PURPOSE:The summary presented herein represents Part I of the three-part series dedicated to Clinically Localized Prostate Cancer: AUA/ASTRO Guideline, discussing risk assessment, staging, and risk-based management in patients diagnosed with clinically localized prostate cancer. Please refer to Parts II and III for discussion of principles of active surveillance, surgery and follow-up (Part II), and principles of radiation and future directions (Part III).MATERIALS AND METHODS:The systematic review utilized to inform this guideline was conducted by an independent methodological consultant. A research librarian conducted searches in Ovid MEDLINE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews. The methodology team supplemented searches of electronic databases with the studies included in the prior AUA review and by reviewing reference lists of relevant articles.RESULTS:The Clinically Localized Prostate Cancer Panel created evidence- and consensus-based guideline statements to aid clinicians in the management of patients with clinically localized prostate cancer. Statements regarding risk assessment, staging, and risk-based management are detailed herein.CONCLUSIONS:This guideline aims to inform clinicians treating patients with clinically localized prostate cancer. Continued research and publication of high-quality evidence from future trials will be essential to further improve care for these men.

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.

PURPOSE:The summary presented herein represents Part II of the three-part series dedicated to Clinically Localized Prostate Cancer: AUA/ASTRO Guideline, discussing principles of active surveillance and surgery as well as follow-up for patients after primary treatment. Please refer to Parts I and III for discussion of risk assessment, staging, and risk-based management (Part I), and principles of radiation and future directions (Part III).MATERIALS AND METHODS:The systematic review utilized to inform this guideline was conducted by an independent methodological consultant. A research librarian conducted searches in Ovid MEDLINE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews. The methodology team supplemented searches of electronic databases with the studies included in the prior AUA review and by reviewing reference lists of relevant articles.RESULTS:The Clinically Localized Prostate Cancer Panel created evidence- and consensus-based guideline statements to aid clinicians in the management of patients with clinically localized prostate cancer. Statements regarding active surveillance, surgical management, and patient follow-up are detailed.CONCLUSION:This guideline aims to inform clinicians treating patients with clinically localized prostate cancer. Continued research and publication of high-quality evidence from future trials will be essential to further improve care for these men.

The subset of the population that received bladder-drained allograft pancreata during peak utilization of the technique in the 1990s is approaching 20-30 postoperative years. This time frame is salient, as it parallels the time in which patients in the urologic literature develop adenocarcinomas after bladder reconstruction using gastrointestinal segments. We present the case of a 57-year-old simultaneous pancreas/kidney recipient who presented with microhematuria twenty-four years after transplantation and was found to have an adenocarcinoma of the duodenum of his failed, bladder-drained pancreas. After allograft pancreatectomy/duodenectomy, he remains disease-free eleven months postoperatively. As this patient population ages, practitioners should consider pathology of the donor duodenum and pancreas in recipients who present with gross or microscopic hematuria.

