was 1 and 2, respectively. We documented Gleason score upgrade in 49 of 180 cases (27.2%) and up-stage in 82 (45.6%). The incidence of urinary retention catheter requirement of greater than 48 hours was 3.2% and the incidence of transient orthostatic hypotension was 5%. No urinary tract infections were documented. A total of 38 men received radical extirpative therapy, 11 radiation and 45 cryotherapy while 60 enrolled in a targeted focal therapy study, 44 entered active surveillance and 5 underwent other focal investigational treatments. Post-mapping data on 12 men were not available for analysis. CONCLUSIONS: Three-dimensional mapping biopsy revealed that a significant portion of men initially diagnosed with apparently low risk disease harbored clinically significant cancers requiring more aggressive therapy. The technique also enabled a number of men with low risk disease to elect surveillance or another less morbid option.

Methods of developing UWIN, the modified American Urological Association symptom score.

PURPOSE: The American Urological Association symptom score instrument is widely used to assess lower urinary tract symptom severity in men. We describe the methods used to develop a shorter form of the American Urological Association symptom score that may provide symptom score assessment with minimal compromise in accuracy. MATERIALS AND METHODS: Complete American Urological Association symptom score data were collected on 8,731 men who attended Prostate Cancer Awareness Week in 2003 or 2004. Correlation analysis and area under the ROCs were used to determine the best reduced index and cutoff points in scores for the severity categories of mild, moderate and severe. RESULTS: The number of responses in the original 7 American Urological Association symptom score items was lowered from 6 to 4 and for the bothersome index it was lowered from 7 to 3. Four of the original 7 items were retained. Cronbach's α was 0.851 for the symptom score items in our data. The combination of items with the best joint correlation to the American Urological Association symptom score and bothersome score was UWIN (urgency, weak stream, incomplete emptying and nocturia). The correlation of UWIN with the American Urological Association symptom score was 0.938. The correlation of UWIN bother to the American Urological Association bothersome score was 0.638. The ROC for the mild, moderate and severe UWIN categories compared to the categorized American Urological Association symptom score was 0.96, 0.97 and 0.99, respectively. CONCLUSIONS: The UWIN instrument may potentially be a valuable tool to assess American Urological Association symptom score severity and bother. Clinical validation of this instrument is indicated in a prospective comparative study.

Validation of the modified American Urological Association symptom score.

PURPOSE: We created a shorter version of the American Urological Association symptom score, called UWIN (urgency, weak stream, incomplete emptying and nocturia). MATERIALS AND METHODS: Participants in Prostate Cancer Awareness Week from 2006 and 2007 were administered the regular American Urological Association symptom score and UWIN. A total of 278 participants completed each questionnaire. Total scores of each participant for the American Urological Association symptom score (range 0 to 35) and UWIN (range 0 to 12) were evaluated using Spearman's correlation coefficients and Bland-Altman plots to determine the level of agreement between the 2 questionnaires. RESULTS: The correlation between the total American Urological Association symptom score (range 0 to 35) and the total UWIN score (range 0 to 12) was 0.913 (p<0.0001). The correlation between the quality of life question on the American Urological Association symptom score and UWIN was 0.821 using the Spearman correlation coefficient (p<0.0001). A second analysis performed using Bland-Altman plots showed good agreement between the American Urological Association symptom score and UWIN. Overall, respondents tended to have slightly higher UWIN total scores than their American Urological Association symptom scores. CONCLUSIONS: This study validates that the UWIN questionnaire can be used in place of the American Urological Association symptom score. The UWIN questionnaire will lessen the burden on the respondent, broaden the applicability of the instrument and make collecting data as efficient and effective as possible.

Metastatic renal cell carcinoma to the prostate and seminal vesicle.

