An Evaluation of Peer-Rated Surgical Skill and its Relationship With Detrusor Muscle Sampling in Transurethral Resection of Bladder Tumor

OBJECTIVE

To assess the reliability of peer-review of TURBT videos as a means to evaluate surgeon skill and its relationship to detrusor sampling.

METHODS

Urologists from an academic health system submitted TURBT videos in 2019. Ten blinded peers evaluated each surgeon's performance using a 10-item scoring instrument to quantify surgeon skill. Normalized composite skill scores for each surgeon were calculated using peer ratings. For surgeons submitting videos, we retrospectively reviewed all TURBT pathology results (2018-2019) to assess surgeon-specific detrusor sampling. A hierarchical logistic regression model was fit to evaluate the association between skill and detrusor sampling, adjusting for patient and surgeon factors.

RESULTS

Surgeon skill scores and detrusor sampling rates were determined for 13 surgeons performing 245 TURBTs. Skill scores varied from -6.0 to 5.1 [mean: 0; standard deviation (SD): 2.40]. Muscle was sampled in 72% of cases, varying considerably across surgeons (mean: 64.5%; SD: 30.7%). Among 8 surgeons performing >5 TURBTs during the study period, adjusted detrusor sampling rate was associated with sending separate deep specimens (odds ratio [OR]: 1.97; 95% confidence interval [CI]: 1.02-3.81, P = .045) but not skill (OR: 0.81; 95% CI: 0.57-1.17, P = .191).

CONCLUSION

Surgeon skill was not associated with detrusor sampling, suggesting there may be other drivers of variability of detrusor sampling in TURBT.

Inflammatory bowel disease induces inflammatory and pre-neoplastic changes in the prostate

BACKGROUND

Inflammatory bowel disease (IBD) has been implicated as a risk factor for prostate cancer, however, the mechanism of how IBD leads to prostate tumorigenesis is not known. Here, we investigated whether chronic intestinal inflammation leads to pro-inflammatory changes associated with tumorigenesis in the prostate.

METHODS

Using clinical samples of men with IBD who underwent prostatectomy, we analyzed whether prostate tumors had differences in lymphocyte infiltrate compared to non-IBD controls. In a mouse model of chemically-induced intestinal inflammation, we investigated whether chronic intestinal inflammation could be transferred to the wild-type mouse prostate. In addition, mouse prostates were evaluated for activation of pro-oncogenic signaling and genomic instability.

RESULTS

A higher proportion of men with IBD had T and B lymphocyte infiltration within prostate tumors. Mice with chronic colitis showed significant increases in prostatic CD45 + leukocyte infiltration and elevation of three pro-inflammatory cytokines-TIMP-1, CCL5, and CXCL1 and activation of AKT and NF-kB signaling pathways. Lastly, mice with chronic colitis had greater prostatic oxidative stress/DNA damage, and prostate epithelial cells had undergone cell cycle arrest.

CONCLUSIONS

These data suggest chronic intestinal inflammation is associated with an inflammatory-rich, pro-tumorigenic prostatic phenotype which may explain how gut inflammation fosters prostate cancer development in men with IBD.

It's all in the name: Does nomenclature for indolent prostate cancer impact management and anxiety?

BACKGROUND

Despite consensus guidelines, many men with low-grade prostate cancer are not managed with active surveillance. Patient perception of the nomenclature used to describe low-grade prostate cancers may partly explain this discrepancy.

METHODS

A randomized online survey was administered to men without a history of prostate cancer, presenting a hypothetical clinical scenario in which they are given a new diagnosis of low-grade prostate cancer. The authors determined whether diagnosis nomenclature was associated with management preference and diagnosis-related anxiety using ratings given on a scale from 1 to 100, adjusting for participant characteristics through multivariable linear regression.

RESULTS

The survey was completed by 718 men. Compared with Gleason 6 out of 10 prostate cancer, the term grade group 1 out of 5 prostate cancer was associated with lower preference for immediate treatment versus active surveillance (β = -9.3; 95% CI, -14.4, -4.2; P < .001), lower diagnosis-related anxiety (β = -8.3; 95% CI, -12.8, -3.8; P < .001), and lower perceived disease severity (β = -12.3; 95% CI, -16.5, -8.1; P < .001) at the time of initial diagnosis. Differences decreased as participants received more disease-specific education. Indolent lesion of epithelial origin, a suggested alternative term for indolent tumors, was not associated with differences in anxiety or preference for active surveillance.