TPS286 Background: Most patients (pts) who die of prostate cancer (pca) had potentially curable localized disease when first diagnosed, but their cancer subsequently relapsed to an incurable state. Neoadjuvant intense androgen deprivation therapy (ADT) has led to exceptional pathologic responses in up to 30% of pts with intermediate or high risk localized disease, with evidence of longer term clinical benefit. Prostate cancers with loss of the tumor suppressor gene PTEN, however, are resistant to neoadjuvant therapy that only targets the Androgen Receptor. Ipatasertib has shown efficacy in metastatic castration resistant prostate cancer (mCRPC), especially in pts with tumors that lack PTEN. Methods: This is a single arm study of darolutamide 600 mg BID, ipatasertib, and ADT. The initial phase I portion includes pts with nonmetastatic or mCRPC. Pts start with a lead-in of ipatasertib for 7 days, followed by ipatasertib combined with darolutamide 600 mg BID. The dose limiting toxicity period is the first 4 weeks of combination therapy. The phase I portion will enroll 6-18 pts. The phase II portion is given neoadjuvantly and includes pts with high risk localized pca. Pts receive up to 24 weeks of darolutamide 600 mg BID and ipatasertib at the recommended phase II dose (RP2D), followed by prostatectomy 14-42 days after cycle 6. The phase II portion will enroll up to 20 pts (17 evaluable pts) with high risk pca, with an early evaluation for efficacy after 9 pts are enrolled and with an additional stopping rule for safety. Key eligibility criteria for the phase II portion include 2 or more cores of grade group 4 or higher cancer on prostate needle biopsy or grade group 3 or higher with T3 or T4 disease, no distant metastatic disease, and PTEN loss (defined as 50% or more of tumor tissue being negative for PTEN expression). Exclusion criteria for both portions include small cell carcinoma, bowel inflammation, lung disease, diabetes mellitus requiring insulin, and conditions requiring strong CYP3A inducers or inhibitors. The primary endpoint for the phase I lead-in is to identify the RP2D of ipatasertib. The primary endpoint for the phase II portion is the combined rate of pathologic complete response (defined as absence of pathologic disease on hematoxylin and eosin (H&E) stain (ypT0)), or with presence of minimal residual disease ( < 5 mm linearly). We employ a Simon MiniMax two-stage design with 90.5% power to detect the difference between the null hypothesis (5% or less response rate) and the alternative hypothesis (30% response rate) with one-sided type I error of 0.05. Key secondary endpoints are safety, 2 year biochemical recurrence free survival, and rate of PSA 0 (undetectable PSA with testosterone recovery and no additional therapy). Enrollment to the phase 1 portion began in September 2021, and the study is available at select Big Ten institutions. Clinical trial information: NCT04737109.

You have accessJournal of UrologyPenile & Testicular Cancer I (MP40)1 Sep 2021MP40-16 CAN CLOMIPHENE CITRATE BE USED TO TREAT HYPOGONADISM IN TESTICULAR CANCER PATIENTS FOLLOWING CHEMOTHERAPY? Aisha Siebert, Jake Miller, Evan Panken, Gregory Auffenberg, Richard Fantus, Joshua Halpern, Nelson Bennett, Robert Brannigan, Brian Myre, and James Wren Aisha SiebertAisha Siebert More articles by this author , Jake MillerJake Miller More articles by this author , Evan PankenEvan Panken More articles by this author , Gregory AuffenbergGregory Auffenberg More articles by this author , Richard FantusRichard Fantus More articles by this author , Joshua HalpernJoshua Halpern More articles by this author , Nelson BennettNelson Bennett More articles by this author , Robert BranniganRobert Brannigan More articles by this author , Brian MyreBrian Myre More articles by this author , and James WrenJames Wren More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002055.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Testicular cancer is the most common cancer in males aged 15-39, yet curative treatment with radical orchiectomy and chemotherapy renders 38% of males hypogonadal. Clomiphene is used in an off-label fashion to treat hypogonadism in males with infertility but despite being an inexpensive oral alternative testosterone replacement therapy, it is not commonly used to treat hypogonadal testicular cancer survivors following chemotherapy. To assess the use of clomiphene in hypogonadal testicular cancer survivors treated with radical orchiectomy and chemotherapy. METHODS: Following IRB approval, we performed a retrospective chart analysis of all patients who had undergone a radical orchiectomy from 2004 to 2020. Inclusion criteria were males >18 years of age who had undergone a radical orchiectomy and chemotherapy for testicular cancer who were subsequently treated with clomiphene due to symptomatic hypogonadism (testosterone<300ng/dL). Mean testosterone levels were compared using a paired, two-tailed t-test. Luteinizing hormone (LH) levels were compared using a one-tailed, two-sample t-test assuming equal variance. RESULTS: In total, 476 radical orchiectomies were performed with 10 patients meeting the inclusion criteria (Table 1). Clomiphene was associated with a 273 ng/dL mean increase in testosterone (215 ng/dL to 486 ng/dL), in post chemotherapy patients (Fig 1, A). No side effects or evidence of disease recurrence occurred. No false positive elevation of HCG tumor markers related to clomiphene induced LH increase occurred (7.0 IU/L to 13.8 IU/L) (Fig 1, B). CONCLUSIONS: This is the first study to assess the use of clomiphene in hypogonadal testicular cancer survivors following chemotherapy. Clomiphene was associated with an increase in testosterone levels with no associated side effects or evidence of disease recurrence. Further studies are needed to define the role of clomiphene use in hypogonadal testicular cancer survivors. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e720-e721 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Aisha Siebert More articles by this author Jake Miller More articles by this author Evan Panken More articles by this author Gregory Auffenberg More articles by this author Richard Fantus More articles by this author Joshua Halpern More articles by this author Nelson Bennett More articles by this author Robert Brannigan More articles by this author Brian Myre More articles by this author James Wren More articles by this author Expand All Advertisement Loading ...

