Clinical safety and efficacy of microwave ablation for small renal masses

PURPOSE

CT-guided MWA is a safe and effective tool that should be utilized in the treatment of small renal masses (SRMs). We aim to clarify the utility of CT-guided MWA by examining patient outcomes such as recurrence, treatment success, changes in renal function, and complications.

METHODS

A retrospective review of consecutive patients with SRMs who underwent same day renal mass biopsy (RMB) and CT-guided MWA between 2015 and 2022 was performed. Treatment safety was assessed by 30-day complications according to the Clavien-Dindo system and change in eGFR >30 days post-procedure. Treatment efficacy was defined by local recurrence and incomplete treatment rates and calculated using the Kaplan-Meier method.

RESULTS

A total of 108 renal masses were found in 104 patients. The overall complication rate was 7.4% (8/108), of which 4 were major complications (3.7%). For those with renal function available >30 days post ablation, the median eGFR was 47.2 (IQR: 36.0, 57), compared to 52.3 (IQR: 43.7, 61.5) pre-ablation, p<0.0001. 5-year local recurrence free survival was 86%. Among those with biopsy proven malignancy (n= 66), there were five local recurrences (7.54%) occurring at a median of 25.1 months (IQR 19.9, 36.2) and one case (1.5%) of incomplete treatment.

CONCLUSIONS

As the medical field continues to evolve towards less invasive interventions, MWA offers a valuable tool in the management of renal masses. With low major complication and recurrence rates, our findings support the utility of CT-guided MWA as a tool for treatment of SRMs.

Background and Update for ECOG-ACRIN EA8212: A Randomized Phase 3 Trial of Intravesical Bacillus Calmette-Guérin (BCG) Versus Intravesical Docetaxel and Gemcitabine Treatment in BCG-naïve High-grade Non-muscle-invasive Bladder Cancer (BRIDGE)

EA8212 BRIDGE is a phase 3 randomized trial comparing BCG vs GemDoce for BCG naïve high-risk non-muscle-invasive bladder cancer. This article provides an explanation for the rationale of the clinical trial and details the study design.

Pelvic Organ Preservation in Non-muscle-invasive Bladder Cancer: Less Is More

Radical cystectomy (RC) is a treatment option for high-risk non-muscle-invasive bladder cancer (NMIBC) but is associated with high morbidity and a negative impact on quality of life. Reproductive or pelvic organ-sparing cystectomy (ROSC) techniques have emerged as a potential strategy to mitigate some potential effects of standard RC. Here we discuss current knowledge regarding oncological, functional, and sexual function outcomes associated with ROSC and their applicability in NMIBC. These outcomes can be used to make informed clinical decisions regarding cystectomy technique in appropriately staged and selected patients with NMIBC. PATIENT SUMMARY: We reviewed results for bladder cancer control, urinary function, and sexual function after removal of the bladder with and without techniques to spare reproductive or pelvic organs. We found evidence of better sexual function outcomes with a sparing approach without compromise of cancer control. Further studies are needed to assess urinary function and pelvic floor-related outcomes.

Neddylation inhibition sensitises renal medullary carcinoma tumours to platinum chemotherapy

BACKGROUND

Renal medullary carcinoma (RMC) is a highly aggressive cancer in need of new therapeutic strategies. The neddylation pathway can protect cells from DNA damage induced by the platinum-based chemotherapy used in RMC. We investigated if neddylation inhibition with pevonedistat will synergistically enhance antitumour effects of platinum-based chemotherapy in RMC.

METHODS

We evaluated the IC50 concentrations of the neddylation-activating enzyme inhibitor pevonedistat in vitro in RMC cell lines. Bliss synergy scores were calculated using growth inhibition assays following treatment with varying concentrations of pevonedistat and carboplatin. Protein expression was assessed by western blot and immunofluorescence assays. The efficacy of pevonedistat alone or in combination with platinum-based chemotherapy was evaluated in vivo in platinum-naïve and platinum-experienced patient-derived xenograft (PDX) models of RMC.

