Delta radiomic patterns on serial bi-parametric MRI are associated with pathologic upgrading in prostate cancer patients on active surveillance: preliminary findings

Objective

The aim of this study was to quantify radiomic changes in prostate cancer (PCa) progression on serial MRI among patients on active surveillance (AS) and evaluate their association with pathologic progression on biopsy.

Methods

This retrospective study comprised N = 121 biopsy-proven PCa patients on AS at a single institution, of whom N = 50 at baseline conformed to the inclusion criteria. ISUP Gleason Grade Groups (GGG) were obtained from 12-core TRUS-guided systematic biopsies at baseline and follow-up. A biopsy upgrade (AS+) was defined as an increase in GGG (or in number of positive cores) and no upgrade (AS-) was defined when GGG remained the same during a median period of 18 months. Of N = 50 patients at baseline, N = 30 had MRI scans available at follow-up (median interval = 18 months) and were included for delta radiomic analysis. A total of 252 radiomic features were extracted from the PCa region of interest identified by board-certified radiologists on 3T bi-parametric MRI [T2-weighted (T2W) and apparent diffusion coefficient (ADC)]. Delta radiomic features were computed as the difference of radiomic feature between baseline and follow-up scans. The association of AS+ with age, prostate-specific antigen (PSA), Prostate Imaging Reporting and Data System (PIRADS v2.1) score, and tumor size was evaluated at baseline and follow-up. Various prediction models were built using random forest (RF) classifier within a threefold cross-validation framework leveraging baseline radiomics (Cbr), baseline radiomics + baseline clinical (Cbrbcl), delta radiomics (CΔr), delta radiomics + baseline clinical (CΔrbcl), and delta radiomics + delta clinical (CΔrΔcl).

Results

An AUC of 0.64 ± 0.09 was obtained for Cbr, which increased to 0.70 ± 0.18 with the integration of clinical variables (Cbrbcl). CΔr yielded an AUC of 0.74 ± 0.15. Integrating delta radiomics with baseline clinical variables yielded an AUC of 0.77 ± 0.23. CΔrΔclresulted in the best AUC of 0.84 ± 0.20 (p < 0.05) among all combinations.

Conclusion

Our preliminary findings suggest that delta radiomics were more strongly associated with upgrade events compared to PIRADS and other clinical variables. Delta radiomics on serial MRI in combination with changes in clinical variables (PSA and tumor volume) between baseline and follow-up showed the strongest association with biopsy upgrade in PCa patients on AS. Further independent multi-site validation of these preliminary findings is warranted.

Novel radiomic analysis on bi-parametric MRI for characterizing differences between MR non-visible and visible clinically significant prostate cancer

Background

around one third of clinically significant prostate cancer (CsPCa) foci are reported to be MRI non-visible (MRI─).

Objective

To quantify the differences between MR visible (MRI+) and MRI^─ CsPCa using intra- and peri-lesional radiomic features on bi-parametric MRI (bpMRI).

Methods

This retrospective and multi-institutional study comprised 164 patients with pre-biopsy 3T prostate multi-parametric MRI from 2014 to 2017. The MRI^─ CsPCa referred to lesions with PI-RADS v2 score < 3 but ISUP grade group > 1. Three experienced radiologists were involved in annotating lesions and PI-RADS assignment. The validation set (D_v) comprised 52 patients from a single institution, the remaining 112 patients were used for training (D_t). 200 radiomic features were extracted from intra-lesional and peri-lesional regions on bpMRI.Logistic regression with least absolute shrinkage and selection operator (LASSO) and 10-fold cross-validation was applied on D_t to identify radiomic features associated with MRI^─ and MRI⁺ CsPCa to generate corresponding risk scores R^MRI─ and R^MRI+. R_bpMRI was further generated by integrating R^MRI─ and R^MRI+. Statistical significance was determined using the Wilcoxon signed-rank test.

Results

Both intra-lesional and peri-lesional bpMRI Haralick and CoLlAGe radiomic features were significantly associated with MRI^─ CsPCa (p < 0.05). Intra-lesional ADC Haralick and CoLlAGe radiomic features were significantly different among MRI^─ and MRI⁺ CsPCa (p < 0.05). R_bpMRI yielded the highest AUC of 0.82 (95 % CI 0.72-0.91) compared to AUCs of R^MRI+ 0.76 (95 % CI 0.63-0.89), and PI-RADS 0.58 (95 % CI 0.50-0.72) on D_v. R_bpMRI correctly reclassified 10 out of 14 MRI^─ CsPCa on D_v.

Conclusion

Our preliminary results demonstrated that both intra-lesional and peri-lesional bpMRI radiomic features were significantly associated with MRI^─ CsPCa. These features could assist in CsPCa identification on bpMRI.

Disparities in cause-specific mortality by race and sex among bladder cancer patients from the SEER database

PURPOSE

Previous literature shows that more bladder cancer patients overall die from causes other than the primary malignancy. Given known disparities in bladder cancer outcomes by race and sex, we aimed to characterize differences in cause-specific mortality for bladder cancer patients by these demographics.

METHODS

We identified 215,252 bladder cancer patients diagnosed with bladder cancer from 2000 to 2017 in the SEER 18 database. We calculated cumulative incidence of death from seven causes (bladder cancer, COPD, diabetes, heart disease, external, other cancer, other) to assess differences in cause-specific mortality between race and sex subgroups. We used multivariable Cox proportional hazards regression and Fine-Gray competing risk models to compare risk of bladder cancer-specific mortality between race and sex subgroups overall and stratified by cancer stage.

RESULTS

17% of patients died from bladder cancer (n = 36,923), 30% died from other causes (n = 65,076), and 53% were alive (n = 113,253). Among those who died, the most common cause of death was bladder cancer, followed by other cancer and diseases of the heart. All race-sex subgroups were more likely than white men to die from bladder cancer. Compared to white men, white women (HR: 1.20, 95% CI: 1.17-1.23) and Black women (HR: 1.57, 95% CI: 1.49-1.66) had a higher risk of dying from bladder cancer, overall and stratified by stage.

CONCLUSION

Among bladder cancer patients, death from other causes especially other cancer and heart disease contributed a large proportion of mortality. We found differences in cause-specific mortality by race-sex subgroups, with Black women having a particularly high risk of dying from bladder cancer.

Characterization of Changes in Penile Microbiome Following Pediatric Circumcision

BACKGROUND

While microbiome and host regulation contribute independently to many disease states, it is unclear how circumcision in pediatric population influences subsequent changes in penile microbiome.

OBJECTIVE

Our study aims to analyze jointly paired taxonomic profiles and assess pathways implicated in inflammation, barrier protection, and energy metabolism.

DESIGN, SETTING, AND PARTICIPANTS

We analyzed 11 paired samples, periurethral collection, before and after circumcision, to generate microbiome and mycobiome profiling. Sample preparation of 16S ribosomal RNA and internal transcribed spacer sequencing was adapted from the methods developed by the National Institutes of Health Human Microbiome Project.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We obtained the predictive functional attributes of the microbial communities between samples using Silva-Tax4Fun and the Greengenes-Phylogenetic Investigation of Communities by Reconstruction of Unobserved States (PICRUSt) approach. The predictive functioning of the microbial communities was determined by linearly combining the normalized taxonomic abundances into the precomputed association matrix of Kyoto Encyclopedia of Genes and Genomes orthology reference profiles.

RESULTS AND LIMITATIONS

Several notable microbiome and mycobiome compositional differences were observed between pre- and postcircumcision patients. Pairwise comparisons across taxa revealed a significant decrease (p < 0.05, false discovery rate corrected) of microbiome organisms (Clostridiales, Bacteroidales, and Campylobacterales) and mycobiome (Saccharomycetales and Pleosporales) following circumcision. A total of 14 pathways were found to differ in abundance between the pre- and postcircumcision groups (p < 0.005, false discovery rate <0.1 and linear discriminant analysis score >3; five enriched and nine depleted). The pathways reduced after circumcision were mostly involved with amino acid and glucose metabolism, while pathways prior to circumcision were enriched in genetic information processing and transcription processes. As expected, enrichment in methyl-accepting chemotaxis protein, an integral membrane protein involved in directed motility of microbes to chemical cues and environment, occurred prior to circumcision, while the filamentous hemagglutinin pathway (a strong immunogenic protein) was depleted after circumcision CONCLUSIONS: Our results offer greater insight into the host-microbiota relationship of penile circumcision and may serve to lay the groundwork for future studies focused on drivers of inflammation, infection, and oncogenesis.