Importance:Understanding variation in patient-reported outcomes following radical prostatectomy may inform efforts to reduce morbidity after this procedure.Objective:To describe patient-reported urinary outcomes following radical prostatectomy in the diverse practice settings of a statewide quality improvement program and to explore whether surgeon-specific variations in observed outcomes persist after accounting for patient-level factors.Design, Setting, and Participants:This prospective population-based cohort study included 4582 men in the Michigan Urological Surgery Improvement Collaborative who underwent radical prostatectomy as primary management of localized prostate cancer between April 2014 and July 2018 and who agreed to complete validated questionnaires prior to surgery and at 3, 6, and 12 months after surgery. Data were analyzed from 2019 to June 2019.Exposures:Radical prostatectomy.Main Outcomes and Measures:Patient- and surgeon-level analyses of patient-reported urinary function 3 months after radical prostatectomy. Outcomes were measured using validated questionnaires with results standardized using previously published methods. Urinary function survey scores are reported on a scale from 0 to 100 with good function established as a score of 74 or higher.Results:For the 4582 men undergoing radical prostatectomy within the Michigan Urological Surgery Improvement Collaborative who agreed to complete surveys, mean (SD) age was 63.3 (7.1) years. Survey response rates varied: 3791 of 4582 (83%) responded at baseline, 3282 of 4137 (79%) at 3 months, 2975 of 3770 (79%) at 6 months, and 2213 of 2882 (77%) at 12 months. Mean (SD) urinary function scores were 88.5 (14.3) at baseline, 53.6 (27.5) at 3 months, 68.0 (25.1) at 6 months, and 73.7 (23.0) at 12 months. Regression analysis demonstrated that older age, lower baseline urinary function score, body mass index (calculated as weight in kilograms divided by height in meters squared) of 30 or higher, clinical stage T2 or higher, and lack of bilateral nerve-sparing surgery were associated with a lower probability of reporting good urinary function 3 months after surgery. When evaluating patients with good baseline function, the rate at which individual surgeons' patients reported good urinary function 3 months after surgery varied broadly (0% to 54.5%; P < .001). Patients receiving surgery from top-performing surgeons were more likely to report good 3-month function. This finding persisted after accounting for patient risk factors.Conclusions and Relevance:In this study, patient- and surgeon-level urinary outcomes following prostatectomy varied substantially. Documenting surgeon-specific variations after accounting for patient factors may facilitate identification of surgical factors associated with superior outcomes.

This study examined the relationship between stimulant medications used for the treatment of attention deficit hyperactivity disorder and semen parameters. We performed a retrospective cohort study at a large, academic institution between 2002 and 2020. We included men with a semen analysis without prior spermatotoxic medication use, empiric medical therapy exposure or confounding medical diagnoses (varicocele, Klinefelter's syndrome, cryptorchidism, cystic fibrosis, diabetes, cancer or cancer‐related treatment, and azoospermia). Men were stratified by stimulant exposure (methylphenidate or amphetamines). A multivariable linear regression was fit to assess the association between individual semen parameters, age, stimulant exposure and non‐stimulant medication use. Of 8,861 men identified, 106 men had active prescriptions for stimulants within 90 days prior to semen testing. After controlling for age and exposure to non‐stimulant medications, stimulant use was associated with decreased total motile sperm count (β: −18.00 mil/ejaculate and standard error: 8.44, p = 0.033) in the setting of decreased semen volume (β: −0.35 ml, and standard error: 0.16, p = 0.035), but not sperm concentration, motility and morphology. These findings suggest a role for reproductive physicians and mental health providers to consider counselling men on the potential negative impact of stimulants prescribed for attention deficit hyperactivity disorder on semen volume during fertility planning.

