Biochemical failure-rate and preservation of erectile function after prostate seed brachytherapy in early-onset prostate cancer.

INTRODUCTION: To analyze biochemical failure-free survival and erectile dysfunction (ED) in younger men treated with prostate seed brachytherapy (PB). MATERIALS AND METHODS: Included were patients ≤ 55 years treated with PB. Erectile function at baseline and after treatment were assessed using the physician-reported CTCAE version 4.0. Biochemical failure (BF) was defined according to the Phoenix Consensus definition (PSA nadir + 2 ng/mL). The log-rank test (Kaplan-Meier method) and cox-regression analysis was used to calculate BF-free survival. RESULTS: Between July 2005 and November 2020, a total of 137 patients ≤ 55 years (range 44-55 years old) were treated with PB. Median follow up was 72 months. Twenty percent had Gleason 3+4 disease and 6% a PSA >10 ng/mL. Median prostate volume was 34 cc. Actuarial biochemical failure free survival at 5, 7, and 10 years, were 98%, 95% and 89%, respectively. Five patients received local salvage treatment. On multivariate analysis, CAPRA-score (HR 4.46, 95%CI 1.76-11.33, p = 0.002) and the dosimetric measure D90 > 130 Gy (p = 0.03) were predictive of BF. Five deaths occurred in our cohort, two due to cardiovascular reasons and three due to another malignancy. At baseline, all patients were able to have erections with or without medication. At 5 years and 7 years after PB, 80% and 64% of patients had little or no ED (erections without the need for medication) respectively. CONCLUSION: In young-onset patients treated with PB, failure rates are similar to their older counterparts. Sexual function decreases with time, even in patients with good sexual function.

The interaction between inflammation, urinary symptoms and erectile dysfunction in early-stage prostate cancer treated with brachytherapy.

Erectile function has been shown to decline as a function of increasing peripheral blood inflammatory markers, namely the neutrophil-to-lymphocyte ratio (NLR). We evaluated if the association between NLR and erectile dysfunction (ED) applies to patients with localised prostate cancer. We included 1,282 patients who underwent brachytherapy. ED was classified before treatment according to the Terminology Criteria for Adverse Event Scale version 3.0. ED was defined as the need for the use of oral pharmacologic or mechanical assistance to have satisfactory sexual function. We found that patients with ED were older (p < .001), more likely to have hypertension (p = .002), statin use (p = .002), diabetes (p < .001) or an IPSS ≥ 8 (p < .001). On univariable logistic regression analysis, an NLR of ≥3 was statistically significantly associated with ED (OR 1.32, p = .029). But on multivariable analysis, the association between elevated NLR and ED was not statistically significant (p = .17). Significant were age (OR 1.12, p < .001), IPSS ≥ 8 (OR 1.50, p = .008), the presence of hypertension, hyperlipidemia and diabetes (OR 2.27, p < .001), and prostate volume (OR 0.99, p = .041). The NLR does appear to be a surrogate marker of chronic inflammation that causes baseline ED in patients with localised prostate cancer.

180W-LBO GreenLight XPS laser vaporization for benign prostatic hyperplasia: our experience with current markers of surgical proficiency for durable and reproducible outcomes.

INTRODUCTION: This study aims at analyzing the impact of reaching current markers of proficiency on intra and postoperative clinical outcomes of laser vaporization with 180W GreenLight XPS in the treatment of benign prostatic hyperplasia. MATERIALS AND METHODS: A retrospective analysis was conducted on a prospectively collected database of 328 consecutive patients who underwent photoselective vaporization of the prostate (PVP) using Greenlight XPS performed by a single experienced laser surgeon. A logarithmic model was used to evaluate the case number to attain benchmark criteria for durable treatment. We compared clinical outcomes before and after current markers of proficiency, defined as either an energy density of 4kJ/cm³ or a 6 month prostate-specific antigen (PSA) drop of = 50%, were attained. RESULTS: Energy delivered per prostate volume increased significantly with experience. The published benchmark values of 4kJ/cm³ and 6 month PSA drop of 50% were attained after 190 and 155 cases, respectively. There were no significant differences between groups in intraoperative complications or postoperative functional outcomes. However, the number of Clavien-Dindo category I adverse events significantly decreased with experience. Sub-analysis evaluating prostate volumes ≤ 80 cm³ and > 80 cm³ demonstrated comparable clinical outcomes before and after technical proficiency. CONCLUSION: In our experience, the case volume required to achieve consistent reference values related to durable clinical outcomes and surgical proficiency was > 150 cases. However, desirable clinical outcomes were attained before reaching current markers of proficiency, regardless of preoperative prostate size. This suggests that current thresholds of technical proficiency may not be a good predictor of satisfying clinical outcomes.