RESULTS

The RMC cell lines demonstrated IC50 concentrations of pevonedistat below the maximum tolerated dose in humans. When combined with carboplatin, pevonedistat demonstrated a significant in vitro synergistic effect. Treatment with carboplatin alone increased nuclear ERCC1 levels used to repair the interstrand crosslinks induced by platinum salts. Conversely, the addition of pevonedistat to carboplatin led to p53 upregulation resulting in FANCD2 suppression and reduced nuclear ERCC1 levels. The addition of pevonedistat to platinum-based chemotherapy significantly inhibited tumour growth in both platinum-naïve and platinum-experienced PDX models of RMC (p < .01).

CONCLUSIONS

Our results suggest that pevonedistat synergises with carboplatin to inhibit RMC cell and tumour growth through inhibition of DNA damage repair. These findings support the development of a clinical trial combining pevonedistat with platinum-based chemotherapy for RMC.

Repeat Transurethral Resection of Muscle-invasive Bladder Cancer Prior to Radical Cystectomy is Prognostic but Not Therapeutic

PURPOSE

We sought to evaluate the impact of repeat transurethral resection of bladder tumor prior to radical cystectomy on oncologic outcomes in a contemporary cohort at a tertiary care center.

MATERIALS AND METHODS

An Institutional Review Board approved review of 657 patients diagnosed with muscle-invasive bladder cancer who underwent radical cystectomy at our institution for clinical stage T2 urothelial carcinoma between 2005 and 2017 was performed. Patients with and without repeat transurethral resection of bladder tumor were matched 1-to-1 by propensity score. Matching was done by age, gender, receipt of neoadjuvant chemotherapy, preoperative hydronephrosis, variant histology, lymphovascular invasion, or carcinoma in situ on index transurethral resection of bladder tumor.

RESULTS

A total of 548 patients with muscle-invasive bladder cancer were included after matching (2 groups of 274 patients). Kaplan-Meier estimates of recurrence-free and overall survival demonstrated no significant difference based upon performance of repeat transurethral resection of bladder tumor (P = 1.0 and P = .3, respectively). When outcomes were stratified by pathology of repeat transurethral resection of bladder tumor specimens, those with pT0 had superior recurrence-free and overall survival compared to those with residual muscle invasive disease (P < .001 and P = .001, respectively). Notably, more than 60% of patients who were pT0 on repeat transurethral resection of bladder tumor had residual disease at the time of radical cystectomy.

CONCLUSIONS

Repeat transurethral resection of bladder tumor prior to radical cystectomy, irrespective of receipt of neoadjuvant chemotherapy, was not associated with improved survival outcomes in this propensity score matched muscle-invasive bladder cancer cohort. The absence of residual tumor on pathological evaluation of repeat transurethral resection of bladder tumor specimen was prognostic and was associated with improved survival outcomes. However, a large percentage of patients with pT0 disease on repeat transurethral resection of bladder tumor had residual disease on radical cystectomy pathology.

Efficacy of Surgery on the Primary Tumour in Patients with Metastatic Bladder Cancer: A Comprehensive Review

BACKGROUND: The benefit of surgery of the primary tumor in metastatic bladder cancer is unknown. OBJECTIVE: Perform a comprehensive contemporary literature review on the benefit of surgery of the primary tumor in metastatic bladder cancer. METHODS: Ovid MEDLINE, Ovid EMBASE, and Cochrane Library from January 1, 1990 to April 20, 2020 were queried for relevant articles published in English. Each article was evaluated by at least two content experts prior to inclusion which were blinded to the other’s evaluation. A third content expert was used when there was not a unanimous decision. Additional articles were added at the discretion of the authors. RESULTS: Long-term survival is possible in patients with initially unresectable and/or limited metastatic disease. Multi-modal therapy with chemotherapy and surgery have the most favorable outcomes when compared to single treatment modalities in selected populations. Patients who demonstrate a robust response to pre-surgical therapy are likely to benefit the most from consolidative surgery. Patients with distant metastatic disease may benefit from consolidative surgery; however, this benefit may only be seen in those with metastatic disease limited to one site. CONCLUSIONS: Surgery of the primary tumor in metastatic bladder cancer either in the setting of surgery alone, consolidative therapy or coupled with adjuvant therapy may be beneficial in well selected patients and should generally be limited to those who have a response to primary chemotherapy. Randomized clinical control trials are needed to further our understanding of the role of surgery in metastatic bladder cancer. Systematic Review Registration number: CRD42020182861

What Women Want: Radical Cystectomy and Perioperative Sexual Function Educational Needs

OBJECTIVE

To assess the extent and adequacy of pre-operative sexual function (SF) counseling in females undergoing radical cystectomy (RC) and develop educational material to improve identified deficits.