You have accessJournal of UrologyInfertility: Epidemiology & Evaluation I (MP21)1 Sep 2021MP21-07 PERCEPTIONS OF FERTILITY AMONG MEN WITH ABNORMAL SEMEN PARAMETERS WHO HAVE NOT UNDERGONE UROLOGIC EVALUATION Minh Pham, Siddhant Ambulkar, Richard Fantus, Matthew Hudnall, Jeremy Lai, James Wren, Nelson Bennett, Gregory Auffenberg, David Chu, Robert Brannigan, and Joshua Halpern Minh PhamMinh Pham More articles by this author , Siddhant AmbulkarSiddhant Ambulkar More articles by this author , Richard FantusRichard Fantus More articles by this author , Matthew HudnallMatthew Hudnall More articles by this author , Jeremy LaiJeremy Lai More articles by this author , James WrenJames Wren More articles by this author , Nelson BennettNelson Bennett More articles by this author , Gregory AuffenbergGregory Auffenberg More articles by this author , David ChuDavid Chu More articles by this author , Robert BranniganRobert Brannigan More articles by this author , and Joshua HalpernJoshua Halpern More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002006.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Reproductive endocrinologists (REI) are the gatekeepers for infertility care and often initiate the male partner evaluation, including the order and review of semen testing. This may lead to patient misperceptions regarding fertility status and whether to pursue urologic evaluation. In these men, we aimed to evaluate patient perceptions of fertility status after REI evaluation. METHODS: We surveyed adult men with abnormal semen analyses over a 1-year period who did not see a reproductive urologist. Questionnaires were administered by email and/or telephone, collecting demographic and clinical data, as well as perceptions of reproductive health. Primary self-reported outcomes were: 1) Did the patient recall being informed of an abnormal semen test result? 2) Did the patient consider their fertility status abnormal? A secondary outcome was urology referral. Multivariable logistic regression models were fit, adjusting for abnormal semen parameters. RESULTS: Of 310 men contacted, 85 (27.4%) responded. After excluding men who reported seeing a urologist, our cohort included 75 men. Seventeen (22.6%) men recalled being told their semen analysis was abnormal, and 14 (18.7%) understood their fertility was abnormal. Multivariable logistic regression (Table) showed that oligospermia, but not other semen parameter abnormalities, was significantly associated with men being told their semen analysis was abnormal (odds ratio [OR]: 7.52; 95% confidence interval [CI]: 1.77–32.1; p=0.006) & believing they had abnormal fertility (OR: 5.78; 95% CI: 1.22–27.3, p=0.027). Only 6 (8%) men reported receiving a referral to urology. CONCLUSIONS: The majority of men with impaired semen parameters seen by REI-only had inaccurate perceptions of their semen test results and fertility status. This was accompanied by a low rate of urologic referral, which represents missed opportunities for male partner evaluation. These data highlight the critical role for the reproductive urologist in counseling and caring for couples presenting for initial fertility evaluation. Source of Funding: Grant support K23DK125670 (NIDDK) to Dr. Chu © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e348-e348 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Minh Pham More articles by this author Siddhant Ambulkar More articles by this author Richard Fantus More articles by this author Matthew Hudnall More articles by this author Jeremy Lai More articles by this author James Wren More articles by this author Nelson Bennett More articles by this author Gregory Auffenberg More articles by this author David Chu More articles by this author Robert Brannigan More articles by this author Joshua Halpern More articles by this author Expand All Advertisement Loading ...