The Patient Burden of Bladder Outlet Obstruction after Prostate Cancer Treatment.

PURPOSE: Bladder outlet obstruction after prostate cancer therapy imposes a significant burden on health and quality of life in men. Our objective was to describe the burden of bladder outlet obstruction after prostate cancer therapy by detailing the type of procedures performed and how often those procedures were repeated in men with recurrent bladder outlet obstruction. MATERIALS AND METHODS: Using SEER (Surveillance, Epidemiology and End Results)-Medicare linked data from 1992 to 2007 with followup through 2009 we identified 12,676 men who underwent at least 1 bladder outlet obstruction procedure after prostate cancer therapy, including external beam radiotherapy in 3,994, brachytherapy in 1,485, brachytherapy plus external beam radiotherapy in 1,847, radical prostatectomy in 4,736, radical prostatectomy plus external beam radiotherapy in 369 and cryotherapy in 245. Histogram, incidence rates and Cox proportional hazards models with repeat events analysis were done to describe the burden of repeat bladder outlet obstruction treatments stratified by prostate cancer therapy type. We describe the type of bladder outlet obstruction surgery grouped by level of invasiveness. RESULTS: At a median followup of 8.8 years 44.6% of men underwent 2 or more bladder outlet obstruction procedures. Compared to men who underwent radical prostatectomy those treated with brachytherapy and brachytherapy plus external beam radiotherapy were at increased adjusted risk for repeat bladder outlet obstruction treatment (HR 1.2 and 1.32, respectively, each p <0.05). After stricture incision the men treated with radical prostatectomy or radical prostatectomy plus external beam radiotherapy were most likely to undergo dilation at a rate of 34.7% to 35.0%. Stricture resection/ablation was more common after brachytherapy, external beam radiotherapy or brachytherapy plus external beam radiotherapy at a rate of 28.9% to 41.2%. CONCLUSIONS: Almost half of the men with bladder outlet obstruction after prostate cancer therapy undergo more than 1 procedure. Furthermore men with bladder outlet obstruction after radiotherapy undergo more invasive endoscopic therapies and are at higher risk for multiple treatments than men with bladder outlet obstruction after radical prostatectomy.

Neurogenic Lower Urinary Tract Dysfunction in Adults with Cerebral Palsy: Outcomes following a Conservative Management Approach.

PURPOSE: Cerebral palsy is characterized by motor impairment following injury to the developing brain. Neurogenic lower urinary tract dysfunction is estimated to affect at least a third of children with cerebral palsy. However there are limited data as patients transition to adulthood. We sought to describe the symptoms, sequelae and management of neurogenic lower urinary tract dysfunction in adults with cerebral palsy. MATERIALS AND METHODS: We retrospectively reviewed the charts of adult patients with cerebral palsy between 2011 and 2014. Patients with prior bladder reconstruction or catheterization based bladder drainage were excluded from study. Cerebral palsy severity was determined using GMFCS (Gross Motor Function Classification System). A conservative evaluation and treatment paradigm was used. Noninvasive treatments were encouraged. Specifically clean intermittent catheterization, which is often not feasible, is avoided unless urinary retention, hydronephrosis or refractory lower urinary tract symptoms develop. RESULTS: There were 121 patients included in final analysis. Median age was 25 and 61 patients (50%) had GMFCS level V. Noninvasive management failed in 28 of 121 patients (23%) as defined by hydronephrosis in 9, persistent urinary retention in 10 and refractory lower urinary tract symptoms/incontinence in 9. Urethral clean intermittent catheterization was poorly tolerated. Of all patients 25% showed evidence of urolithiasis during the study period. Surgical intervention was rare and associated with significant morbidity. CONCLUSIONS: Adults with cerebral palsy may present with variable signs and symptoms of neurogenic lower urinary tract dysfunction. Conservative treatment was successful in more than 75% of patients. Clean intermittent catheterization was poorly tolerated in patients in whom conservative treatment failed. Surgical intervention was rarely indicated and it should be reserved for select individuals.