CONCLUSIONS

Within a hypothetical clinical scenario, nomenclature for low-grade prostate cancer affects initial perception of the disease and may alter subsequent decision making, including preference for active surveillance. Disease-specific education reduces the differential impact of nomenclature use, reaffirming the importance of comprehensive counseling and clear communication between the clinician and patient.

Evaluation of Opioid Prescribing Patterns and Drivers of Variation Following Endoscopic Procedures for Benign Prostatic Hyperplasia Across an Integrated Academic Health System

OBJECTIVES

To evaluate patient, provider, and facility factors associated with variation in opioid prescribing after endoscopic procedures for benign prostatic hyperplasia across a large academic health system to drive improvement efforts.

METHODS

Opioids prescribed at discharge for patients who underwent an endoscopic prostate procedure March 2018-November 2019 were analyzed. Multivariable logistic and linear regression were used to evaluate the relationship between patient, provider, and facility factors and the receipt of any opioid prescription and the quantity prescribed.

RESULTS

We included 724 patients who had surgery with one of 26 urologists across five facilities. 222 (30.7%) received an opioid prescription, and the average morphine milligram equivalents (MMEs) prescribed was 97.9±33.5. We found wide variation in the proportion of patients who received an opioid prescription across surgeons (range 0%-88.9%) and facilities (range 19.9%-66.7%) and the average MMEs prescribed (range 25-188.5). Outpatient surgery (OR 2.32; 95% confidence interval [CI] 1.22-4.40, P = .010) and preoperative opioid use (OR 15.04; CI 9.65-23.45, P < .001) were associated with higher rates of opioid prescribing, while prescribing decreased with increasing patient age (OR 0.97; CI 0.95-0.99, P = 0.016). Multivariable linear regression analysis demonstrated an association between surgery at satellite facilities, having a surgeon in practice for at least 20 years, and higher surgeon volume with increased MMEs prescribed.

CONCLUSIONS

Opioid prescribing following endoscopic prostate procedures varied widely. Targeted interventions tailored to younger patients, those taking opioids preoperatively, recipients of outpatient surgery and those undergoing surgery at satellite facilities may be particularly high yield given the association between these factors and increased postoperative prescribing.

Insurance coverage, stage at diagnosis, and time to treatment following dependent coverage and Medicaid expansion for men with testicular cancer

Introduction

We sought to assess the impact of Affordable Care Act Dependent Care Expansion (ACA-DCE), which allowed dependent coverage for adults aged 19–25, and Medicaid expansion on outcomes for men with testicular cancer.

Methods

Using a US-based cancer registry, we performed adjusted difference-in-difference (DID) analyses comparing outcomes between men aged 19–25 (n = 8,026) and 26–64 (n = 33,303) pre- (2007–2009) and post-ACA-DCE (2011–2016) and between men in states that expanded Medicaid (n = 2,296) to men in those that did not (n = 2,265)pre- (2011–2013) and post-Medicaid expansion (2015–2016).

Results

In ACA-DCE analysis, rates of uninsurance decreased (DID -5.64, 95% confidence interval [CI] -7.23 to -4.04%, p<0.001) among patients aged 19–25 relative to older patients aged 26–64. There was no significant DID in advanced stage at diagnosis (stage≥II; p = 0.6) or orchiectomy more than 14 days after diagnosis (p = 0.6). For patients who received chemotherapy or radiotherapy as their first course of treatment, treatment greater than 60 days after diagnosis decreased (DID -4.84%, 95% CI -8.22 to -1.45%, p = 0.005) among patients aged 19–25 relative to patients aged 26–64. In Medicaid expansion states, rates of uninsurance decreased (DID -4.20%, 95% CI -7.67 to -0.73%, p = 0.018) while patients receiving chemotherapy or radiotherapy greater than 60 days after diagnosis decreased (DID -8.76, 95% CI -17.13 to -0.38%, p = 0.040) compared to rates in non-expansion states. No significant DIDs were seen for stage (p = 0.8) or time to orchiectomy (p = 0.1).