Renal cell carcinoma (RCC) a common malignancy with potential to metastasize to visceral organs. However, it uncommonly spreads to the lower genitourinary tract. We present a man with a history of RCC status post radical nephrectomy in April 2012. He presented 8 years later with obstructive lower urinary tract symptoms and an elevated prostate specific antigen (PSA). Further imaging showed a large enhancing mass with internal blood vessels posterior to the left prostate and seminal vesicle. A prostate biopsy was performed and consistent with metastatic RCC. He was ultimately treated with immunotherapy and focal stereotactic radioablation.

Boosting immune response with GM-CSF optimizes primary cryotherapy outcomes in the treatment of prostate cancer: a prospective randomized clinical trial.

OBJECTIVE: We explored the association of prostate cryotherapy and immunomodulation with granulocyte-macrophage colony-stimulating factor (GMCSF) in the generation of detectable tumor-specific T- and B-cell responses in men with prostate cancer. MATERIALS AND METHODS: A randomized pilot study of patients assigned to either cryotherapy alone (Control group) or in combination with GMCSF (Treatment group). The impact of therapy on the development of T- and B-cell responses against tumor-related antigens was studied using enzyme-linked immune absorbent spot (ELISpot) and protein microarray panels (Sematrix) assays, respectively. Fold changes in response to treatment were calculated by normalization of post-treatment ELISpot values against the mean pre-cryoablation response. Student t tests between treatment and control groups at 4 weeks and 12 weeks across all the antigens were performed. RESULTS: A total of 20 patients were randomized to either control or treatment arm. At 4 weeks after cryotherapy, the treatment group demonstrated an average fold change in cancer antigen-related antibodies of 2.8% above their mean baseline values, whereas controls averaged an 18% change below mean baseline (p < 0.05). At 12 weeks, antibody response in treatment group increased to 25% above baseline, while the average of control group patients remained 9% below baseline (p < 0.05). Patients in treatment group displayed, on average, higher ELISPOT readings for the 4- and 12-week times points (527 vs 481 for PSA and 748 vs 562 for PAP). CONCLUSIONS: GMCSF appeared to broadly elevate antibodies against prostate-specific and nonspecific antigens. Prostate antigen-specific T-cell responses were more enhanced over non-prostate-specific responses, preferentially in the treatment group. Our findings suggest a possible therapeutic effect of adjuvant immunotherapy in association with cryotherapy for the treatment of prostate cancer.

The Impact of Performing a 3D Mapping Biopsy Prior to Primary Cryotherapy for the Treatment of Prostate Cancer.

OBJECTIVE: To study the implications of adding a 3D mapping biopsy (3DMB) prior to prostate cryotherapy (PCT) for the treatment of prostate cancer on the following outcomes: recurrence and biochemical failure (BCF), quality of life outcomes, and complication rates. METHODS: A retrospective analysis of patients treated with either targeted focal therapy, or subtotal CT for localized prostate cancer was performed. The cohort was stratified by patients who had only had a transrectal ultrasound-guided biopsy (TRUS) and those who had undergone 1 additional 3DMB before definitive treatment. Pre- and postprocedural Prostate Symptom Score (IPSS) and Sexual Health Inventory for Men (SHIM) surveys were collected. BCF was defined using the Phoenix criteria. Patients with BCF were re-biopsied. Differences in pre/post changes in IPSS and SHIM scores were examined with Mann-Whitney U tests, binary measures with chi-square tests, and pre/post changes in PSA with t tests. A Kaplan-Meier time to BCF and recurrence analysis is presented. RESULTS: A total of 534 patients underwent PCT following TRUS only (n = 331) and TRUS with subsequent 3DMB (n = 203) between March 2007 and June 2016. No differences were observed in IPSS (P = .60) or SHIM scores drop (P = .06) between groups. PSA drop seemed more pronounced in the TRUS only biopsy group compared to the 3DMB, but again without statistical significance (P = .06). Recurrence rate and BCF were lower in the 3DMB group (P <.01). There was a higher rate of short-term complications detected in the TRUS only group (P = .02). CONCLUSION: BCF and local recurrence rates were lower among patients who underwent a confirmatory 3DMB before PCT, most likely due to better risk stratification in these patients. The addition of a 3DMB did not seem to adversely impact either rate of complications or functional outcomes.