A population-based analysis of the effect of marital status on overall and cancer-specific mortality in patients with squamous cell carcinoma of the penis.

PURPOSE: The association between marital status and tumor stage and grade, as well as overall mortality (OM) and cancer-specific mortality (CSM) received little attention in patients with squamous cell carcinoma of the penis (SCCP). METHODS: We relied on the surveillance, epidemiology, and end results (SEER) 17 database to identify patients diagnosed with primary SCCP. Logistic and Cox regression models, respectively, addressed the effect of marital status on the rate of locally advanced disease and its effect on OM and CSM. Covariates consisted of age, race, socioeconomic status, year of surgery, and SEER registries. RESULTS: Between 1988 and 2006, 1,884 patients with SCCP were identified. At surgery, 1,192 (63.3 %) were married and 966 (51.3 %) had locally advanced disease. In multivariable logistic regression models predicting locally advanced disease at surgery, unmarried men had a 1.5-fold higher (p < 0.001) risk than others. In multivariable Cox models predicting CSM, marital status had no effect [hazard ratio (HR) = 1.3, p = 0.1]. Finally, in multivariable Cox models predicting OM, unmarried men had a 1.3-fold higher (p = 0.001) risk than others. CONCLUSION: Unmarried men tend to present with less favorable disease stage at SCCP. Moreover, unmarried men tend to live less long than their married counterparts. However, marital status has no effect on CSM.

Short term outcomes of GreenLight vapor incision technique (VIT) of the prostate: comparison of outcomes to standard GreenLight 120W HPS vaporization in prostate volumes greater than 80 cc.

INTRODUCTION: To evaluate a hybrid technique involving GreenLight 120W HPS vapor incision tissue removal in prostate glands > 80 cc. MATERIALS AND METHODS: Vapor incision technique (VIT) was performed in 25 consecutive men with a prostate > 80 cc by a single surgeon from May 2010 until September 2010. VIT involved adenoma incisions at 5 and 7-o'clock positions followed by 3, 9 and 12 o'clock down to the surgical capsule. Side-fire vaporization along the capsule excised transurethral resection of the prostate (TURP) like tissue strips for later retrieval. Functional evaluations were performed at 1 and 3 months. Outcomes and complications were compared retrospectively to baseline and a size matched- cohort of 25 men who previously underwent standard vaporization-only photoselective vaporization prostatectomy (PVP). RESULTS: The VIT and control subgroups were comparable. Mean laser time, operative time and energy usage were reduced in the VIT group compared to controls (35 min versus 48 min; 63 min versus 80 min; and 227 k versus 325 kJ respectively; all p < 0.05). At 3 months the VIT subgroup demonstrated improved Qmax and post void residual (PVR) (197% versus 173%, 88% versus 72%; all p < 0.05) compared to control. VIT showed a 68% reduction in mean preoperative PSA at 3 months compared to 50% for the control group (p<0.01). Hospital stay, catheterization time and complication rates were comparable. CONCLUSIONS: Our data demonstrates that VIT provides superior short term outcomes to standard HPS-PVP in men with prostate volumes > 80 cc. VIT appears to be more time-efficient, consumes less energy and obtains tissue for pathological evaluation. Further follow up is required to assess the durability of GreenLight HPS-VIT to PVP vaporization-only for large prostate glands.

Is robotic surgery cost-effective: yes.

PURPOSE OF REVIEW: With the expanding use of new technology in the treatment of clinically localized prostate cancer (PCa), the financial burden on the healthcare system and the individual has been important. Robotics offer many potential advantages to the surgeon and the patient. We assessed the potential cost-effectiveness of robotics in urological surgery and performed a comparative cost analysis with respect to other potential treatment modalities. RECENT FINDINGS: The direct and indirect costs of purchasing, maintaining, and operating the robot must be compared to alternatives in treatment of localized PCa. Some expanding technologies including intensity-modulated radiation therapy are significantly more expensive than robotic surgery. Furthermore, the benefits of robotics including decreased length of stay and return to work are considerable and must be measured when evaluating its cost-effectiveness. SUMMARY: Robot-assisted laparoscopic surgery comes at a high cost but can become cost-effective in mostly high-volume centers with high-volume surgeons. The device when utilized to its maximum potential and with eventual market-driven competition can become affordable.