Conclusions

Men with testicular cancer had lower uninsurance rates and decreased time to delivery of chemotherapy or radiotherapy following ACA-DCE and Medicaid expansions. Time to orchiectomy and stage at diagnosis did not change following either insurance expansion.

Survival following upfront chemotherapy for treatment-naïve metastatic prostate cancer: a real-world retrospective cohort study

BACKGROUND

Upfront chemotherapy prolongs overall survival for men with metastatic, hormone-sensitive prostate cancer (mHSPC) based on data from clinical trials. We sought to assess the association between upfront chemotherapy and overall survival in men with mHSPC in a real-world cohort.

METHODS

We performed a retrospective cohort study of men with de novo, treatment-naïve metastatic prostate cancer from a large, national cancer database in the United States (2014-2015). Men in the upfront chemotherapy group received chemotherapy within 4 months of diagnosis (n = 1033, 28%) versus no chemotherapy or chemotherapy later than 12 months after diagnosis (controls; n = 2704, 72%). Overall survival was assessed using Kaplan-Meier estimates and compared using multivariable Cox regression analysis.

RESULTS

After a median follow-up of 23 months, median overall survival was 35.7 months in the upfront chemotherapy group and 32.5 months for controls (log-rank p < 0.001). After adjusting for patient and clinical variables, upfront chemotherapy was associated with longer overall survival (hazard ratio 0.78, 95% confidence interval 0.68-0.89, p < 0.001). In exploratory analyses, the association between upfront chemotherapy and overall survival did not differ by age groups, race, or number of comorbidities (all interaction p > 0.2).

CONCLUSIONS

In this real-world cohort, upfront chemotherapy for mHSPC was associated with longer overall survival. These data support the continued use of chemotherapy for men with mHSPC regardless of race or age if they are fit for chemotherapy and underscore the importance of evaluating cancer therapeutics outside of clinical trials to demonstrate treatment efficacy in populations that may be underrepresented in clinical trials.

Predictors of use and overall survival for patients undergoing metastasectomy for bladder cancer in a national cohort

OBJECTIVES

To determine the use of surgical resection of metastatic disease in a large national sample and its association with overall survival.

METHODS

The National Cancer Database was queried for patients with metastatic bladder cancer (2004-2016). Overall survival was assessed using Kaplan-Meier and multivariable Cox analyses. The associations between covariates and use of metastasectomy were assessed with multivariable logistic regression.

RESULTS

Of the 16 382 patients with metastatic bladder cancer included, 6.8% underwent metastasectomy. Its use increased over time (4.7% in 2004 to 6.6% in 2016; per year odds ratio 1.02, 95% confidence interval 1.00-1.04, P = 0.019). Median survival was 7.0 months for patients who received metastasectomy and 5.1 months for those who did not (hazard ratio 0.85, 95% confidence interval 0.79-0.91, P < 0.001). In subgroup analyses, metastasectomy predicted longer survival in patients with lung (hazard ratio 0.73, 95% confidence interval 0.61-0.88, P = 0.001) or brain metastases (hazard ratio 0.58, 95% confidence interval 0.35-0.96, P = 0.035) and in patients with variant histology (hazard ratio 0.80, 95% confidence interval 0.69-0.93, P = 0.003).

CONCLUSIONS

In a national sample, the use of metastasectomy for bladder cancer is low. Furthermore, metastasectomy is associated with longer survival overall and in multiple subgroups. However, these results should be validated in future studies.

Bladder Cancer Following Medicaid Expansion: No Changes in the Diagnosis of Muscle-Invasive Disease and Time to Treatment