Photodynamic therapy for treatment of solid tumors--potential and technical challenges.

Photodynamic therapy (PDT) involves the administration of photosensitizer followed by local illumination with visible light of specific wavelength(s). In the presence of oxygen molecules, the light illumination of photosensitizer can lead to a series of photochemical reactions and consequently the generation of cytotoxic species. The quantity and location of PDT-induced cytotoxic species determine the nature and consequence of PDT. Much progress has been seen in both basic research and clinical application in recent years. Although the majority of approved PDT clinical protocols have primarily been used for the treatment of superficial lesions of both malignant and non-malignant diseases, interstitial PDT for the ablation of deep-seated solid tumors are now being investigated worldwide. The complexity of the geometry and non-homogeneity of solid tumor pose a great challenge on the implementation of minimally invasive interstitial PDT and the estimation of PDT dosimetry. This review will discuss the recent progress and technical challenges of various forms of interstitial PDT for the treatment of parenchymal and/or stromal tissues of solid tumors.

Emerging role of HIFU as a noninvasive ablative method to treat localized prostate cancer.

The use of high-intensity focused ultrasound (HIFU) as a method for ablation of a localized tumor growth is not new. Several attempts have been made to apply the principles of HIFU to the treatment of pelvic, brain, and gastrointestinal tumors. However, only in the past decade has our understanding of the basic principles of HIFU allowed us to further exploit its application as a radical and truly noninvasive, intent-to-treat, ablative method for treating organ-confined prostate cancer. Prostate cancer remains an elusive disease, with many questions surrounding its natural history and the selection of appropriate patients for treatment yet to be answered. HIFU may play a crucial role in our search for an efficacious and safe primary treatment for localized prostate cancer. Its noninvasive and unlimited repeatability potential is appealing and unique; however, long-term results from controlled studies are needed before we embrace this new technology. Furthermore, a better understanding of HIFU's clinical limitations is vital before this treatment modality can be recommended to patients who are not involved in well-designed clinical studies. This review summarizes current knowledge about the basic principles of HIFU and its reported efficacy and morbidity in clinical series published since 2000.

Prospective Outcome Analysis of the Safety and Efficacy of Partial and Complete Cryoablation in Organ-confined Prostate Cancer.

OBJECTIVE: To determine the rate of complications and change in International Prostate Symptom Score and Sexual Health Inventory for Men scores following cryotherapy treatment of low- and intermediate-risk prostate cancer. The secondary end points were the change in prostate-specific antigen post cryotherapy and biopsy-proven recurrence. MATERIALS AND METHODS: Enrollment occurred from 2007 to 2015 to assess long-term complications of cryotherapy. A prostate biopsy was performed at 1 year or in the event of biochemical failure. Subjects were staged and graded by standard 12- to 14-core transrectal ultrasound (TRUS) biopsy. A subset of subjects underwent additional 3-dimensional mapping biopsy if the cancer was suspected to be downgraded. Analyses of functional outcomes were stratified into focal and nonfocal treatments. RESULTS: The study consisted of 393 men with low- and intermediate-risk prostate cancer, aged 44-89 years. Patient IPSS scores improved significantly in the nonfocal treatment strata at all time points and after 1 year in the focal strata with a median drop at 1 year of 4 points (P <.001). No significant difference was detected for a change in preprocedural SHIM score in either treatment strata after 2 years (P >.7). Eighty-two patients (20.9%) had a rise in prostate-specific antigen resulting in biochemical failure. Seventy patients had detected recurrence for an overall recurrence rate of 20.4% in 343 patients. A total of 109 patients (27.7%) reported urinary retention and urgency post cryotherapy, with 15.3% requiring catheterization for up to 3 weeks. Thirty-seven patients (9.4%) experienced urethral meatal stricture, and 36 patients (9.2%) reported unresolved new-onset erectile dysfunction. CONCLUSION: Complication rates, most significantly erectile dysfunction, are decreased in this study compared with those previously reported in the literature for cryotherapy for prostate cancer.