PATIENT SUMMARY

Our study showed a significant reduction in bacteria and fungi after circumcision, particularly anaerobic bacteria, which are known to be potential inducers of inflammation and cancer. This is the first study of its kind showing the changes in microbiome after circumcision, and some of the changes that occur in healthy infants after circumcision that may explain the differences in cancer and inflammatory disorders in adulthood.

Skene's Gland Malignancy: A Case Report and Systematic Review

OBJECTIVE

To present a recent clinical case of Skene's gland carcinoma and review all published literature of Skene's gland malignancy with associated treatment and outcomes.

METHODS

We review a new case of metastatic Skene's gland adenocarcinoma. We then performed a systematic search of PubMed and Ovid-Medline through December 2021 and retrieved English language articles for review. Peer-reviewed articles were deemed eligible if they included patients with Skene's gland malignancy. Reports were reviewed for pathologic accuracy, patient characteristics, clinical presentation, tumor pathology, treatment and outcome.

RESULTS

We reviewed 211 articles and included 15 cases from 1974 to 2022. The median patient age was 71 years (range 46-88). The most common presentation was an asymptomatic periurethral or urethral lesion in five cases (33.3%), followed by hematuria or vaginal bleeding in three patients (20.0%). In eight cases, a prostate-specific antigen was measured and found to be elevated, range 0.8-60.8 ng/mL. Treatment approaches varied and included local excision in eight cases, radical surgical resection in two cases, radiation therapy in two cases, and adjunctive androgen deprivation therapy in one case. Pathology was consistent with adenocarcinoma resembling prostate in all cases. In all cases tested, prostate-specific antigen normalized after definitive therapy of any type. Median follow up was 11.5 months, and there were no cases of recurrence or mortality secondary to Skene's gland adenocarcinoma.

CONCLUSION

There are 15 published cases of a Skene's gland malignancy, all adenocarcinoma resembling prostate. Local excision is most often utilized for treatment, with androgen deprivation therapy emerging as a new treatment consideration.

Risk factors for postoperative Clostridium difficile infection after radical cystectomy for bladder cancer: a NSQIP database analysis

INTRODUCTION

Patients undergoing cystectomy for bladder cancer are at an increased risk for Clostridium difficile infection (CDI) due to prolonged antibiotics and underlying comorbidities. We aim to evaluate CDI risk factors in cystectomy patients.

MATERIALS AND METHODS

Utilizing National Surgical Quality Improvement Program (NSQIP), patients undergoing cystectomy with diagnosis of bladder cancer between 2015-2017 were included. Baseline demographics including age, sex, comorbidities, and preoperative labs were collected. Univariate and multivariable logistic regression were used to evaluate risk factors for and complications of CDI during the index hospitalization.

RESULTS

There were a total of 6,432 patients included in the analysis, with 6,242 (96%) and 190 (4%) in the non-CDI vs. CDI groups, respectively. Patients with a diagnosis of postoperative CDI were more likely to be female [4.09% vs. 2.71%, p = 0.001] and have lower preoperative albumin [3.78 g/dL (0.52) vs. 3.92 g/dL (0.48), p = 0.003]. Patients with a history of female sex (OR 1.46, p = 0.03), neobladder (OR 1.57, p = 0.01), and low preoperative albumin (OR 1.45, p = 0.04) were at the highest risk for development of CDI postoperatively. Patients with a diagnosis of CDI were more likely to experience readmission within 30 days (31.1% vs. 19.2%, p < 0.001).

CONCLUSION

Utilizing the NSQIP database, we identified predictors for development of CDI in cystectomy patients. Female sex, continent diversion, and low preoperative albumin all significantly increased the rate of CDI. While our findings are retrospective, they are compelling enough to warrant further prospective investigation.

Prostate Surface Distension and Tumor Texture Descriptors From Pre-Treatment MRI Are Associated With Biochemical Recurrence Following Radical Prostatectomy: Preliminary Findings

Objective

To derive and evaluate the association of prostate shape distension descriptors from T2-weighted MRI (T2WI) with prostate cancer (PCa) biochemical recurrence (BCR) post-radical prostatectomy (RP) independently and in conjunction with texture radiomics of PCa.

Methods

This retrospective study comprised 133 PCa patients from two institutions who underwent 3T-MRI prior to RP and were followed up with PSA measurements for ≥3 years. A 3D shape atlas-based approach was adopted to derive prostate shape distension descriptors from T2WI, and these descriptors were used to train a random forest classifier (C_S) to predict BCR. Texture radiomics was derived within PCa regions of interest from T2WI and ADC maps, and another machine learning classifier (C_R) was trained for BCR. An integrated classifier C_S+R was then trained using predictions from C_S and C_R. These models were trained on D₁ (N = 71, 27 BCR+) and evaluated on independent hold-out set D₂ (N = 62, 12 BCR+). C_S+R was compared against pre-RP, post-RP clinical variables, and extant nomograms for BCR-free survival (bFS) at 3 years.

Results

C_S+R resulted in a higher AUC (0.75) compared to C_R (0.70, p = 0.04) and C_S (0.69, p = 0.01) on D₂ in predicting BCR. On univariable analysis, C_S+R achieved a higher hazard ratio (2.89, 95% CI 0.35–12.81, p < 0.01) compared to other pre-RP clinical variables for bFS. C_S+R, pathologic Gleason grade, extraprostatic extension, and positive surgical margins were associated with bFS (p < 0.05). C_S+R resulted in a higher C-index (0.76 ± 0.06) compared to CAPRA (0.69 ± 0.09, p < 0.01) and Decipher risk (0.59 ± 0.06, p < 0.01); however, it was comparable to post-RP CAPRA-S (0.75 ± 0.02, p = 0.07).

Conclusions

Radiomic shape descriptors quantifying prostate surface distension complement texture radiomics of prostate cancer on MRI and result in an improved association with biochemical recurrence post-radical prostatectomy.

Impact of Music on Postoperative Pain, Anxiety, and Narcotic Use After Robotic Prostatectomy: A Randomized Controlled Trial

Background:

Music is a safe and cost-effective intervention that can reduce postoperative pain and anxiety. We investigated the effects of music therapy on postoperative recovery in patients undergoing robotic-assisted laparoscopic prostatectomy (RALP).

Methods:

Subjects were males 18 years and older undergoing RALP at a single tertiary care institution. Patients were randomized to music or control groups. The music group received 30 minutes of music in the recovery area and on postoperative day (POD) 1, while the control group was not provided postoperative music. Inpatient narcotic use (morphine milligram equivalent, or MME) and outpatient narcotic use were measured, and the State-Trait Anxiety Inventory (STAI) survey was completed on POD 1 and POD 7 by an inpatient advanced practitioner (AP). T-test and Chi-square were used to compare the groups. Linear regression was used to adjust for age, blood loss, and inpatient MME.

Results:

A total of 40 patients were prospectively recruited. There was no statistically significant difference in the hourly MME (2.06 [0.71–3.17] vs. 1.55 [0.83-3.37]) or total MME (49.52 [17–76] vs. 37.25 [20-69]) used in the music vs. non-music arms, respectively. Evaluation of STAI questionnaire revealed no overall differences in anxiety levels among the two groups on POD 1 or POD 7. After adjusting for age, blood loss, and inpatient MME use, patients assigned to the music intervention had a 26% reduction in post-hospitalization use.

Conclusion:

Our prospective randomized study suggests that music can be an AP-driven adjunct to facilitate postoperative patient comfort and reduce narcotic use upon discharge in prostate cancer patients.

Pediatric Thoracolumbar Spinal Injuries in United States Trauma Centers

OBJECTIVES

Injuries are the leading cause of morbidity and mortality in children ages 1 to 18 years. There are limited studies about pediatric thoracolumbar (TL) spinal injuries; the purpose of this study was to characterize TL spinal injuries among pediatric patients evaluated in US trauma centers.

METHODS

This was a retrospective cohort study of the National Trauma Data Bank. Patients aged 1 to 18 years with a thoracic or lumbar spinal injury sustained by blunt trauma during calendar years 2011 through 2016 were included. Cervical spinal injuries, death before arrival, or penetrating trauma were excluded. The data was abstracted, and missing data was addressed by imputations. Data was analyzed using descriptive statistics and multinomial logistic regressions.