BACKGROUND: Bladder cancer patients who are insured experience improved outcomes. Medicaid expansion aimed to increase insurance coverage and improve access to care. However, the association between Medicaid expansion and stage at diagnosis or time to treatment for those with advanced bladder cancer is unknown. OBJECTIVE: We sought to determine to association of Medicaid expansion with stage at diagnosis, and time to treatment for patients with muscle-invasive bladder cancer. METHODS: A US-based cancer registry was utilized to evaluate the association between Medicaid expansion and cancer stage at diagnosis, insurance rates, and time to treatment (>60 days from diagnosis) for those diagnosed with bladder cancer. We compared outcomes in non-Medicare-aged patients in non-expansion states (n = 16,602) and expansion states (n = 15,921) before (years 2012-2013) and after (years 2015-2016) Medicaid expansion with adjusted difference-in-differences (DIDs) using multivariable linear regression. RESULTS: The DIDs of percentage of bladder cancer patients with Stage≥II disease (0.02%; 95% confidence interval [CI] –1.91 to 1.95%, p = 0.9), without insurance (–0.65%; 95% CI –1.71 to 0.41), and with metastatic disease at diagnosis (–0.07%; 95% CI –1.14 to 1.00, both p > 0.10) did not change following insurance expansion despite an increase in Medicaid coverage (6.03%; 95% CI 4.79 to 7.29, p < 0.01). Any treatment with either cystectomy, radiation or systemic therapy > 60 days after diagnosis of stage≥II disease did not change (DID 1.48%; 95% CI –3.29 to 6.25%, p = 0.50). On subgroup analysis of patients living in low-income regions, the rates of stage≥II disease, no insurance, metastatic disease, and time to treatment did not significantly change. CONCLUSION: Medicaid expansion was not associated with changes in advanced cancer stage at diagnosis or time to treatment in newly diagnosed bladder cancer patients.

Medicaid Expansion Did not Improve Time to Treatment for Young Patients With Metastatic Renal Cell Carcinoma

INTRODUCTION

The absence of health insurance coverage has been associated with worse outcomes for patients with metastatic renal cell carcinoma (mRCC). Medicaid expansion in the United States was an important provision of the Affordable Care Act, which increased the number of low-income individuals eligible for Medicaid starting in January 2014 in several states. The effect of Medicaid expansion on access to healthcare for patients with mRCC is unknown.

MATERIALS AND METHODS

We performed a retrospective cohort study of 6844 patients aged < 65 years with mRCC at diagnosis within the National Cancer Database. We compared the time to treatment and the rates of no insurance before (2012-2013) and after (2015-2016) expansion between patients living in states that had and had not expanded Medicaid using difference-in-difference (DID) analyses. DIDs were calculated using linear regression analysis with adjustment for sociodemographic covariates.

RESULTS

The rate of no insurance did not change in the expansion states compared with the nonexpansion states (DID, -0.55%; 95% confidence interval, -3.32% to 2.21%; P = .7). The percentage of patients receiving treatment within 60 days of diagnosis had increased in the expansion states from 43% to 49% and in the nonexpansion states from 42% to 46% after expansion. No change was found in treatment within 60 days of diagnosis among all patients (DID, 2.81%; 95% confidence interval, -2.61% to 8.22%; P = .3).

CONCLUSIONS

Medicaid expansion was not associated with improved healthcare access for patients with mRCC as reflected by timely treatment. Future work should assess the association between Medicaid expansion and oncologic outcomes.

National practice patterns for lymph node irradiation in 197,000 men receiving external beam radiotherapy for localized prostate cancer

PURPOSE

Controversy surrounds the benefit of pelvic lymph node irradiation (PLN-RT) in localized prostate cancer (CaP). Our objective was to determine the practice patterns and predictors of PLN-RT in a national cohort.

MATERIALS AND METHODS

The National Cancer Data Base (2005-2015) was leveraged to obtain men diagnosed with nonmetastatic CaP treated with external beam radiotherapy (n = 197,378). Multivariable logistic regressions were used to assess temporal trends and factors associated with PLN-RT.

RESULTS

PLN-RT occurred in 37% of patients overall, which increased to 41% by 2015. When stratified by risk group, there was no significant difference in PLN-RT over time in low, favorable intermediate, unfavorable intermediate, or high-risk CaP. PLN-RT increased for men with very high-risk disease (51%-60%; odds ratio per year 1.34, 95% confidence inrerval 1.06-1.70, P = 0.013). Increased odds of PLN-RT was associated with higher risk disease, addition of hormone therapy, treatment at community hospitals, and shorter patient travel distance to treatment facilities. Surprisingly, 26% and 34% of low and favorable intermediate risk CaP received PLN-RT, respectively. Predictors of PLN-RT among these patients included treatment at a community practice and use of brachytherapy or hormone therapy.

CONCLUSIONS

PLN-RT occurred in about one-third of men receiving external beam radiotherapy and increased over time, mostly in men with very high-risk CaP for unclear reasons. Of concern, over one-quarter of low-risk men receive PLN-RT. Further work is needed to understand the heterogeneity in PLN-RT use. We await the completion of RTO G 09-24 to better understand the role of PLN-RT for men with localized CaP.