INTRODUCTION Understanding best practices in perioperative care is critical for quality of care for our urology patients. We compiled a single, concise resource that provides recommendations for optimizing postoperative outcomes in patients undergoing urological surgery. METHODS Optimal postoperative care includes minimizing complications, optimizing recovery and improving patient outcomes. The assembled White Paper multidisciplinary writing team included experts in a number of different areas (urologists, nurses, anesthesiologists) to address a comprehensive set of topics that urological providers face when caring for postoperative patients. This article provides a summary of key elements to optimize postoperative care in adult urological surgery, including in-hospital considerations, transition/discharge, and followup and surveillance. RESULTS In-hospital postoperative considerations include checklists, handoffs for safe transitions from the anesthesia to surgical team, level of care planning and enhanced recovery after surgery (ERAS®). Embedded in ERAS are postoperative nutrition, mobilization, wound care, judicious use of catheters and drains, and postoperative medications and transfusions. As the patient transitions to the outpatient setting, the urologist must provide clear and readable postoperative education, which includes medication management and coordinated followup with primary care providers and home health as needed. Finally, followup visits should be carefully considered using innovative methods such as telehealth and patient reported outcomes to elevate postoperative and long-term care. CONCLUSIONS This article summarizes postoperative factors that may impact surgical outcomes in urology. By understanding and applying best practices for postoperative care, urologists can optimize the quality of care for their patients.

OBJECTIVES To assess the impact of confirmatory tests on active surveillance (AS) biopsy disease reclassification and progression to treatment in men with favorable risk prostate cancer (FRPC). METHODS We searched the MUSIC registry for men with FRPC managed with AS without or with a confirmatory test. Confirmatory tests included (1) repeat prostate biopsy, (2) genomic tests, (3) prostate magnetic resonance imaging (MRI), or (4) MRI followed by a post-MRI biopsy. Confirmatory test results were deemed reassuring (RA) or nonreassuring (nonRA) according to predefined criteria. Kaplan-Meier curves and multivariable Cox regression models were used to compare surveillance biopsy disease reclassification-free survival and treatment-free survival. RESULTS Of the 2,514 men with FRPC who were managed on AS, 1211 (48%) men obtained a confirmatory test. We noted differences in the 12-month unadjusted surveillance biopsy disease reclassification-free probability (68%, 83%, and 90%, P < .0001) and 24-month unadjusted treatment-free probability (55%, 81%, and 79%, P < .0001), for men with nonRA confirmatory tests, no confirmatory test, and RA confirmatory tests, respectively. Excluding patients with genomic confirmatory tests, men with RA confirmatory tests were associated with a lower hazard (hazard ratio [HR] 0.57, 95% confidence interval [CI] 0.38-0.84, P = .005) and men with nonRA confirmatory tests had an increased hazard (HR 1.97, 95% CI 1.22-3.19, P = .006) of surveillance disease reclassification compared with men without confirmatory tests in the multivariable model. CONCLUSION These data suggest men with RA confirmatory tests have less surveillance biopsy reclassification and remain on AS longer than men with nonRA test results. Confirmatory tests may help risk stratify men considering active surveillance. (C) 2020 Elsevier Inc.

IMPORTANCE After radical prostatectomy, adverse pathologic features and postoperative prostate-specific antigen (PSA) levels can herald disease recurrence or progression. Postoperative radiotherapy (RT) remains beneficial in this setting. OBJECTIVE To examine the evidence supporting the use of postoperative RT as well as recent advances that help determine timing, scope, and use in combination with androgen deprivation therapy (ADT) with or without lymphatic irradiation. EVIDENCE REVIEW A search was conducted of MEDLINE (Ovid), Embase (Elsevier), and the Cochrane Library (Wiley) databases, in addition to clinical trial registries. The reference list of included studies was reviewed for relevant articles. The search was limited to studies published between January 1, 2014, and December 31, 2019. FINDINGS After 548 citations were screened, 27 articles were selected for inclusion. In addition to conventional imaging, positron-emission tomographic (PET)-based radiotracers can aid in disease localization. While PET imagingmay influence management with RT, studies are underway examining this issue, and several limitations must be considered, such as limited detectability at lower PSA levels and regional sensitivity. Available genomic classifiers can risk stratify patients or assess potential added benefit of RT. Prospective validation is underway with cooperative group trials. Adjuvant RT, on the basis of adverse pathologic features (such as extraprostatic extension or positive margins) is beneficial in terms of disease control, but it is unclear whether this therapy translates into more meaningful clinical benefit (eg, improved overall survival and a reduction in metastasis), which has been demonstrated by only 1 older, prospective randomized study. Preliminary data suggest that for a relatively favorable-risk population (low Gleason score but with positive margins), PSA monitoringmay be a reasonable alternative in some men. Use of androgen deprivation therapy and lymphatic irradiation should be considered in higher-risk cohorts (those with high PSA, high Gleason score, seminal vesicle invasion or node positivity) in conjunction with postoperative RT. CONCLUSIONS AND RELEVANCE The findings of this review suggest that postprostatectomy RT should be considered for men with prostate cancer in the setting of adverse pathologic features; in carefully selected patients with favorable characteristics, close PSA monitoring is an option. Androgen deprivation therapy and pelvic lymphatic irradiation should be considered for higher risk cohorts (eg, higher PSA values, higher Gleason score). PET imaging and molecular studies remain unproven as decision tools.