Mid term outcomes of initial 250 case experience with GreenLight 120W-HPS photoselective vaporization prostatectomy for benign prostatic hyperplasia: comparison of prostate volumes < 60 cc, 60 cc-100 cc and > 100 cc.

INTRODUCTION: The aim of this study was to compare the efficacy of GreenLight 120W-HPS (American Medical Systems, Minnetonka, Minnesota, USA) laser vaporization for men with obstructive benign prostatic hyperplasia (BPH) according to prostate volumes < 60 cc, 60 cc-100 cc and > 100 cc. MATERIAL AND METHODS: The clinical data of 250 men with symptomatic BPH who underwent photoselective vaporization prostatectomy (PVP) by a single surgeon between July 2007 and August 2009 were retrospectively analyzed. Prostate volumes were measured by using transrectal ultrasonography (TRUS). Functional evaluations were performed at 3, 6 and 12 months with a prostate-specific antigen (PSA) obtained at 6 months. All men were stratified into three groups according to TRUS volume. RESULTS: Among the 250 consecutive PVP patients, 134, 76 and 40 men had prostate volumes < 60 cc, 60 cc-100 cc and > 100 cc, respectively. Mean laser time and delivered energy were 31, 44 and 59 minutes; 163, 309 and 473 kJ respectively (p < 0.01 for all). At 1 year, mean International Prostate Symptom Score (IPSS) improved by 69%, 63% and 50%, Qmax increased by 194%, 175% and 162% and post void residual (PVR) decreased by 88%, 81% and 71%, respectively (p < 0.01 for all). Mean decrease in preoperative PSA at 6 months was 63%, 52% and 41% (p < 0.01), respectively. Hospital stay, catheterization time and complication rates were comparable between groups, however retreatment rates were significantly higher for prostates >100 cc (1.5% versus 2.6% versus 9%; p = 0.02). CONCLUSIONS: Although larger prostates require more time and energy delivery, PVP is safe and efficacious for patients with lower urinary tract symptoms (LUTS) regardless of prostate size. Laser vaporization for glands > 100 cc appears to have a reduced reduction in PSA and a higher 9% rate of retreatment indicating that PVP for larger prostates remains to be optimized.

Subclinical inflammation as a predictor for erectile dysfunction after brachytherapy for localized prostate cancer.

PURPOSE: Neutrophil-to-lymphocyte ratio (NLR), a marker for subclinical inflammation, has been previously shown to be associated with erectile dysfunction (ED). We studied the potential predictive value of the NLR on ED after prostate brachytherapy (PB) for PCa. METHODS AND MATERIALS: Between July 2005 and January 2021, 842 patients were included in this retrospective study of a prospectively maintained database. ED was assessed using the Common Terminology Criteria for Adverse Events (CTCAE) physician-reported scale. ED was defined as a Grade 2 or 3 function. NLR count was determined 1-2 months before PB and separated into values PB <2 and ≥2. Patient characteristics and erectile function at last follow-up were compared for patients with a Univariate and multivariate analyses were performed to evaluate the predictive value of baseline NLR ≥2 on post-PB ED. RESULTS: Baseline NLR ≥2 was found to be a statistically significant predictor of post-PB ED on both univariate (p = 0.002) and multivariate analyses (p = 0.008). Furthermore, the difference in ED prevalence between the NLR <2 and NLR ≥2 groups became more pronounced with longer follow-up after PB. The ED rate at 5 years post-PB was 43% for the NLR ≥2 groups, compared to 29% for the NLR <2 groups. CONCLUSIONS: Subclinical systemic inflammation is a potentially important factor for predicting sexual toxicity after pelvic radiotherapy. NLR may be used as a proxy for predicting post-PB ED.

Pilot trial of telemedicine in urology: Video vs. telephone consultations.