Rates and Predictors of Conversion to Open Surgery During Minimally Invasive Radical Cystectomy

OBJECTIVE

To assess the frequency of minimally invasive radical cystectomy (MIRC) conversion to open surgery, what factors influence conversion, whether or not the benefits of MIRC vs open radical cystectomy (ORC) persist after conversion, and compare ORC and MIRC outcomes.

MATERIALS AND METHODS

We performed a retrospective cohort study from the National Cancer Data Base (2010 to 2013) analyzing patients who underwent completed MIRC (n = 5750), converted MIRC (n = 245), and ORC (n = 12,053) without prior radiotherapy. Multivariable logistic and linear regression analyses were used to assess the association between covariates, open conversion as well as surgical approach, and secondary outcomes such as positive surgical margins (PSMs), use of lymphadenectomy, lymph node yield, hospital length of stay (LOS), and 30-day readmission.

RESULTS

Rates of conversion were independent of patient factors such as race, sex, use of neoadjuvant chemotherapy, and clinical stage. Conversion occurred in 245 of 5750 MIRCs (4.3%) and declined over time (5.8% in 2010 vs 3.2% in 2013, odds ratio [OR] 0.50, 95% confidence interval [CI] 0.34-0.75, p = 0.001). MIRC was associated with fewer positive margins, higher lymph node yield, shorter LOS, and fewer readmissions compared with ORC, however, patients requiring open conversion had longer median hospital stays (8 days vs 7 days, p = 0.013), lower median lymph node yields (14 vs 17, p = 0.007), more PSMs (17% vs 11%, p = 0.006), and more 30-day readmissions (14% vs 9%, p = 0.008) compared to nonconverted. Converted MIRC had similar hospital LOS and 30-day readmission rates compared to ORC.

CONCLUSION

Open conversion during MIRC is uncommon and has decreased in recent years despite the rising use of MIRC. MIRC had better short-term outcomes compared with ORC. These benefits were negated with open conversion; however, outcomes were similar compared to planned ORC.

Ambicor Two-Piece Inflatable Penile Prosthesis: Background and Contemporary Outcomes

INTRODUCTION

The two-piece inflatable penile prosthesis (IPP; Ambicor) might be a preferred option for men with erectile dysfunction (ED) who have significant retroperitoneal scarring, limited manual dexterity, or other issues. There are reported differences in outcomes and patient and partner satisfaction between three-piece and two-piece IPPs.

AIM

To report contemporary outcomes, patient and partner satisfaction, and mechanical durability data of the two-piece compared with the three-piece IPP.

METHODS

A PubMed search was performed related to two-piece penile prostheses. Emphasis was placed on perioperative outcomes and patient and/or partner satisfaction scores. Non-English-language articles were excluded.

MAIN OUTCOME MEASURES

Use of the Ambicor two-piece penile prosthesis was assessed by outlining the contemporary literature. The etiology of ED in this population, mechanical attributes, penile morphologic changes, satisfaction, and its use in special populations were reviewed.

RESULTS

The most common etiology of ED for placement of the device remains a vasculogenic cause (range = 11-62%). Overall complication rates were 2.1% to 11.2% for the general population. Mechanical failure was seen in 0.7% to 6.1%. Infection rates were 0.7% to 4.8%. Spontaneous deflation was seen in approximately 25%. Higher complication rates were found in transgender patients after neophallus creation and the two-piece IPP could offer better durability compared with the three-piece IPP. Longer operative times, greater use of advanced dilation techniques, and greater length loss also have been reported. Overall satisfaction rates are higher than 85%.

CONCLUSION

The predominant etiology of ED for two-piece penile prosthesis placement is vasculogenic. There is a trend toward IPP insertion in patients after radical prostatectomy or who have spinal cord injury. The two-piece device has similar complication rates and high patient satisfaction scores compared with three-piece IPPs. Further larger prospective studies are needed to validate our findings, resolve discrepancies in published outcomes, and contribute to the sparse data on this subject. Ko OS, Bennett NE. Ambicor Two-Piece Inflatable Penile Prosthesis: Background and Contemporary Outcomes. Sex Med Rev 2018;6:319-327.