RESULTS

A total of 20,062 patients were included in the study. Thoracolumbar spinal injuries were more commonly sustained by 16- to 17-year-olds (45.7%), boys (56.6%), and White (74.8%). The injuries were often from a motor vehicle collision (MVC) (55.2%) and resulted in a bone injury (82.3%). Mechanism of injury and age were significant in predicting injury type. A fall was more likely than MVC to result in disc injury (odds ratio [OR], 1.70; 95% confidence interval [CI], 1.24-2.33), strain injury (OR, 1.18; 95% CI, 1.05-1.34), or cord injury (OR, 1.27; 95% CI, 1.12-1.45). Younger children were more likely than adolescents to present with disc injury (OR, 2.79; 95% CI, 1.75-4.45), cord injury (OR, 1.46; 95% CI, 1.18-1.81), or strain injury (OR, 1.37; 95% CI, 1.09-1.72).

CONCLUSIONS

To our knowledge, this is the largest pediatric TL spinal study. Clinicians should consider TL spinal injuries when adolescents present after an MVC, and specifically, TL spinal cord injuries when young children present after a fall. Additionally, pediatric TL spinal injury prevention should highlight motor vehicle and fall safety.

Cost of Care in Open Cystectomy Patients Across Time and Space: Does it matter?

BACKGROUND: Many variables may affect the cost of open radical cystectomy (RC) care, including surgical approach, diversion type, patient comorbidities, and postoperative complications. OBJECTIVE: To determine factors associated with changes in cost of care following open radical cystectomy (ORC) for bladder cancer using the National Inpatient Sample (NIS). METHODS: Patients in the NIS with a diagnosis of bladder cancer who underwent ORC with ileal conduit from 2012–2017 using ICD-9-CM and ICD-10-CM codes were identified. Baseline demographics including age, race, region, postoperative complications, and length of stay were obtained. Univariable and multivariable logistic regression were used to identify factors associated with cost variation including demographics, clinical characteristics, surgical factors, and discharge quarter (Q1-Q4). RESULTS: 5,189 patients were included in the analysis, with 4,379 at urban teaching hospitals. On multivariable regression analysis, female sex [$1,734 ($1,024–2,444) p < 0.001)], a greater Elixhauser comorbidity score [$93 ($62–124), p < 0.001], presence of any inpatient complication [$1,531 ($894–2,168), p < 0.001], and greater length of stay [$1,665 ($1,536–1,793), p < 0.001] were associated with a greater cost of hospitalization. Discharge in Q3 (July to September) relative to Q2 (April to June) was associated with a higher cost [$1,113 ($292–1,933), p = 0.008. Trends were similar at urban non-teaching and rural hospitals, except discharge quarter was not associated with a significant change in cost. CONCLUSIONS: Significant differences in cost of ORC with ileal conduit exist with respect to patient sex, medical comorbidities, and discharge timing. These differences may relate to greater disease burden in female patients, patient complexity, and variation in postoperative care in academic programs.

The Impact of Race and Sex on Metastatic Bladder Cancer Survival

OBJECTIVE

To characterize the epidemiological profile of metastatic bladder cancer (BC) and assess mortality rate with respect to race and gender across the three most common histologies of bladder cancer-Transitional Cell Carcinoma, Adenocarcinoma, and SCC (Squamous Cell Carcinoma).

MATERIALS AND METHODS

The Surveillance, Epidemiology, and End Results Program database (2000-2017) was queried for all metastatic bladder cancer patients at presentation. Our primary exposure consists of four race/gender combinations. One-way ANOVA and Chi-square tests compared categorical and continuous variables across the exposure variable, respectively. Univariable and multivariable Cox proportional hazards regression analyses were used to examine the association between race/gender combinations and the overall and cancer specific survival adjusting for the other variables.

RESULTS

A total of 312,846 bladder cancer patients, 6337 with distant metastases and 11,446 with regional metastases were evaluated. Black female cancer specific survival in metastatic disease was disproportionally lower compared to all race/gender for Transitional Cell Carcinoma 4.3% (95% CI: 1.6-8.9), SCC 2.6% (95% CI: 0.2-11.8), and Adenocarcinoma 6.4% (0.4%-25%). In regional metastastatic disease, worse cancer specific mortality was associated with identifying as a Black Female (aHR 1.17, P = .023), SCC (aHR 1.8, P <.001), increasing age (aHR 1.3, P <.001), and poorly differentiated grade (aHR 2.01, P <.001).

CONCLUSION

Black females experience excess mortality in overall and cancer oncologic outcomes in metastatic BC. Our findings contribute to the body of research warranting examination of the impact of social determinants of health and provider decisions on BC survivorship and contribute to physician decision making in the treatment and surveillance of bladder cancer.

Opioid prescription patterns among urologists as compiled from within Medicare

INTRODUCTION

We aimed to evaluate opioid prescribing patterns of urologists across the United States (U.S.) and the District of Columbia (D.C.) using publicly available data from Medicare Part D. Our secondary analysis was to identify any loco-regional trends that may exist within the U.S.

METHODS

We queried publicly reported information from the Part D prescriber database, which is compiled from beneficiaries enrolled within the Medicare Part D prescription drug program. Only providers with the specialty description of urologist were included in this study.

RESULTS

Between 2013 and 2017, a five-year average of 452 901 opioid claims by 9640 urologists - amounting to $5 357 114 USD and comprising 3.78% of all claims made - were identified. The state of Maine featured the highest percentage of opioid claims in relation to all claims (5.81%). West Virginia had the greatest average total opioid claims per provider (90), while Michigan featured the highest average proportion of opioid claims per provider (10.63%). The fewest opioid claims were processed within the Mid-Atlantic and New England regions.

CONCLUSIONS

A multitude of factors likely contributes to variability between states. Urologists should be increasingly aware of their individual prescription tendencies and use available drug monitoring programs to reduce unnecessary prescriptions, all while providing more targeted and appropriate pain management.

Peri-operative outcomes between primary and replacement artificial urinary sphincter surgery: An ACS-NSQIP analysis

Objective: To evaluate differences in perioperative clinical outcomes in men undergoing artificial urinary sphincter (AUS) implantation in primary versus replacement settings. Secondarily, we aimed to identify patient-related factors contributing to complications associated with AUS placement.

Materials and Methods: A review of the American College of Surgeons-National Surgical Quality Improvement Program was performed between 2010 and 2018 identifying males undergoing AUS implantation. Subjects were further subdivided into primary implantation or removal/replacement of AUS simultaneously via current procedural terminology codes 53445 and 53447, respectively. 30-Day postoperative outcomes were compared between cohorts using t-test and Fisher’s exact test. The relationship between patient factors and complications was evaluated using logistic regression.

Results: A total of 1,892 patients were identified: 1,445 primary AUS placement and 447 AUS replacement procedures. Patients undergoing AUS replacement were statistically older than those undergoing primary implantation (71.4 vs 69.7 years, P < .001). AUS replacement procedures were associated with an increased rate of superficial surgical site infection (SSI) compared to primary procedures (1.3% vs 0.4%, P = .042). There were no differences identified between cohorts for deep SSI, cardiopulmonary complications, reoperation, operative time, or length of stay. Logistic regression demonstrated that higher body mass index was found to be independent risk factors for any complications, and diabetes mellitus was associated with increased risk of AUS-related readmission.

Conclusion: Within the perioperative period, patients undergoing replacement AUS have an increased risk of superficial SSI compared to primary AUS implantation. These findings can assist with appropriate perioperative counseling of patients undergoing primary and replacement AUS implantations.

An integrated nomogram combining deep learning, Prostate Imaging-Reporting and Data System (PI-RADS) scoring, and clinical variables for identification of clinically significant prostate cancer on biparametric MRI: a retrospective multicentre study

Background

Biparametric MRI (comprising T2-weighted MRI and apparent diffusion coefficient maps) is increasingly being used to characterise prostate cancer. Although previous studies have combined Prostate Imaging–Reporting & Data System (PI-RADS)-based MRI findings with routinely available clinical variables and with deep learning-based imaging predictors, respectively, for prostate cancer risk stratification, none have combined all three. We aimed to construct an integrated nomogram (referred to as ClaD) combining deep learning-based imaging predictions, PI-RADS scoring, and clinical variables to identify clinically significant prostate cancer on biparametric MRI.