INTRODUCTION: In the past year, due to the COVID-19 pandemic, in-person clinical activities have been drastically restricted, driving the already growing interest in the use of telemedicine in the urban setting to reduce unnecessary commute. Therefore, there has been a rapid shift to telephone and video consultations in outpatient practice. We sought to conduct a pilot trial to establish feasibility and acceptability of video consultations as an alternative to telephone consultations in urology patients to inform the design of a future randomized controlled trial. METHODS: We conducted a single-center, prospective, non-randomized pilot trial comparing telephone consultations (TC) vs. video consultations (VC) for urology outpatient visits. Two patient questionnaires were used to collect demographic information, as well as data about acceptability, feasibility, satisfaction, cost, and issues with telemedicine. Questions were identical for both VC and TC except for certain questions inquiring about issues specific to each technology. RESULTS: Forty-eight TC and 66 VC urology patients were included in this study. Patients believed that telemedicine visits did not significantly hinder their ability to communicate with their urologists and that these visits would be associated with cost savings. There was 1/48 (2.1%) failed TC and 16/66 (24.2%) failed VC. VC failures were concentrated at the beginning of the trial prior to giving feedback to the VC platform creators, with only one failure occurring thereafter. When comparing TC to VC, differences between the two patient groups were small but tended to be in favor of VC. Patients' satisfaction was greater with VC compared to TC. Both modalities were associated with many cost benefits for patients. CONCLUSIONS: Despite more technical issues with VC, this modality is feasible and acceptable to patients, likely due to improved shared decision-making with VC. Future considerations for trials comparing VC and TC should include adequate Wi-Fi infrastructure and choice of platform. For the VC, continuous knowledge transfer between investigators and platform engineers plays an important role in limiting failed encounters.

Racial disparities and socioeconomic status in men diagnosed with testicular germ cell tumors: a survival analysis.

BACKGROUND: Previous reports indicated that African-American men with testicular germ cell tumors (TGCTs) have more aggressive tumor characteristics and less favorable outcomes than other men. The authors of this report evaluated the effects of race and socioeconomic status (SES) on stage distribution, overall mortality (OM), and cancer-specific mortality (CSM) in men with TGCTs. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was used to identify 22,553 men who were diagnosed with TGCTs between 1988 and 2006. Kaplan-Meier and Cox regression analyses were generated to predict OM and CSM. Covariates of the analyses included race, SES, age, histologic subtype, disease stage, procedure type, SEER registry, and year of diagnosis. The interaction between race and SES also was examined. RESULTS: Overall, there were 516 African-American men, 21,090 Caucasian men, and 947 men of other races. African-Americans (14.9%) and individuals with low SES (10.7%) had a higher proportion of distant stage disease. CSM and OM rates were significantly higher for African-American patients and for patients who resided in low SES counties. Multivariate analyses revealed that African-American men and men with low SES were more likely to die of OM and CSM relative to Caucasian men (P < .001) and men with high SES (P < .001), respectively. The interaction between race and SES was not significant. CONCLUSIONS: African-American race and low SES appeared to predispose men to more advanced disease stages and to higher OM and CSM rates. These observations may warrant race-specific and/or SES-specific adjustments in the treatment of TGCT.

Tumor grade improves the prognostic ability of American Joint Committee on Cancer stage in patients with penile carcinoma.

PURPOSE: Penile cancer is rare. Thus, predicting cancer specific mortality may be difficult. We devised an accurate and yet easily applicable predictive rule that compares favorably with 2 previous models (73.8% and 74.7% accuracy, respectively). MATERIALS AND METHODS: We identified patients treated with primary tumor excision for all stages of penile squamous cell carcinoma between 1998 and 2006. Disease stage definitions using Surveillance, Epidemiology and End Results stage, American Joint Committee on Cancer stage and TNM classification, and tumor grade were used to predict cancer specific mortality. Predictive accuracy estimates were compared using the DeLong method for related AUCs. RESULTS: Surveillance, Epidemiology and End Results stage alone (1 predictor variable) was least accurate (74.5%). American Joint Committee on Cancer stage with tumor grade (2 predictor variables) was the most simple and most accurate (80.9%, p <0.001). A benefit similar to that of American Joint Committee on Cancer stage with tumor grade was seen for TNM classification and TG (80.7%, p = 0.8). However, this rule (4 predictor variables) was more complex than American Joint Committee on Cancer stage and tumor grade. CONCLUSIONS: American Joint Committee on Cancer stage combined with tumor grade is the simplest, most accurate cancer specific mortality prediction rule after primary tumor excision for penile squamous cell carcinoma. This method is also more accurate than 2 previous cancer specific mortality prediction rules.

A contemporary population-based assessment of the rate of lymph node dissection for penile carcinoma.