Targeted focal therapy: a minimally invasive ablation technique for early prostate cancer.

The morbidities associated with prostate cancer treatments have improved over the years. However, potential overtreatment and the risks of adverse events associated with radical treatment still pose a considerable challenge. Targeted focal therapy (TFT) of prostate cancer appears to be part of a logical continuum in the quest to improve upon the management of early organ-confined disease. TFT is a procedure in which only the cancer in the gland is ablated. The normal gland, sphincter, and in most cases the neurovascular bundles are preserved. Therefore, this approach averts some of the common complications of more radical therapy. Initial experience has been encouraging; however, long-term data and full implementation of emerging advances in imaging are urgently needed before the widespread adoption of this approach. In this review, we present the current status of our knowledge about this procedure and the most important challenges that need to be addressed. We also present the initial results with this approach at our center.

Initial Experience of Targeted Focal Interstitial Laser Ablation of Prostate Cancer with MRI Guidance.

INTRODUCTION: To develop and evaluate a technique of 3.0 Tesla magnetic resonance (MR) guided laser ablation based on 3-dimentional mapping biopsy (3DMB) for low risk prostate cancer. MATERIALS AND METHODS: The study was approved by the institutional review board and was the Health Insurance Portability and Accountability Act compliant. The prospective study was performed on seven 3DMB proven low risk prostate cancer patients. In the first phase of the procedure the patient's prostate was aligned to a position concordant with prior 3DMB using the transperineal grid and fiduciary golden marker coordinates. In the second phase ablation was performed using MR thermometry to determine the ablation endpoint and lesion coverage. Immediately after treatment dynamic contrast-enhanced MR imaging was done. Prostate-specific antigen testing was performed 3 and 12 months after the treatment and compared by ANOVA test. A follow up biopsy was done one year following ablation. RESULTS: The entire procedure took less than 2 hours and all patients tolerated the procedure well. There was a significant difference in prostate-specific antigen value before and 3 months after the treatment (p = 0.005). Four out of 6 patients had positive follow up biopsy for cancer. CONCLUSION: This study verifies the feasibility and safety of treating low risk prostate cancer with laser therapy guided by 3.0T MR imaging based on 3DMB.

Validation of the Urgency, Weak stream, Incomplete emptying, and Nocturia (UWIN) score compared with the American Urological Association Symptoms Score in assessing lower urinary tract symptoms in the clinical setting.

OBJECTIVE: To validate the Urgency, Weak stream, Incomplete emptying, and Nocturia (UWIN) survey for patients with lower urinary tract symptoms (LUTS) by comparison with the American Urological Association Symptoms Score (AUA-SS). The hypothesis is that the UWIN will perform as well as the AUA-SS in assessing LUTS symptoms and quality of life. The AUA-SS is complex for many patients and can be misunderstood. The UWIN questionnaire was developed to serve as a simpler and shorter version of the AUA-SS, with the intent of improving accuracy and minimizing error in assessing LUTS. The UWIN consists of 4 questions scored 0-3 to give a maximum score of 12. METHODS: We screened 700 patients in the urology clinic between 2011 and 2012. We enrolled 593 patients who completed the AUA-SS survey and UWIN in the same clinic visit. The AUA-SS and UWIN responses were evaluated using Spearman correlation coefficients and Bland-Altman graphs. RESULTS: Correlation coefficients were calculated between the corresponding AUA-SS and UWIN items on 593 matched surveys, demonstrating a strong correlation coefficient of 0.81 or greater for each question, which was statistically significant (P <.0001). The correlation coefficient between the total scores of the AUA and UWIN was 0.89 (P <.01). A second analysis was performed using Bland-Altman plots between AUA-SS and UWIN including total score, quality of life, and categories, which showed a good agreement. CONCLUSION: The UWIN appears to provide results comparable to the AUA-SS, while using a simpler format and taking less time to complete.