Methods

In this retrospective multicentre study, we included patients with prostate cancer, with histopathology or biopsy reports and a screening or diagnostic MRI scan in the axial view, from four cohorts in the USA (from University Hospitals Cleveland Medical Center, Icahn School of Medicine at Mount Sinai, Cleveland Clinic, and Long Island Jewish Medical Center) and from the PROSTATEx Challenge dataset in the Netherlands. We constructed an integrated nomogram combining deep learning, PI-RADS score, and clinical variables (prostate-specific antigen, prostate volume, and lesion volume) using multivariable logistic regression to identify clinically significant prostate cancer on biparametric MRI. We used data from the first three cohorts to train the nomogram and data from the remaining two cohorts for independent validation. We compared the performance of our ClaD integrated nomogram with that of integrated nomograms combining clinical variables with either the deep learning-based imaging predictor (referred to as DIN) or PI-RADS score (referred to as PIN) using area under the receiver operating characteristic curves (AUCs). We also compared the ability of the nomograms to predict biochemical recurrence on a subset of patients who had undergone radical prostatectomy. We report cross-validation AUCs as means for the training set and used AUCs with 95% CIs to assess the performance on the test set. The difference in AUCs between the models were tested for statistical significance using DeLong’s test. We used log-rank tests and Kaplan-Meier curves to analyse survival.

Findings

We investigated 592 patients (823 lesions) with prostate cancer who underwent 3T multiparametric MRI at five hospitals in the USA between Jan 8, 2009, and June 3, 2017. The training data set consisted of 368 patients from three sites (the PROSTATEx Challenge cohort [n=204], University Hospitals Cleveland Medical Center [n=126], and Icahn School of Medicine at Mount Sinai [n=38]), and the independent validation data set consisted of 224 patients from two sites (Cleveland Clinic [n=151] and Long Island Jewish Medical Center [n=73]). The ClaD clinical nomogram yielded an AUC of 0·81 (95% CI 0·76–0·85) for identification of clinically significant prostate cancer in the validation data set, significantly improving performance over the DIN (0·74 [95% CI 0·69–0·80], p=0·0005) and PIN (0·76 [0·71–0·81], p<0·0001) nomograms. In the subset of patients who had undergone radical prostatectomy (n=81), the ClaD clinical nomogram resulted in a significant separation in Kaplan-Meier survival curves between patients with and without biochemical recurrence (HR 5·92 [2·34–15·00], p=0·044), whereas the DIN (1·22 [0·54–2·79], p=0·65) and PIN nomograms did not (1·30 [0·62–2·71], p=0·51).

Interpretation

Risk stratification of patients with prostate cancer using the integrated ClaD nomogram could help to identify patients with prostate cancer who are at low risk, very low risk, and favourable intermediate risk, who might be candidates for active surveillance, and could also help to identify patients with lethal prostate cancer who might benefit from adjuvant therapy.

Funding

National Cancer Institute of the US National Institutes of Health, National Institute for Biomedical Imaging and Bioengineering, National Center for Research Resources, US Department of Veterans Affairs Biomedical Laboratory Research and Development Service, US Department of Defense, US National Institute of Diabetes and Digestive and Kidney Diseases, The Ohio Third Frontier Technology Validation Fund, Case Western Reserve University, Dana Foundation, and Clinical and Translational Science Collaborative.

Abdominal and vaginal pelvic support with concomitant hysterectomy for uterovaginal pelvic prolapse: a comparative systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

While approximately 225,000 pelvic organ prolapse (POP) surgeries are performed annually in the US, there is no consensus on the optimal route for pelvic support for the initial treatment of uterovaginal prolapse (UVP). Our objective is to compare the outcomes of abdominal sacrocolpopexy (ASC) to vaginal pelvic support (VPS) with either uterosacral ligament suspension (USLS) or sacrospinous ligament fixation (SSF) in combination with hysterectomy for treating apical prolapse.

METHODS

A systematic search was performed through March 2021. Studies comparing ASC with VPS for treatment of UVP were included in the review. The primary outcome was the rate of overall anatomic prolapse failure per studies' definition. Secondary outcomes included evaluating isolated recurrent vaginal wall prolapse, postoperative POP-Q points, total vaginal length (TVL), and Pelvic Floor Distress Inventory (PFDI-20) scores. Random effect analyses were generated utilizing R 4.0.2.

RESULTS

Out of 4225 total studies, 4 met our inclusion criteria, including 226 patients in the ASC group and 199 patients in the VPS group. ASC was not found to be associated with a higher rate of vaginal wall prolapse recurrence (OR = 0.6; 95% CI = 0.2-2.4; P = 0.33). There was no significant difference between groups for anterior or apical vaginal wall prolapse recurrence (P = 0.58 and P = 0.97, respectively). ASC was associated with significantly longer TVL (mean difference [MD]: 1.01; 95% CI = 0.33-1.70; P = 0.02) and better POP-Q Ba scores [MD = -0.23; 95% CI = -0.37; -0.10; P = 0.01].

CONCLUSIONS

ASC and vaginal pelvic support (either USLS or SSF) have comparable anatomical outcomes. However, weak evidence of a difference in TVL and Ba was found. The strength of the evidence in this study is based on the small number of observational studies. A large, randomized trial is highly warranted.

Does prior surgical interventional therapy for BPH affect the oncological or functional outcomes after primary whole-gland prostate cryoablation for localized prostate cancer?

BACKGROUND

To assess whether prior interventional treatment for benign prostatic hyperplasia (BPH) influences oncologic or functional outcomes following primary whole-gland prostate cryoablation.

METHODS

Among 3831 men with prostate cancer who underwent primary whole-gland prostate cryoablation, we identified 160 with a history of prior BPH interventional therapy including transurethral needle ablation (n = 6), transurethral microwave thermotherapy (n = 9), or transurethral resection of the prostate (n = 145). Patients with a history of medically treated or unspecified BPH therapy were excluded from the study. Oncological and functional outcomes were compared between men with and without prior BPH interventional therapy.

RESULTS

In unadjusted analyses, prior interventional BPH therapy was associated with higher risks of postoperative urinary retention (17.5% vs. 9.6%, p = 0.001) and new-onset urinary incontinence (39.9% vs. 19.4%, p > 0.001) compared with no prior therapy. Interventional BPH therapy was not correlated with the risk of developing a rectourethral fistula (p = 0.84) or new-onset erectile dysfunction (ED) at 12 months (p = 0.08) following surgery. On multivariable regression, prior interventional BPH therapy was associated with increased risk of urinary retention (OR 1.9, 95%, p = 0.015) and new-onset urinary incontinence (OR 2.13, p < 0.001). The estimated 5 years Kaplan-Meier survival analysis showed no statistically significant difference (p = 0.3) in biochemical progression free survival between those who underwent interventional BPH therapy compared with those who did not. Local disease recurrence assessed by post cryoablation positive for-cause prostate biopsy showed no significant difference between the two groups (25.4% vs. 28.7%, p = 0.59).

CONCLUSIONS

Prior interventional BPH therapy did not affect the oncologic outcomes nor did it increase the risk of rectourethral fistula or ED in sexually performing patients prior to cryosurgery. Prior interventional BPH therapy was associated with increased risk of urinary retention and incontinence after primary whole-gland prostate cryoablation for prostate cancer.

A novel imaging based Nomogram for predicting post-surgical biochemical recurrence and adverse pathology of prostate cancer from pre-operative bi-parametric MRI

Background

We developed and validated an integrated radiomic-clinicopathologic nomogram (RadClip) for post-surgical biochemical recurrence free survival (bRFS) and adverse pathology (AP) prediction in men with prostate cancer (PCa). RadClip was further compared against extant prognostics tools like CAPRA and Decipher.

Methods

A retrospective study of 198 patients with PCa from four institutions who underwent pre-operative 3 Tesla MRI followed by radical prostatectomy, between 2009 and 2017 with a median 35-month follow-up was performed. Radiomic features were extracted from prostate cancer regions on bi-parametric magnetic resonance imaging (bpMRI). Cox Proportional-Hazards (CPH) model warped with minimum redundancy maximum relevance (MRMR) feature selection was employed to select bpMRI radiomic features for bRFS prediction in the training set (D₁, N = 71). In addition, a bpMRI radiomic risk score (RadS) and associated nomogram, RadClip, were constructed in D₁ and then compared against the Decipher, pre-operative (CAPRA), and post-operative (CAPRA-S) nomograms for bRFS and AP prediction in the testing set (D₂, N = 127).