BACKGROUND: The adherence rate to National Cancer Institute (NCI) recommendations regarding inguinal lymph nodes dissection (ILND) in high grade T1 (G3T1) and T2-4 squamous cell carcinoma of the penis (SCCP) is not known. We assessed ILND rates in a North American cohort. MATERIALS AND METHODS: The 17 registries of the Surveillance, Epidemiology, and End Results (SEER) database included 868 patients with SCCP, diagnosed between 1988 and 2006. Analyses consisted of univariable and multivariable logistic regression models. RESULTS: Overall, 27.6% of patients underwent an ILND. ILND rates were directly proportional with T stage: 19.0%, 30.5%, 30.6%, and 32.6% for, respectively, G3T1, T2, T3, and T4 SCCP (chi-square trend, P = 0.01). ILND rates also increased over time and were 19.3, 27.3, 30.7, and 30.8% for respectively, 1988-1995, 1996-2000, 2001-2003, and 2004-2006 periods (chi-square trend, P = 0.03). Finally, ILND rates decreased with patient age and were 42.6, 33.2, 24.7, and 7.3% for, respectively, patients aged ≤ 57, 58-68, 69-78 and ≥ 79 years of age (chi-square trend, P < 0.001). All 3 variables (T-stage, year of primary tumor excision and patient age) achieved independent predictor status in multivariable analyses. CONCLUSIONS: The overall rate of ILND is low. Nonetheless, there is an upward trend over time. Our data indicate that the adherence to the NCI ILND guidelines is suboptimal. In consequence, ILNDs should be more strongly encouraged.

Impact of surgical experience on in-hospital complication rates in patients undergoing minimally invasive prostatectomy: a population-based study.

BACKGROUND: The relationship between provider volume and complication and transfusion rates in patients undergoing minimally invasive prostatectomy (MIRP) for prostate cancer has not been assessed. Temporal trends in MIRP annual surgical caseload (AC), impact of MIRP surgical experience (SE), and in-hospital complication and transfusion rates were evaluated. METHODS: Between 2002 and 2008, 2,666 patients in Florida underwent MIRP. Surgical experience was defined as the number of procedures performed from the beginning of the study until each individual MIRP. Multivariable logistic regression models using generalized estimating equations assessed the relationship between SE and in-hospital complication and transfusion rates. RESULTS: Overall AC and SE ranged from 1-171 and 1-500, respectively. Between 2002 and 2005, 94-100% of surgeons were considered as low AC tertile (≤15 MIRP) vs. 76-82% between 2006 and 2008. For the same time periods, low AC tertile surgeons performed 46-100 and 27-32% of all MIRPs respectively. Multivariable logistic regression models revealed 51 and 68% lower complication rates in patients operated on by surgeons of intermediate (17-76 MIRPs) and high SE (≥77 MIRPs) relative to surgeons of low SE (≤16 MIRPs). Similarly, transfusion rates were 80 and 83% lower for the same groups. CONCLUSIONS: Our study is the first to indicate that high SE reduces MIRP complication and transfusion rates. Despite this observation, even in the most contemporary study year, most MIRP surgeons (82%) were in the low AC tertile and contributed to as many as 32% of all MIRPs. These findings should be considered at informed consent.

Trends of retroperitoneal lymphadenectomy use in patients with nonseminomatous germ cell tumor of the testis: a population-based study.

BACKGROUND: Retroperitoneal lymphadenectomy (RPLND), chemotherapy, and active surveillance represent treatment options for patients with nonseminomatous germ-cell tumors of the testis (NSGCTT). Our objective was to assess the utilization rate of RPLND in patients with NSGCTT. METHODS: Within the Surveillance, Epidemiology and End Results (SEER) cohort, 4,620 and 1,671 patients with stage I and II NSGCTT were diagnosed between the years 1988 and 2006. Univariable and multivariable logistic regression analyses were performed to test the predictors of RPLND use in respectively patients with stage I and II NSGCTT. RESULTS: The rate of RPLND according to stage I and II was 27 and 58%, respectively. In patients with stage I disease, the rate of RPLND decreased from 39% in 1988-1995 to 18% in 2004-2006 (P < 0.001), and remained stable for stage II patients (62-56%, P = 0.2). Regional variability existed regarding the rate of RPLND use only in stage I (Utah: 51% vs. Louisiana: 16%). Multivariable analyses performed in stage I NSGCTT revealed that year of diagnosis, SEER registry, and age were significant predictors of RPLND use. However, none of these variables achieved statistical significance within stage II NSGCTT patients. CONCLUSIONS: In patients with stage I NSGCCT, the RPLND utilization rate decreased during the study span. This observation may be ascribed to wider use of surveillance or chemotherapy. No temporal difference was recorded in patients with stage II NSGCCT.