METHODS

A 10-question survey was electronically delivered to all females who underwent RC at a single institution between 2015 and 2020. 23 of 145 patients responded (15.9%). In addition, women on the Bladder Cancer Advocacy Network (BCAN) patient discussion board were also queried. The primary outcome was the development of a patient educational handout based on patient perception of pre-operative SF counseling and self-reported changes in post-operative SF.

RESULTS

22 women, 84% of whom were sexually active, met the inclusion criteria. More than half (12/22, 54.5%) reported receiving no pre-operative counseling regarding possible SF changes while another 27.3% (6/22) received some counseling but desired more. Most women rated vaginal preservation as moderate to very important (17/22, 77.3%) and nearly all women noted at least one change in SF, most commonly dyspareunia (13/22, 59.1%). Most also desired more information regarding female sexual health. Separately, the BCAN discussion board was queried regarding patient preference for modality of pre-operative counseling. 77.8% (14/18) preferred a discussion with provider and 13/18 (72.2%) also wanted a written handout.

CONCLUSIONS

Sexual dysfunction is prevalent following RC in women and many desire more pre-operative counseling, regardless of disease stage or receipt of chemotherapy. These findings supported our development of interventions to improve pre-operative education as well as strategies to address post-operative SF changes, such as dyspareunia.

Tumor diameter response in patients with metastatic clear cell renal cell carcinoma is associated with overall survival

OBJECTIVE

Tumor shrinkage of at least 10% after presurgical targeted molecular therapy (TMT) in renal cell carcinoma (RCC) patients has been associated with better overall survival (OS) outcomes. We characterized primary and metastatic tumor diameter response and OS in patients with metastatic clear cell RCC (ccRCC) who received preoperative TMT, immunotherapy, or both followed by deferred cytoreductive nephrectomy (dCN).

MATERIALS AND METHODS

Patients with metastatic ccRCC (n = 198) who underwent preoperative therapy and dCN from 2005 to 2019 were identified retrospectively. Longest primary and metastatic tumor diameters were calculated using cross-sectional images obtained before systemic therapy and dCN using the Response Evaluation Criteria in Solid Tumors. Patients were stratified by tumor shrinkage of at least 10% in the primary and/or metastatic tumors after systemic therapy. The Kaplan-Meier method was used to estimate OS, and Cox proportional hazards models were used to assess the association of patient characteristics with OS.

RESULTS

In total, 31.31% of patients had only metastatic tumor shrinkage (MTS) ≥ 10%, 8.08% had only primary tumor shrinkage (PTS) ≥ 10%, 32.32% had PTS and MTS ≥ 10%, and 28.28% had PTS/MTS < 10%. The median OS, number of patients with tumor shrinkage ≥ 10%, and International Metastatic Database Consortium (IMDC) scores were similar among the 3 systemic therapy groups (all P ≥ 0.80). Patients with MTS ≥ 10%, PTS ≥ 10%, and PTS/MTS ≥ 10% had significantly longer median OS compared to patients with PTS/MTS < 10% (P < 0.01). Patients with intermediate-risk IMDC scores had significantly longer median OS compared to patients in the poor-risk group. After adjusting for preoperative therapy and IMDC risk group, MTS ≥ 10%, PTS ≥ 10%, and PTS/MTS ≥ 10% were associated with better OS outcomes (HR 0.48 95% CI 0.32-0.73, P < 0.001; HR 0.48, 95% CI 0.23-0.98, P = 0.04; HR 0.44, 95% CI 0.29-0.67, P < 0.001, respectively).

CONCLUSIONS

Intermediate risk score and shrinkage of at least 10% in the primary tumor, metastases, or both were associated with better OS outcomes in patients with metastatic ccRCC who underwent dCN independent of the type of preoperative systemic therapy.