Findings

“RadClip yielded a higher C-index (0.77, 95% CI 0.65-0.88) compared to CAPRA (0.68, 95% CI 0.57-0.8) and Decipher (0.51, 95% CI 0.33-0.69) and was found to be comparable to CAPRA-S (0.75, 95% CI 0.65-0.85). RadClip resulted in a higher AUC (0.71, 95% CI 0.62-0.81) for predicting AP compared to Decipher (0.66, 95% CI 0.56-0.77) and CAPRA (0.69, 95% CI 0.59-0.79).”

Interpretation

RadClip was more prognostic of bRFS and AP compared to Decipher and CAPRA. It could help pre-operatively identify PCa patients at low risk of biochemical recurrence and AP and who therefore might defer additional therapy.

Funding

The National Institutes of Health, the U.S. Department of Veterans Affairs, and the Department of Defense.

Validating the Martini Staging System for Rectourethral Fistula: A Meta-Analysis of Postoperative Outcomes

OBJECTIVE

To validate the Martini staging system for postoperative rectourethral fistula (RUF) utilizing data from previous studies to determine whether it can accurately predict postoperative success rate.

METHODS

A systematic search of peer-reviewed studies was conducted through January, 2020. The primary inclusion criteria for the studies were studies that evaluated outcomes based on the etiology of the fistula (ie, radiotherapy/ablation [RA] vs nonradiotherapy/ablation [NRA]). Martini RUF classification was utilized for the subgroup analysis.

RESULTS

Out of 1948 papers, 7 studies with a total of 490 patients (251 in RA vs 239 NRA) were included in this study. Receiving RA increased the risk of permanent bowel diversion by 11.1 folds, eventual fistula recurrence by 9.1 folds, and post-op urinary incontinence (UI) by 2.6 folds. Similarly, compared to a Grade 0 fistula, a Grade I fistula increased the risk of permanent bowel diversion by 9.1 folds, fistula recurrence by 20 folds, and post-op UI by 2.7 folds. There were some valuable variables that were not captured by the Martini classification.

CONCLUSION

Overall, the Martini classification system is efficacious in stratifying post-op complications from RUF repair based on the grade and etiology; however, it is limited in application. There is an opportunity for the development of more comprehensive staging systems in this domain.

Gender Disparities in Bladder Cancer-Specific Survival in High Poverty Areas Utilizing Ohio Cancer Incidence Surveillance System (OCISS)

OBJECTIVE

To better understand the interplay of socioeconomic and demographic traits on bladder cancer outcomes utilizing the Ohio state cancer registry, Ohio Cancer Incidence Surveillance System (OCISS).

METHODS

We obtained demographic, clinical and outcome data on 47,182 bladder cancer cases diagnosed from 1996 to 2016 from OCISS. Multivariable Cox proportional hazards regression to calculate hazard ratios (HRs) and 95% confidence intervals (95% CIs) for the association between sex, race and poverty and survival, adjusting age, stage, and primary treatment.

RESULTS

Within the OCISS database, there were 47,182 patients with a diagnosis of bladder cancer identified, with females representing 12,056 (26%) of the population. There were a total of 9255(35.2%) deaths due to bladder cancer, with median follow-up time of 4.4 years. After adjusting for confounding variables, women were statistically significantly less likely to die from any cause (HR: 0.94, 95% CI: 0.91-0.96), compared with men, but more likely to die from bladder cancer (HR: 1.21, 95% CI: 1.15-1.27). We also found that after adjusting for confounding variables, including sex and poverty, black race was statistically significantly associated with a higher risk of overall (HR: 1.12, 95% CI: 1.06-1.18) and bladder cancer-specific mortality (HR: 1.25, 95% CI: 1.15-1.36).

CONCLUSION

Using the OCISS database, female gender, self-reported black race, and neighborhood poverty level were associated with worse bladder cancer-specific survival. By recognizing these disparities, we can prospectively address risk factors in efforts to improve survival among these patient populations.

Epidural Anesthesia is Associated With Increased Complications in Cystectomy Patients: A NSQIP Analysis

OBJECTIVE

To identify differences in short-term outcomes and readmission rates in cystectomy patients managed with general anesthesia compared to those undergoing general anesthesia and adjuvant epidural anesthesia.

METHODS

Utilizing the National Surgical Quality Inpatient Program database, patients who underwent a cystectomy with ileal conduit between 2014 and 2017 were included. Patients were further subdivided based on additional anesthesia modality; general anesthesia vs general anesthesia plus epidural anesthesia. Propensity score-matching was used to adjust for baseline differences between cohorts using 1:1 caliper width of 0.15 for the propensity score through the nearest neighbor. Stepwise multivariable logistic regression was used to identify preoperative and intraoperative predictors associated with 30-day procedure related readmission, complications, and length of stay.

RESULTS

About 2956 patients met our inclusion and exclusion criteria and eligible for propensity score matching. Compared to general anesthesia, adjuvant epidural anesthesia showed an increased odds of procedure related complications (adjusted Odds Ratio (aOR): 1.264, 95% CI: 1.019-1.567, P = .033). There was an increased trend for development of pulmonary emboli (13 [1.8%] vs 4 [0.5%], P = .051) in the adjuvant epidural cohort. Combined general with epidural anesthesia demonstrated no difference in length of stay, readmission, or reoperation rate in comparison to general anesthesia alone.

CONCLUSION

Cystectomy patients who underwent general anesthesia plus epidural anesthesia demonstrated a higher percentage of any procedural related complication without change in postoperative stay, reoperation rate, or readmission rate compared to patients undergoing general anesthesia alone.

Inter-imaging accuracy of computed tomography, magnetic resonance imaging, and transrectal ultrasound in measuring prostate volume compared to the anatomic prostatic weight

OBJECTIVE

To evaluate the accuracy of transrectal ultrasound (TRUS), computed tomography (CT), and magnetic resonance imaging (MRI) compared to the reference standard of the post-surgical anatomic prostatic weight (APW).

MATERIAL AND METHODS

A total of 349 patients from two institutions were included. The CT and MRI dimensions, and TRUS-reported prostate volumes (PV) were obtained. The prolate ellipsoid formula was used to calculate PV. Cross-sectional measurements were evaluated and compared to the reported post-surgical pathology measurements and calculated pathology volume (path PV). A basic statistical analysis was performed using the Pearson correlation, Bland-Altman analysis, and Passing-Bablok regression.

RESULTS

A total of 198 patients were included in the MRI group, 118 in the CT group, 295 in the TRUS group, and 51 in the all-inclusive common cohort. The MRI PV demonstrated a good to excellent correlation with the APW (r=0.79). The CT PV demonstrated a good correlation with APW (r=0.78). The TRUS PV showed a correlation with APW (r=0.67). The correlations identified in each individual group held true in the common cohort as well. The path PV showed an excellent correlation with APW (r=0.87), followed by MRI PV (r=0.81), then CT PV (r=0.73), and lastly TRUS PV (r=0.71).

CONCLUSION

MRI and CT are equally effective in assessing the PV, and they can be readily utilized to guide the benign prostatic hyperplasia (BPH) management without repeating in-office TRUS. This is not only cost-effective, but also eliminates patient anxiety and discomfort.

Variability in Prices for Erectile Dysfunction Medications-Are All Pharmacies the Same?

BACKGROUND

Variability in prices of medications is a well-known phenomenon; however, this variability has not been quantified in the realm of erectile dysfunction (ED) medications. ED medications are ideal for this quantification, because they are often not covered by insurances; therefore, the cost is the most direct reflection of price variability among pharmacies as they affect the patients.

AIM

To evaluate the variability in cash prices for phosphodiesterase type 5 inhibitors (PDEIs) for ED. We also evaluated whether certain types of pharmacies consistently offer better pricing than others, and whether there was any correlation with demographic factors.

METHODS

331 pharmacies were contacted within a 25-mile radius of our institution to obtain the cash price for 4 commonly used ED medications with prespecified doses. After exclusion, 323 pharmacies were categorized as chain, independent, wholesale, or hospital-associated. Cash prices for the specified medications were evaluated. In addition, we identified demographic and socioeconomic factors to determine if these had an impact on median drug pricing within each zip code.