Radical cystectomy for patients with pT4 urothelial carcinoma in a large population-based study.

OBJECTIVE: • To examine cancer-specific mortality (CSM) in patients with pT4N0₋3 M0 urothelial carcinoma of the urinary bladder (UCUB) and to compare it to patients with pT3N0₋3 M0, in a population-based cohort treated with radical cystectomy (RC). PATIENTS AND METHODS: • RCs were performed in 5625 pT3-T4b0₋3 M0 patients with UCUB within 17 Surveillance, Epidemiology and End Results (SEER) registries between 1988 and 2006. • Univariable and multivariable models tested the effect of pT4a vs pT4b vs pT3 stages on CSM. • Covariates consisted of age, gender, race, lymph node status and SEER registries. • All analyses were repeated in 3635 pN(0) patients. RESULTS: • Of 5625 patients, 2043 (36.3%) had pT4aN0₋3 , 248 (4.4%) had pT4bN0₋3 and 3334 had pT3N0₋3 (59.3%) UCUB. • The 5-year CSM was 57.6% vs 81.7% vs 53.9% for, respectively, pT4aN0₋3 vs pT4bN0₋3 vs pT3N0₋3 patients (all log-rank P= 0.008). • In multivariable analyses the rate of CSM was 2.3-fold higher in pT4b vs pT3 (P < 0.001), 1.1-fold higher in pT4a vs pT3 (P= 0.002) and 2.0-fold higher in pT4a vs pT4b patients. • After restriction to pN0 stage, pT4b patients had a 2.3-fold higher rate of CSM than pT3 patients (P < 0.001) and pT4b patients had a 2.1-fold higher rate of CSM than pT4a patients (P < 0.001). • The CSM rate was the same for pT4a and pT3 patients (P= 0.1). CONCLUSIONS: • Our findings indicate that patients with pT4a UCUB have similar CSM as those with pT3 UCUB. • Consequently, RC should be given equal consideration in patients with pT3 and pT4a UCUB.

GreenLight 180W XPS photovaporization of the prostate: how I do it.

Transurethral resection of the prostate (TURP) is the most common surgical intervention for benign prostatic hyperplasia (BPH), largely due to lower urinary tract symptoms refractory to medical therapy. TURP remains the gold standard for men with prostates sized 30g-80g, while open prostatectomy has been the preferred option for men with glands larger than 80g-100 g and those with other lower urinary tract anomalies such as large bladder stones or bladder diverticula. Unfortunately, these procedures have complications including bleeding (often requiring transfusion in 7%-13% of cases), electrolyte abnormalities (2% TURP syndrome), erectile dysfunction (6%-10%), and retrograde ejaculation (50%-75%). The overall incidence of a second intervention (repeat TURP, urethrotomy and bladder neck incision) has been reported in 12% and 15% of men at 5 and 10 years following TURP. Alternative therapies have been developed with the aim of reducing the level of complications while maintaining efficacy. These include microwave therapy, transurethral needle ablation, and a range of laser procedures (Holmium, Diode, Thulium and 532nm-Greenlight). Photoselective vaporization of the prostate (PVP), initially launched as a 60W prototype, was ultimately introduced to the urology community as a 80W system (American Medical Systems, Minnetonka, Minnesota, USA), has been the predominant device used in clinical trials. This 1st generation used an Nd:YAG laser beam passed through a potassium-titanyl-phosphate (KTP) crystal, halving the wavelength (to 532nm), doubling the laser's frequency, and resulting in a green light. Outcomes have demonstrated a reduced frequency and severity of clinical complications, however it was limited to smaller prostate sizes. In 2006, the 120W lithium triborate laser (LBO), also known as the GreenLight HPS (High Performance System) laser was introduced. This laser utilizes a diode pumped Nd:YAG laser light that is emitted through an LBO instead of a KTP crystal, resulting in a higher-powered 532 nm wavelength green light laser while still using the same 70-degree deflecting, side firing, silica fiber delivery system. The HPS offered an 88% more collimated beam and smaller spot size, resulting in much higher irradiance or power density in its 2 predecessors (60W and 80W) with a beam divergence of 8 versus 15 degrees. The primary aim for this upgrade was to reduce lasing time and improve clinical outcomes while demonstrating the same degree of safety for patients. Limitations of the 120W system included treatment of large prostates greater than 80g-100g and increased cost related to fiber devitrification and fracture. In 2011, the 180W-Greenlight XPS system was introduced, not only with increased power setting to vaporize tissue quicker but significant fiber-design changes. Internal cooling, metal-tip cap protection and FiberLife (temperature sensing feedback), better preserve the integrity of the fiber generally producing a 1-fiber per case expectation. Initial personal experience with XPS has provided comparable outcomes related to morbidity, but with the opportunity to perform a more complete and rapid procedure. Published clinical data with the XPS is unfortunately lacking. The objective of this report is to detail our approach and technique for GreenLight XPS drawing on personal experience with both enucleation and vaporization techniques with various laser technologies along with having performed over 500 GreenLight HPS and 100 XPS procedures. In this regard, recommendations for training are also made, which relate to existing users of the 80W and 120W GreenLight laser as well as to new laser users.