Revisiting an Old Conundrum: A Systematic Review and Meta-Analysis of Intravesical Therapy for Treatment of Urothelial Carcinoma of the Prostate

BACKGROUND

The optimal management of non-invasive (mucosal and/or ductal) urothelial carcinoma of the prostate remains elusive and there is a paucity of data to guide treatment.

OBJECTIVE

Our objective was to systematically review and synthesize treatment responses to conservative management of non-invasive prostatic urothelial carcinoma using intravesical therapy.

METHODS

A systematic literature search using MEDLINE, EMBASE, Cochrane Library, SCOPUS, and Web of Science databases from inception to November 2019 was performed. Risk of bias assessment was performed using the Newcastle-Ottawa scale for non-randomised studies. Pooled estimates of complete response in the bladder and prostate and prostate only were performed using a random effects model. Pre-specified subgroup analyses were generated to assess differences in complete responses for: BCG therapy vs other agents, ductal vs mucosal involvement, CIS vs papillary tumors and TURP vs no TURP.

RESULTS

Nine studies including 175 patients were identified for inclusion in the systematic review and meta-analysis. All were retrospective case series and most evaluated response to BCG therapy. The pooled global complete response rate for intravesical therapy was 60%(95%CI: 0.48, 0.72), and for prostate 88%(95%CI: 0.81, 0.96). Pre-specified analyses did not demonstrate statistically significant differences between subgroups of interest.

CONCLUSIONS

Management of non-invasive prostatic urothelial carcinoma using intravesical therapy yields satisfactory results. Caution should be taken in treating patients with papillary tumors and ductal involvement, as data for these populations is limited. TURP may not improve efficacy, but is required for staging. Current recommendations are based on low quality evidence, and further research is warranted.

Impact of CoVID-19 on resident and fellow education: Current guidance and future opportunities for urologic oncology training programs

Coronavirus Disease 2019 has impacted all aspects of urologic training. Didactics have shifted to a virtual platform and new approaches to surgical training have been undertaken. There has been a shift in research away from the laboratory space, with an increased focus on clinical outcomes and multi-institutional collaborations. Finally, there have been impacts on home life, questions about time away from work, case logs and case minimums, as well as how to manage resident and fellow reassignment. Herein, we review the current state of urologic education in the United States, focusing specifically on urologic oncology and highlight opportunities for the future.

Survival following cytoreductive nephrectomy: a comparison of existing prognostic models

OBJECTIVE

To validate models currently used to predict metastatic renal cell carcinoma (mRCC) outcomes in a cohort of patients undergoing cytoreductive nephrectomy (CN).

PATIENTS AND METHODS

A total of 10 RCC prognostic models (International Metastatic RCC Database Consortium [IMDC]; Memorial Sloan Kettering Cancer Center [MSKCC]; Culp; Leibovich; University of California at Los Angeles Integrated Staging System [UISS]; Stage, Size, Grade, and Necrosis [SSIGN]; Yaycioglu; Karakiewicz; Cindolo; and Margulis) were chosen based on clinical relevance and use in clinical trial design. Model validation was performed using patients who underwent CN at a single institution between 2005 and 2017, and model discrimination (ability to select patients at risk of death) was assessed. Concordance indices (c-index) were calculated and compared with originally published c-indices.

RESULTS

A total of 515 CN patients were stratified according to the prognostic models. A total of 387 (75%) died over the study period, with estimated 3-year survival of 46.1% (95% confidence interval [CI] 41.6-50.4%). All models' discriminatory capacity underperformed when compared to the originally published c-indices. The c-indices ranged from 0.53 (95% CI 0.50-0.56) for the Cindolo model to 0.61 (95% CI 0.58-0.64) for the Leibovich model. The MSKCC and IMDC models performed poorly with c-indices of 0.55 and 0.56, respectively.

CONCLUSION

Currently used prognostic models have limited discriminatory capacity when applied to a modern cohort of patients undergoing CN. They are inadequate for risk stratification and randomisation in prospective clinical trials of untreated patients with mRCC. Caution should be used when using these models for clinical decision making.