MAIN OUTCOME MEASURE

The main outcome was the cost for patients to fill each prescription.

RESULTS

Independent pharmacies provided the lowest cost for 3 of 4 of the PDEIs. The largest price difference for 10 tablets of 100 mg sildenafil between all pharmacies was 38,000%. The median cost difference between independent pharmacies and chain pharmacies for sildenafil was >900%, and >1,100% for independent pharmacies vs hospital-associated pharmacies. Demographic and socioeconomic factors had no impact on the cost.

CLINICAL IMPLICATIONS

Our goal is to promote patient counseling among practitioners and to empower patients to shop for the best prices for their medications.

STRENGTH AND LIMITATIONS

A strength of the study is the large cohort that was surveyed; however, a weakness is that the large majority of the cohort was comprised of chain pharmacies. Mail pharmacies could not be evaluated as they required a valid prescription before offering prices.

CONCLUSION

The drastic differences in cash prices for the PDEIs give us an insight into the variability and cost-inflation of medications in the United States. These patterns hold true for other essential medications as well, and improved transparency will allow patients to make informed decisions when choosing where to purchase their medications. It may also encourage certain pharmacies to provide medications at more affordable prices. Mishra K, Bukavina L, Mahran A, et al. Variability in prices for erectile dysfunction medications-Are all pharmacies the same? J Sex Med 2018;15:1785-1791.

Safety and Efficacy of Intravenous Iron Sucrose for Iron-Deficiency Anemia in Children and Adolescents With Inflammatory Bowel Disease

Background. Anemia is common in inflammatory bowel disease (IBD). Oral iron is widely used but efficacy can be reduced by poor compliance and insufficient absorption. Intravenous iron is safe and effective in adults but is not well studied in children. Purpose. To assess safety and efficacy of intravenous iron sucrose (IVIS) in children with IBD. Methods. We reviewed medical records of IBD patients <22 years of age who received IVIS at our institution between 2009 and 2014. Anemia was defined as hemoglobin (Hgb) level below normal for age and gender and iron-deficiency anemia as serum iron studies and red cell mean corpuscular volume below normal ranges. Each IVIS infusion was evaluated for safety. Efficacy was defined as ≥2 g/dL increase in Hgb ≤12 weeks from IVIS initiation. Results. We identified 88 patients (Crohn's disease, n = 52; ulcerative colitis, n = 33; IBD-unclassified, n = 3) who underwent 329 IVIS infusions over 121 courses. No patient developed anaphylaxis. Six patients developed minor adverse reactions. Of the 121 IVIS courses, 80 were included in the efficacy evaluation. There was a significant rise in Hgb (mean 9.1 ±1.4 to 11.9 ± 1.8 g/dL; P < .0001, paired t test). Overall, 58.7% (47/80 courses) resulted in goal Hgb increase. Conclusions. IVIS is safe and effective in treating iron-deficiency anemia in pediatric IBD. There were only minor adverse events, and the observed rise in Hgb was clinically significant, with the majority achieving goal Hgb.

Gene expression in stress urinary incontinence: a systematic review

INTRODUCTION

A contribution of genetic factors to the development of stress urinary incontinence (SUI) is broadly acknowledged. This study aimed to: (1) provide insight into the genetic pathogenesis of SUI by gathering and synthesizing the available data from studies evaluating differential gene expression in SUI patients and (2) identify possible novel therapeutic targets and leads.

METHODS

A systematic literature search was conducted through September 2017 for the concepts of genetics and SUI. Gene networking connections and gene-set functional analyses of the identified genes as differentially expressed in SUI were performed using GeneMANIA software.

RESULTS

Of 3019 studies, 4 were included in the final analysis. A total of 13 genes were identified as being differentially expressed in SUI patients. Eleven genes were overexpressed: skin-derived antileukoproteinase (SKALP/elafin), collagen type XVII alpha 1 chain (COL17A1), plakophilin 1 (PKP1), keratin 16 (KRT16), decorin (DCN), biglycan (BGN), protein bicaudal D homolog 2 (BICD2), growth factor receptor-bound protein 2 (GRB2), signal transducer and activator of transcription 3 (STAT3), apolipoprotein E (APOE), and Golgi SNAP receptor complex member 1 (GOSR1), while two genes were underexpressed: fibromodulin (FMOD) and glucocerebrosidase (GBA). GeneMANIA revealed that these genes are involved in intermediate filament cytoskeleton and extracellular matrix organization.

CONCLUSION

Many genes are involved in the pathogenesis of SUI. Furthermore, whole-genome studies are warranted to identify these genetic connections. This study lays the groundwork for future research and the development of novel therapies and SUI biomarkers in clinical practice.

Gender Disparity in Cystectomy Postoperative Outcomes: Propensity Score Analysis of the National Surgical Quality Improvement Program Database

BACKGROUND

While female gender is considered a protective determinant in the majority of cancers, outcomes in women diagnosed with bladder cancer have continued to show disproportional mortality when compared with men.

OBJECTIVE

The aim of this retrospective propensity score-matched analysis was to evaluate the intra- and postoperative differences among genders, as well as to evaluate reproductive organ-preserving radical cystectomy (ROPRC) as compared with radical cystectomy (RC) as a potential confounder in female cystectomy patients.

DESIGN, SETTING, AND PARTICIPANTS

Utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), men and women undergoing a cystectomy between 2011 and 2017 were analyzed. In addition, females undergoing ROPRC and RC were analyzed for immediate postoperative outcomes.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Men and women undergoing a cystectomy were evaluated through propensity score matching (PSM) for baseline differences using a 1:1 caliper width of 0.2 to the nearest neighbor. Using multivariable logistic regression analysis, we evaluated differences in the risk of readmission, complications, and reoperation in the immediate postsurgical period in males and females. Similarly, differences were assessed in ROPRC and RC groups.

RESULTS AND LIMITATIONS

We achieved a balance between males and females after PSM: 1263 males and 1263 females treated with cystectomy. The risks of readmission (adjusted odds ratio [aOR] 1.228 [1.005-1.510], p=0.045), superficial surgical site infection (aOR 1.507 [1.095-2.086], p=0.012), and transfusion (aOR 2.031 [1.713-2.411], p<0.001) were increased in females undergoing a cystectomy compared with males. No differences were observed in surgical outcomes in ovarian sparing/RC cohort.

CONCLUSIONS

Using the 2011-2017 NSQIP database, we were able to demonstrate an increased rate of postoperative transfusion, readmission rate, and surgical site infection in females who underwent cystectomy. Our findings suggest that females experience an increased rate of complications in the immediate postoperative period. This may ultimately lead to worse oncologic outcomes in females after an RC. Lastly, we did not find any increased rate of complications in ROPRC as compared with RC.

PATIENT SUMMARY

This study highlights differences in immediate postoperative outcomes between males and females undergoing cystectomy for bladder cancer. Some of these potential differences include higher risk of infection, transfusion, and readmission. These differences may predispose females to worse long-term outcomes. In addition, due to potential benefits of ovarian preservation in the recent literature, we also evaluated the risks and complications of ovarian sparing cystectomy. We found ovarian preservation to be a safe and feasible procedure in a highly selected group of patients.

Sacral neuromodulation treating chronic pelvic pain: a meta-analysis and systematic review of the literature

INTRODUCTION AND HYPOTHESIS

Sacral neuromodulation (SNM) is gaining popularity as a treatment option for chronic pelvic pain (CPP). Our hypothesis is that SNM is effective in improving CPP.

METHODS

A systematic search was conducted through September 2018. Peer-reviewed studies using pre- and postpain intensity scores were selected. The primary outcome was pain improvement on a 10-point visual analog scale (VAS) (adjusted or de novo) in patients with CPP. Secondary outcomes included comparing SNM approaches and etiologies and evaluating lower urinary tract symptoms (LUTS).