Favorable preservation of erectile function after prostate brachytherapy for localized prostate cancer.

PURPOSE: We analyzed the rate of preserved potency after prostate brachytherapy (PB) with radioactive seeds and the impact of patient comorbidities on post-PB erectile dysfunction (ED). METHODS: We included 627 patients who were assessed for pre- and postimplant potency between 2005 and 2017. Assessment was based on the Common Terminology Criteria for Adverse Events Scale (CTCAEs). Logistic regression models were used to assess clinical predictors of preserved potency after PB defined as having sufficient erections for sexual activity with or without the need of oral pharmacologic assistance. Covariates included age, diabetes (DM), hypertension (HTN), dyslipidemia (DLP), coronary artery disease (CAD), International Prostate Symptom Score (IPSS), prostate volume, and Cancer of the Prostate Risk Assessments (CAPRA) score. Patients on androgen deprivation therapy or using five alpha reductase inhibitors were excluded from analyses. RESULTS: Post-PB potency was assessed at an average of 6 months (n = 627), 1 year (n = 538), 2 years (=440), 4 years (n = 272), and 5 years (n = 124). At 2 and 5 years, post-PB potency was preserved in 87% and 84% of patients, respectively. When adjusting for all available covariates, advanced age, pre-PB potency, and the presence of vascular comorbidities (HTN, DM, and DLP) were all predictors of potency at 2 years after PB (all p < 0.01). When performing a sensitivity analysis for vascular comorbidities, the presence of DM had the strongest impact on ED than either HTN or DLP (p < 0.01). CONCLUSION: More than 84% of patients had preserved potency 5 years after PB. Advanced age, pre-PB potency, and vascular comorbidities had a statistically significant impact on potency after PB.

Do Women Have Equal Chances for an Academic Career in Radiation Oncology in Canada? A Comparison With Related Specialties.

PURPOSE: The progress of women in academic medicine appears to be curtailed. We evaluated gender differences in academia for residents in radiation oncology compared with 2 of its related specialties, radiology and medical oncology, across Canada. METHODS AND MATERIALS: We analyzed abstracts presented between 2013 and 2016 at the annual meetings of the Canadian Association of Radiation Oncologists and compared it to the corresponding data for the meetings of the Canadian Association of Radiologists and Canadian Association of Medical Oncology. We further evaluated gender composition of abstracts, presentations, and publications available on PubMed. Conversion rates according to gender and to medical specialties were assessed. Proportions were compared using Fisher exact test or the chi-squared test. RESULTS: Among the 198 presented abstracts, 103 (52%) were published. Radiation oncology had the highest publishing rate with 90% (oncology 56%, radiology 40%). The publication rate between the medical specialties was significantly different (P < .001).Fifty-seven percent of abstracts presented by women were published versus 48% of abstracts presented by men. Overall, there was no significant difference between genders in terms of subsequent conversions into a scientific publication within each specialty (P = .25-1.0).In radiation oncology, women presented 67% of abstracts and published 95% of their presented abstracts, and in medical oncology, 66% of abstracts were from women and 57% of the presented abstracts were published. Among the published abstracts, 83% had the same first author in the abstract and the publication. Among those who lost their first-authorship status, 59% were women. However, there was no statistically significant difference between specialties for loss of first-author status. CONCLUSIONS: We observed that from 2013 to 2016, women had the highest presentation and publication rate in radiation oncology. More prospective data are needed to monitor the progress of women in all specialties and their specific needs.