Neoadjuvant Therapy for Locally Advanced Renal Cell Carcinoma

There has been strong interest in using neoadjuvant therapy to decrease recurrence rates and facilitate surgical resection in locally advanced renal cell carcinoma. To date, no evidence exists to support improvement in oncologic outcomes with neoadjuvant therapy. Likewise, although targeted therapies have shown efficacy in tumor downsizing, this does not often translate to downstaging. Use of presurgical therapy for the purpose of downstaging inferior vena cava tumor thrombi is currently not supported. Future studies evaluating the benefit of newer immune checkpoint inhibitors will determine if there is a larger role for neoadjuvant therapy in locally advanced renal cell carcinoma.

Preoperative metastatic disease burden to predict overall survival following cytoreductive nephrectomy independent of IMDC risk category

652

Background: Studies suggest that overall survival (OS) following cytoreductive nephrectomy (CN) is associated with preoperative tumor measurements including primary tumor diameter, number of metastatic sites, sum of metastatic tumor diameters and primary tumor percent of overall burden. Current risk models, however, do not account for tumor burden. This study evaluated associations between OS and preoperative tumor measurements for patients treated with CN during the targeted therapy era. Methods: Data for consecutive mRCC patients treated with CN at 4 institutions from 2006-2017 were analyzed after determining IMDC risk category, primary tumor (PT) diameter, number of metastatic sites, sum of metastatic tumor diameters and PT percentage of overall burden. Univariate and multivariable (MV) Cox models evaluated tumor measurement and IMDC risk associations with OS. Results: A total of 617 patients were available for analysis. Median PT diameter was 10.0 cm (IQR 7-13cm), number of metastatic sites was 2 (IQR 1-2), sum of metastatic tumor diameters was 4.5 cm (IQR 2-10cm) and PT percent of overall burden was 73.7% (IQR 60-85%). After univariate analysis, all 4 tumor burden measures were associated with OS (p≤0.001 for all). MV models evaluating IMDC risk category with individual tumor burden measurements demonstrated that all measures were predictive as continuous variables: PT diameter (HR 1.03, 95% CI 1.01-1.06, p=0.007), sum of metastatic tumor diameters (HR 1.04, 95% CI 1.02-1.05, p<0.001), PT percent of overall burden (HR 0.43, 95% CI 0.27-0.68, p<0.001), and number of metastatic sites (HR 1.52, 95% CI 1.25-1.85, p<0.001). Additional MV models were created using clinically significant tumor measurement cutoffs and IMDC risk groups. OS was independently associated with IMDC intermediate (HR 3.17, 95% CI 1.84-5.44, p<0.001) and poor risk (HR 3.85, 95% CI 2.21-6.70, p<0.001), PT percentage of overall burden <90% (HR 1.41, 95% CI 1.05-1.89, p=0.021), and >2 metastatic sites (HR 1.60, 95% CI 1.29-2.00, p<0.001). Conclusions: PT and metastatic disease burden are independently associated with OS following CN. Future risk models should include tumor burden measurements.

Origin of somatic transformation in germ cell tumor of testis (TGCT): Role of differentiation versus dedifferentiation in a mature teratoma

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Background: TGCT is a prototype stem-cell malignancy recapitulating the ontogeny of solid tumors. We studied the roles of differentiation versus dedifferentiation in a bona fide well-differentiated tumor, namely mature teratomas, associated with or without somatic transformation. Methods: Between 2001 and 2013, we identified 7 out of 13 cases in which teratoma and somatic transformation were present within the same residual tumor after chemotherapy and resected at our institution with sufficient quantity and quality for DNA and RNA analysis. We performed primary cell culture, flow cytometry, and xenografts to evaluate stem-ness biomarkers and tumor phenotypes of freshly resected mature teratomas. Results: We detected very few mutations within a preselected gene pool (T200) in all tumor samples. The "within patient mutation agreement" from a mutation matrix of 57 genes, in which at least one mutation occurred between teratoma and somatic transformation, was 86.2 to 94.8%. There was disparity in gene expression, including miR7-3HG, ARHGEF35, and DLX6, between the 7 matched tumor pairs (log2 fold change of about 2). Prospective primary cell culture studies using cell surface stem-ness markers (SSEA3, TRA1-60, Cripto-1, CD90, CD133, CD44) indicate presence of stem cells embedded within residual mature teratomas (n = 3) after chemotherapy. Conclusions: Molecular profiling confirms a common clonal origin between teratoma and somatic transformation but refutes the idea of dedifferentiation of teratoma to somatic transformation. Presence of stem cells embedded within mature teratomas and capable of differentiation into separate ontogenetic lineages could account for the origin of somatic transformation in TGCT.[Table: see text]

Intercourse frequency among men presenting to a sexual health clinic: does age matter?