RESULTS

Fourteen of 2175 studies, evaluating 210 patients, were eligible for further analysis. The overall VAS pain score improvement was significant [weighted mean difference (WMD) -4.34, 95% confidence interval (CI) = -5.22, to-3.64, p < 0.0001)]. Regarding SNM approach, both standard and caudal approaches had significant reduction in pain scores: WMD -4.32, CI 95% = -5.32, to -3.31 (p < 0.001) for the standard approach, compared with WMD -4.63, 95% CI = -6.57 to -2.69 (P < 0.001), for the caudal approach (p = 0.75). While significant improvement in pain was observed both in patients with and without interstitial cystitis/bladder pain syndrome (IC/BPS), the observed improvement was lower in patients with (WMD -4.13, CI 95% -5.36 to -2.90 versus without (WMD -5.72, CI 95% = -6.18, to-5.27) IC/BPS (p = 0.02). SNM was effective in treating voiding symptoms (frequency, urgency, nocturia) associated with IC/BPS (all p < 0.01).

CONCLUSIONS

SNM is an effective therapy for CPP in both IC/BSP and non-IC/BSP patients, with better results in non-IC/BSP patients. Outcomes of the antegrade caudal approach were comparable with the standard retrograde approach.

Stromal derived factor-1 plasmid as a novel injection for treatment of stress urinary incontinence in a rat model

INTRODUCTION AND HYPOTHESIS

SDF-1 chemokine enhances tissue regeneration through stem cell chemotaxis, neovascularization and neuronal regeneration. We hypothesized that non-viral delivery of human plasmids that express SDF-1 (pSDF-1) may represent a novel regenerative therapy for stress urinary incontinence (SUI).

METHODS

Seventy-six female rats underwent vaginal distention (VD). They were then divided into four groups according to treatment: pSDF-1 (n = 42), sham (n = 30), PBS (n = 1) and luciferase-tagged pSDF-1 (n = 3). Immediately after VD, the pSDF-1 group underwent immediate periurethral injection of pSDF-1, and the sham group received a vehicle injection followed by leak point pressure (LPP) measurement at the 4th, 7th and 14th days. Urogenital tissues were collected for histology. H&E and trichrome slides were analyzed for vascularity and collagen/muscle components of the sphincter. For the luciferase-tagged pSDF-1 group, bioluminescence scans (BLIs) were obtained on the 3rd, 7th and 14th days following injections. Statistical analysis was conducted using ANOVA with post hoc LSD tests. The Mann-Whitney U test was employed to make pair-wise comparisons between the treated and sham groups. We used IBM SPSS, version 22, for statistical analyses.

RESULTS

BLI showed high expression of luciferase-tagged pSDF-1 in the pelvic area over time. VD resulted in a decline of LPP at the 4th day in both groups. The pSDF1-treated group demonstrated accelerated recovery that was significantly higher than that of the sham-treated group at the 7th day (22.64 cmH₂O versus 13.99 cmH₂O, p < 0.001). Functional improvement persisted until the 14th day (30.51 cmH₂O versus 24.11 cmH₂O, p = 0.067). Vascularity density in the pSDF-1-treated group was higher than in the sham group at the 7th and 14th days (p < 0.05). The muscle density/sphincter area increased significantly from the 4th to 14th day only in the pSDF-1 group.

CONCLUSIONS

Periurethral injection of pSDF-1 after simulated childbirth accelerated the recovery of continence and regeneration of the urethral sphincter in a rat SUI model. This intervention can potentially be translated to the treatment of post-partum urinary incontinence.

Bladder irrigation after transurethral resection of superficial bladder cancer: a systematic review of the literature

INTRODUCTION

The vast majority of bladder cancer is non-muscle invasive with transurethral resection (TURBT) as the gold standard for surgical treatment. There is a high recurrence of bladder cancer post surgery, which adds to the frustration in current urologic practice. Current standard of care to further reduce bladder cancer recurrence is instillation of intravesical chemotherapy (ICT), a practice that is not routinely followed. Several studies point to similar effects with normal saline or water irrigation alone. Our objective is to review the current available literature and provide practicing urologist with an alternative to ICT.

MATERIALS AND METHODS

A systematic search was performed through December 2017. Peer reviewed studies, which evaluated recurrence free survival (RFS) after bladder irrigation with saline or sterile water (SW) post-TURBT were included. Outcomes were analyzed in three groups: ICT, saline and sterile water.

RESULTS

Six studies out of 981, including 1515 patients, were eligible. There was no significant difference between ICT, saline and SW groups regarding to the median RFS at 1 year [ICT: 81%, IQR (77.70, -81.00), SW: 74%, IQR (63.3-74.9), saline: 76.7% IQR (76.0, 77.7), p = 0.21]. While saline irrigation showed the highest median RFS among the groups, there was no statistically significant difference between the three groups [ICT: 70%, IQR (66.25, 73.75), SW: 64.1%, IQR (63.05, 65.15), saline: 73%, IQR (66.85, 74.50), p = 0.49]. Adverse events were more frequent amongst patients in the ICT group in comparison to the saline or water groups.

CONCLUSION

Saline and sterile water irrigation provide an alternative to ICT with equivalent recurrence rate and lower incidence of adverse events.

Younger Men With Prostate Cancer Have Lower Risk of Upgrading While on Active Surveillance: A Meta-analysis and Systematic Review of the Literature

Active surveillance has become a popular option for patients with low risk prostate cancer. Our objective was to examine the correlation between age and the risk of Gleason upgrading and biopsy progression. A systematic search was conducted. Eight studies met our eligibility criteria including 6522 patients with a median age of 65.8 (41-86) years. Per decade decrease in age, the pooled odds ratio and hazard ratio (CI 95%) for Gleason upgrading were 0.83 (0.73-0.94) and 0.87 (0.82-0.92), and for biopsy progression were 0.80 (0.74-0.86) and 0.88 (0.79-0.99), respectively. Overall, younger patients have a lower risk of GS upgrading and biopsy progression.

Double-blind randomized controlled trial of letrozole versus clomiphene citrate in subfertile women with polycystic ovarian syndrome

STUDY QUESTION

Would letrozole as a primary ovulation induction agent generate better pregnancy rates than clomiphene citrate (CC) in subfertile women with anovulatory polycystic ovarian syndrome (PCOS)?

SUMMARY ANSWER

Participants receiving letrozole as a primary treatment achieved a significantly (P = 0.022) higher clinical pregnancy rate per patient (61.2%) compared to CC (43.0%).

WHAT IS KNOWN ALREADY

According to a recent Cochrane systematic review (2014), letrozole appears to improve live-birth (LB) and pregnancy rates in anovulatory women with PCOS, compared to CC. However, the review concluded that the quality of evidence was low due to poor reporting of study methods and possible publication bias.

STUDY DESIGN, SIZE, DURATION

This double-blind randomized controlled trial (RCT) included 159 participants between April 2007 and June 2014. Subjects were randomly allocated to either CC (n = 79) or letrozole (n = 80) in a 1:1 ratio. Both drugs were encapsulated to look identical. Randomization was performed in mixed blocks and stratified by patients’ BMI (<30 and 30–35 kg/m²).

PARTICIPANTS/MATERIALS, SETTING, METHODS

The trial included subfertile women diagnosed with PCOS. Treatment started with one tablet (CC 50 mg, letrozole 2.5 mg) increasing to two in non-responders and continuing until pregnancy or for up to six ovulatory cycles. Non-responders were crossed over to the other treatment after a 6-week break. Cycles were initially monitored with ultrasound follicle tracking then mid-luteal serum progesterone measurement in subsequent cycles.

MAIN RESULTS AND THE ROLE OF CHANCE

Amongst the 159 participants included in the intention-to-treat analysis, four women conceived before treatment and six were lost-to-follow-up. The remaining 149 participants (74 on CC and 75 on letrozole) completed at least the first treatment. Women receiving letrozole achieved a significantly (P = 0.022; absolute difference [95% confidence interval] 18% [3–33%]) higher pregnancy rate (61.%) than those on CC (43%). The median number of treatment cycles received until pregnancy was significantly (log rank P = 0.038) smaller with letrozole (4[3–5] cycles) compared to CC (6[4–7] cycles). LB rates were not statistically (P = 0.089) different between the two groups, although there was a trend towards higher rates on letrozole (48.8%) compared to CC (35.4%). After the crossover, pregnancy and LB rates on letrozole (n = 45; 28.9 and 24.4%, respectively) were not statistically (P = 0.539 and P = 0.601) different from CC (n = 31; 22.6 and 19.4%).

LIMITATIONS, REASONS FOR CAUTION

One possible limitation of this trial may be the exclusion of PCOS women with BMI > 35 kg/m², which would limit the applicability of the results in this subgroup of PCOS. However, this group of women are generally excluded from treatment in the majority of fertility centres, especially in Europe, due to the associated challenges and risks.