We assessed the association between intercourse frequency and sexual function among 583 consecutive males with sexual partners presenting to a men's health clinic over a 2-year period. Median age was 62 and men reported a median of 2 (IQR 0, 5) episodes of intercourse per month. Younger age, shorter relationship duration, higher intercourse satisfaction (IIEF-IS) scores, and higher libido (all p < 0.01) were associated with more frequent intercourse. On multivariable analysis, longer relationship duration was associated with less frequent intercourse (p = 0.03), but was linked to higher overall sexual satisfaction. Age was not a significant predictor of intercourse frequency.

Evaluation of Medical School Grading Variability in the United States: Are All Honors the Same?

PURPOSE

The medical student performance evaluation (MSPE) summarizes a residency applicant's academic performance. Despite attempts to improve standardized clerkship grading, concerns regarding grade inflation and variability at United States medical schools persist. This study's aim was to describe current patterns of clerkship grading and applicant performance data provided in the MSPE.

METHOD

The authors evaluated Electronic Residency Application Service data submitted to a single institution for the 2016-2017 Match cycle. Clerkship grading characteristics regarding grading tiers, school rank, location, and size were obtained. Data regarding methods for summative comparisons such as key word utilization were also extracted. Descriptive statistics were generated, and generalized linear modeling was performed.

RESULTS

Data were available for 137/140 (98%) MD-granting U.S. medical schools. Pass/fail grading was most commonly used during the preclinical years (47.4%). A 4-tier system was most common for clerkship grading (31%); however, 19 different grading schemes were identified. A median of 34% of students received the highest clerkship grade (range, 5%-97%). Students attending a top 20 medical school were more likely to receive the highest grade compared with those attending lower-rated schools (40% vs 32%, P < .001). Seventy-three percent of schools ranked students, most commonly using descriptive adjectives. Thirty-two different adjectives were used.

CONCLUSIONS

There is significant institutional variation in clinical grading practices and MSPE data. For core clerkships where most students received the highest grade, the ability to distinguish between applicants diminishes. A standardized approach to reporting clinical performance may allow for better comparison of residency applicants.

Treatment of non-obstructive, non-struvite urolithiasis is effective in treatment of recurrent urinary tract infections

PURPOSE

To determine if treatment of non-obstructing urolithiasis is effective in management of recurrent UTI.

MATERIALS AND METHODS

A retrospective review was performed of patients undergoing elective management of non-struvite upper tract urinary calculi with recurrent UTI from 2009 to 2016. Recurrent UTI was defined at ≥ 3 UTI in 12 months, with symptoms and documented urine culture. Preoperative CT was performed in all patients to determine stone burden. All patients had postoperative imaging and ≥ 12 months of follow-up. Pre- and postoperative variables were between patients who had recurrent UTI after treatment versus those who did not.

RESULTS

46 patients met inclusion criteria. 42 (91.3%) were female. Median age was 63.7 years (IQR 49.1, 73.4) and median total stone burden was 20 mm (IQR 14-35). Within the cohort, 20 (43.5%) underwent ureteroscopy only, 26 (56.5%) underwent PCNL ± URS, and none underwent ESWL. Median postoperative follow-up was 2.9 years (IQR 2.0, 4.3). Only five patients (10.9%) had recurrent UTI after treatment. 80% were with the preoperative pathogen. The presence of residual stone was an independent risk factor for recurrent UTI after treatment (p < 0.046). Diabetes, hypertension, immunosuppression and chronic kidney disease were not.

CONCLUSIONS

Stone removal for patients with recurrent UTIs was associated with a high rate of success (89.1%) in elimination of further recurrent UTIs. Residual fragments are independently associated with persistent recurrent UTIs and thus, complete stone removal is of paramount importance in treatment of this patient population.

Impact of time from biopsy to surgery on complications, functional and oncologic outcomes following radical prostatectomy

Introduction:

To determine the impact of time from biopsy to surgery on outcomes following radical prostatectomy (RP) as the optimal interval between prostate biopsy and RP is unknown.

Material and methods:

We identified 7, 350 men who underwent RP at our institution between 1994 and 2012 and had a prostate biopsy within one year of surgery. Patients were grouped into five time intervals for analysis: ≤ 3 weeks, 4-6 weeks, 7-12 weeks, 12-26 weeks, and > 26 weeks. Oncologic outcomes were stratified by NCCN disease risk for comparison. The associations of time interval with clinicopathologic features and survival were evaluated using multivariate logistic and Cox regression analyses.

Results:

Median time from biopsy to surgery was 61 days (IQR 37, 84). Median follow-up after RP was 7.1 years (IQR 4.2, 11.7) while the overall perioperative complication rate was 19.7% (1,448/7,350). Adjusting for pre-operative variables, men waiting 12-26 weeks until RP had the highest likelihood of nerve sparing (OR: 1.45, p = 0.02) while those in the 4-6 week group had higher overall complications (OR: 1.33, p = 0.01). High risk men waiting more than 6 months had higher rates of biochemical recurrence (HR: 3.38, p = 0.05). Limitations include the retrospective design.

Conclusions:

Surgery in the 4-6 week time period after biopsy is associated with higher complications. There appears to be increased biochemical recurrence rates in delaying RP after biopsy, for men with both low and high risk disease.

Alteplase Instillation for Upper Urinary Tract Clot Dissolution

Background: We report the first case of instillation of alteplase, a tissue plasminogen activator, to dissolve occlusive upper urinary tract blood clot. Case Presentation: A 67-year-old Caucasian man with a solitary kidney became dialysis dependent because of upper urinary tract clot obstruction after ureteral stent placement for obstructing ureterolithiasis. After failure of more conservative measures, 10 mg of alteplase was instilled through nephrostomy tube daily for 2 consecutive days 30 minutes before manual irrigation with physiologic saline. After alteplase instillation, the occlusive blood clot dissolved with rapid improvement in urinary output and creatinine. Conclusions: Alteplase instillation through nephrostomy tube is a viable option to dissolve obstructing upper urinary tract blood clots.

Impact of anabolic androgenic steroids on sexual function

Background

To describe the impact of supra-physiologic anabolic-androgenic steroid (AAS) use, including agent, dosage, and duration of therapy, on sexual function.

Methods

We reviewed data from an online survey of AAS users to evaluate their sexual function on and off AAS. The online survey consisted of questions addressing demographics, anabolic steroid use and patterns, ancillary medications, testosterone (T)-related symptoms while on and off of therapy, as well as sexual function which was assessed using the 5-item, International Index of Erectile Function (IIEF-5).

Results

A total of 321 men responded to the survey, of which 90 failed to meet inclusion criteria, for a final cohort of 231 AAS users. The majority of men were Caucasian (85%), employed (62%), and younger than 35 years (58%), while an equal mix were single (47%) or married (46%). The mean IIEF-5 was 22.5, with higher scores associated with increased T dosages (>600 mg/week), use of 17-alpha alkylated hormones and anti-estrogens, and absence of concurrent medical conditions. Lower mean IIEF scores were associated with current and pre-AAS low T symptoms, self-reported angry or violent tendencies, self-reported erectile dysfunction (ED), decreased libido, decreased energy, and depression. After controlling for age, low T symptoms and decreased energy remained significantly associated with lower IIEF scores. Among 127 men reporting de novo decreased libido when not taking AAS, several factors were significantly associated including frequency and duration of T and use of adjunctive therapies, while post-cycle therapies were protective. Men who reported any other de novo symptom (decreased energy, libido, muscle mass or depression) after discontinuing T were also more likely to report de novo ED, as well as those using >10 years or for >40 weeks per year.