WIDER IMPLICATIONS OF THE FINDINGS

The results of this trial are consistent with the recent Cochrane systematic review. However, with its robust design, the current RCT provides more valid and compelling evidence for the superiority of letrozole over CC as a primary ovulation induction agent in PCOS women with 40% increase in pregnancy rates and with a shorter time-to-pregnancy. Furthermore, the participants in this RCT are a good representation of subfertile PCOS population receiving fertility treatment in Europe and worldwide. The results are therefore globally generalizable for clinical practice.

STUDY FUNDING/COMPETING INTEREST(S)

This RCT was mainly funded by the R&D Funding Scheme of Derby Hospitals NHS Foundation Trust. The study also received funds from School of Medicine, University of Nottingham. The Trust R&D department was involved in the development of the protocol and the running of the trial. The trial was sponsored and monitored by the University of Nottingham. The authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

www.Clinicaltrials.gov: NCT00478504.

TRIAL REGISTRATION DATE

Registration was verified on 23/05/2007.

DATE OF FIRST PATIENT'S ENROLMENT

25/04/2007.

Vascular lesions of the internal auditory canal

We report here two cases of vascular tumors arising within the internal auditory canal, both of which presented with cerebellopontine angle symptoms and simulated acoustic neurinomas. The first case was an arteriovenous malformation that caused moderate sensorineural hearing loss, tinnitus, vertigo with lateropulsion, facial weakness, and trigeminal hypoesthesia on the same side. The second case was a venous angioma, to our knowledge the first ever reported in this location, which presented with sudden complete deafness and progressive hemifacial spasm. The latter subsided completely after successful total extirpation of this unique tumor. The literature on these extremely rare lesions is also reviewed.

The Golden Potato Cyst Nematode Globodera rostochiensis Pathotype Ro1 in the Saint-Amable Regulated Area in Quebec, Canada

The golden potato cyst nematode, Globodera rostochiensis (Wollenweber, 1923) Behren, is an economically important parasite of potato (Solanum tuberosum L. subsp. tuberosum) and is recognized as a quarantine pest internationally (2). This pest attacks potato plants and causes stunting of the haulm and the root system, leaf yellowing, and tuber yield losses (2). The pathotype scheme proposed by Kort et al. distinguishes five pathotypes (Ro1, Ro2, Ro3, Ro4, and Ro5) of G. rostochiensis using differential Solanum clones (1). Several resistance genes and quantitative trait loci (QTL) that have been identified in wild Solanum species confer resistance to different G. rostochiensis pathotypes and have been introgressed into commercial potato cultivars (2). Determining G. rostochiensis pathotype(s) is essential to implement efficient management strategies, which include using resistant potato varieties. G. rostochiensis was discovered in the municipality of Saint-Amable, Quebec (QC), Canada in 2006 (3) and was subsequently characterized (4). In this study, cysts were collected from 11 representative infested fields and confirmed to be G. rostochiensis (3). The pathotypes of these nematodes were assessed on seven differential clones (S. tuberosum subsp. tuberosum cv. Desiree, S. tuberosum × S. andigena cv. Maris Piper, S. kurtzianum hybrid 60.21.19, S. vernei hybrid 62.33.3, S. vernei hybrid 58.1642/4, S. vernei hybrid 65.346/19, and S. multidissectum hybrid P55/7) in 2007 and 2009. Briefly, in each 1-liter plastic pot containing 907 g (2 lbs) of soil (3:1 loam/grit v v-1), a single differential Solanum clone was planted and 15 cysts from 1 of 11 fields were inoculated. Five replicates were set up for each Solanum-nematode combination and the pots were arranged in a completely randomized design in a greenhouse at 22°C with a 16-h light period per day. Nine weeks after inoculation, cysts were extracted from each pot and counted. Reproduction factor (Rf) for each replicate was calculated (Rf = Pf/Pi; Pf is the final cyst number and Pi is the initial cyst number added to each pot). Rf values were used to categorize the differential clones into two groups, "susceptible" leading to increase in nematode numbers (Rf > 1) and "resistant" resulting in decrease in nematode numbers (Rf ≤ 1) (1). Our results in 2007 and 2009 were consistent and the pathotype of the nematodes collected from all the fields were identified as Ro1. To our knowledge, this is the first time that the pathotype of G. rostochiensis in the Saint-Amable regulated area was identified. Accordingly, potato cultivars carrying genes or QTL resistant to G. rostochiensis pathotype Ro1 can be used to reduce the nematode numbers in infested fields in the Saint-Amable area, QC. References: (1) J. Kort et al. Nematologica 23:333, 1977. (2) R. J. Marks and B. B. Brodie. Potato Cyst Nematodes: Biology, Distribution, and Control. 1st ed. CAB International, Wallingford, 1998. (3) F. Sun et al. Plant Dis. 91:908, 2007. (4) Q. Yu et al. Can. J. Plant Pathol. 32:264, 2010.

Mortality of Pratylenchus penetrans by Volatile Fatty Acids from Liquid Hog Manure

As part of our research program assessing the use of liquid hog manure (LHM) to control root-lesion nematodes, Pratylenchus penetrans, a series of acute toxicity tests was conducted to: (i) examine if non-ionized forms of volatile fatty acids (VFA) are responsible for the mortality of P. penetrans exposed to LHM under acidic conditions, (ii) determine if Caenorhabditis elegans can be a surrogate for P. penetrans in screening tests by comparing their sensitivities to VFA, (iii) characterize the nematicidal effect of individual VFA in LHM to P. penetrans, and (iv) determine whether individual VFA in LHM interact in their toxicity to P. penetrans. LHM was significantly (P Collapse

Key Words

• bioassay
• caenorhabditis elegans
• lhm
• liquid hog manure
• lsm
• liquid swine manure
• management
• nematode
• potato
• pratylenchus penetrans
• root-lesion nematode
• vfa
• volatile fatty acids

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Poor semen quality from patients with malignancies does not rule out sperm banking

Cancer therapy can further impair the already poor semen quality in cancer patients. This study evaluated the prefreeze and postthaw semen quality before treatment of patients with malignancies to examine the rationale for sperm banking for these men. Records of nine patients with different malignant tumors, who had been referred for sperm cryopreservation between 1982 and 1997, were reviewed and the results were compared with those of 50 normal healthy donors. Patients did not differ from donors in age, ejaculate volume, or duration of sexual abstinence. The total motile sperm count (median and interquartile range) was significantly different between patients and donors for prefreeze specimens (P = 0.026) and postthaw specimens (P = 0.008). Also, the percent motility was significantly lower in the patients as compared with the donors in prefreeze (P = 0.035) and postthaw specimens (P = 0.005). The percentage change in motility after thawing was also larger for patient samples (-54% versus -47%, P = 0.39). Other sperm motion characteristics did not significantly differ between the two groups except for postthaw curvilinear velocity (P = 0.01). This study concludes that fresh and frozen thawed semen from patients with malignant tumors is poor in quality but is still adequate for assisted reproductive techniques. As cancer therapy may further impair semen quality, patients should be offered the chance to bank sperm before undergoing cancer therapy.

The effects of cryopreservation on semen from men with sarcoma or carcinoma

PURPOSE

This study evaluated prefreeze and postthaw semen quality before treatment in patients with different types of sarcomas and carcinomas to determine whether cryopreservation would be of value for these patients.

METHODS

Semen specimens were obtained from 50 normal donors and from 21 patients with carcinoma and from 14 patients with sarcoma. The specimens were cryopreserved by a standard freezing procedure using TEST-Yolk buffer. Prefreeze and postthaw sperm motion characteristics were measured.

RESULTS

Prefreeze total motile sperm count was significantly higher in donors (median: 129.6 x 10(6)/ml) than in men with carcinoma (46.9 x 10(6)/ml, P < .001) or sarcoma (66.3 10(6)/ml, P = .04). The percent motility and percent linearity were significantly lower in patients with carcinoma. In postthaw specimens, total motile sperm count, curvilinear velocity, and linearity were significantly lower in patients with carcinoma.

CONCLUSIONS

The two patient groups in this study had poor semen quality when compared with healthy donors both before and after cryopreservation. Sarcoma patients had better semen quality than carcinoma patients. As cancer therapy in these men could significantly impair their reproductive potential, these men should be advised to preserve their semen before starting treatment.