Conclusions

The long-term impact of high dose AAS use on sexual function remains poorly defined. Although high T dosages appeared to be protective of erectile function during use, de novo symptoms such as decreased libido and ED occurred more frequently after discontinuing T, particularly among those using more frequently and for longer durations. Given the importance of these findings, long-term studies evaluating the impacts of discontinuing T on sexual dysfunction are indicated.

Medication patterns and fertility rates in a cohort of anabolic steroid users

BACKGROUND

To describe self-reported medication patterns and fertility rates in a population of anabolic steroid (AS) users.

METHODS

We reviewed data from an online survey of AS users and identified a sub-group who had attempted to achieve a pregnancy with their partners while using AS. The online survey consisted of questions addressing demographics, AS use, ancillary medications, and fertility outcomes.

RESULTS

A total of 97 men (of 231 total respondents) had attempted to achieve a pregnancy while taking AS and comprise the current cohort. The majority of men were 25-44 years old (63.9%), married (75.5%) and Caucasian (88.7%). Ancillary drug use was common with only 5.2% denying drug use other than ASs. The most common reported ancillary drugs were antiestrogens (89.7%) and sexual enhancement medications (SEMs) (68%). The fertility rate was 92.8%, with 82.4% achieving pregnancy within one year. Interestingly, only 13.5% sought fertility evaluation with treatment required in 8.3%. Age at initiation of AS use, maximum dosage utilized, yearly duration of supplementation, and number of years using steroids were not associated with a prolonged duration to pregnancy or decreased rate of pregnancy.

CONCLUSIONS

Despite continued use of ASs, this cohort's self-reported fertility rates are unexpectedly high. This is presumably related to cycling of therapy and concomitant use of fertility preserving medications.

Safety and efficacy of intravesical alum for intractable hemorrhagic cystitis: A contemporary evaluation

Introduction:

Hemorrhagic cystitis (HC) represents a challenging clinical entity. While various intravesical agents have been utilized in this setting, limited data exist regarding safety or efficacy. Herein, then, we evaluated the effectiveness and complications associated with intravesical alum instillation for HC in a contemporary cohort.

Materials and Methods:

We identified 40 patients treated with intravesical alum for HC between 1997-2014. All patients had failed previous continuous bladder irrigation with normal saline and clot evacuation. Treatment success was defined as requiring no additional therapy beyond normal saline irrigation after alum instillation.

Results:

Median patient age was 76.5 years (IQR 69, 83). Pelvic radiation was the most common etiology for HC (n=38, 95%). Alum use decreased patient's transfusion requirement, with 82% (32/39) receiving a transfusion within 30 days before alum instillation (median 4 units) versus 59% (23/39) within 30 days after completing alum (median 3 units) (p=0.05). In total, 24 patients (60%) required no additional therapy prior to hospital discharge. Moreover, at a median follow-up of 17 months (IQR 5, 38.5), 13 patients (32.5%) remained without additional treatment for HC. Adverse effects were reported in 15 patients (38%), with bladder spasms representing the most common event (14/40; 35%). No clinical evidence of clinically significant systemic absorption was detected.

Conclusion:

Intravesical alum therapy is well-tolerated, with resolution of HC in approximately 60% of patients, and a durable response in approximately one-third. Given its favorable safety/efficacy profile, intravesical alum may be considered as a first-line treatment option for patients with HC.

Ureteroarterial Fistulas After Robotic and Open Radical Cystectomy

Ureteroarterial fistulas (UAFs) are defined as an abnormal communication between one of the major arteries and the ureter. Urologists most frequently encounter iatrogenic fistulas occurring in patients with a history of pelvic extirpative surgery, chronic ureteral catheterization, and history of pelvic radiation. We present two cases of UAFs in patients with no history of prior radiation, who underwent open radical cystectomy and robot-assisted radical cystectomy with intracorporeal ileal conduit. Both patients developed postoperative ureteroileal anastomotic leaks that were managed with indwelling ureteral catheters. Furthermore, both patients were having left-sided UAF after presenting with nonlife threatening gross hematuria, which became brisk and pulsatile during ureteral stent exchange. Endovascular stenting was performed in both patients with resolution of hemorrhage and full recovery. In one patient, nephrostomy tubes were placed and ureteral catheters were removed; the second patient was managed with continued ureteral catheterization without further episodes of hematuria.