Introduction Understanding best practices in perioperative care is critical for quality of care for our urologic patients. In the third part of this white paper series, we provide a summary of key elements to optimize postoperative care in adult urologic surgery. Optimal postoperative care includes minimizing postoperative complications, optimizing postoperative recovery and improving patients’ postsurgical outcomes. The assembled white paper multidisciplinary writing team includes experts in a number of different areas (urologists, nurses, anesthesiologists) to address a comprehensive set of topics that urologic providers face when caring for postoperative patients.

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy II (MP37)1 Apr 2019MP37-10 COMPARISON OF CANCER-SPECIFIC OUTCOMES FOLLOWING OPEN VERSUS MINIMALLY-INVASIVE SURGERY FOR T1 KIDNEY CANCER Gregory Auffenberg*, Michael Curry, Renee Genarrelli, Elena Elkin, and Paul Russo Gregory Auffenberg*Gregory Auffenberg* More articles by this author , Michael CurryMichael Curry More articles by this author , Renee GenarrelliRenee Genarrelli More articles by this author , Elena ElkinElena Elkin More articles by this author , and Paul RussoPaul Russo More articles by this author View All Author Informationhttps://doi.org/10.1097/01.JU.0000556040.71806.e9AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVES: As is common with many technologic advances, adoption of minimally invasive kidney cancer surgery (MIS) has somewhat outpaced rigorous research comparing MIS to traditional techniques. After observing multiple, atypical recurrences among those with low stage disease; we sought to compare cancer-specific outcomes among patients with T1 kidney cancer undergoing open versus MIS excision. METHODS: Using SEER – Medicare data, we identified patients over 65 with unilateral, clinical stage T1N0M0, non-urothelial kidney cancer who underwent surgical excision (i.e., radical or partial nephrectomy) as initial treatment between 2004 and 2013. After stratifying the cohort based on whether surgery was open or MIS, we evaluated for an association between approach and four outcomes: overall and cancer-specific survival, rates of second kidney cancer surgery, and rates of post-operative systemic cancer therapy. Regression was used to account for differences across study groups–included covariates: histologic sub-type, grade, radical versus partial nephrectomy, receipt of second treatment, year, Charlson co-morbidity, and age at diagnosis. RESULTS: 5,150 patients met criteria for cohort inclusion. 3,062 (59.5%) underwent MIS. Cox-regression demonstrated no differences in overall or cancer-specific survival associated with surgical approach (HR=1.02, 95% CI 0.91-1.14 and HR=1.00 95% CI 0.87-1.15, respectively; open surgery = reference group). Kaplan-Meier analyses showed no differences in rate of second surgery, however recipients of MIS were more likely to receive systemic cancer therapy (Figure). Importantly, the association between MIS and increased receipt of systemic therapy persisted after adjusting for covariates (HR=1.32; 95% CI 1.09-1.59; p=0.005). CONCLUSIONS: Among patients with T1 kidney cancer, surgical approach (open vs. MIS) was not associated with differences in overall survival, cancer-specific survival, or receipt of second cancer surgery, however, those receiving MIS were more likely to receive systemic cancer therapy post-operatively. As systemic therapy is typically reserved for patients with disease recurrence, this may indicate an important difference in cancer-specific outcomes attributable to surgical approach. Source of Funding: none Chicago, IL; New York, NY© 2019 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 201Issue Supplement 4April 2019Page: e527-e527 Advertisement Copyright & Permissions© 2019 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gregory Auffenberg* More articles by this author Michael Curry More articles by this author Renee Genarrelli More articles by this author Elena Elkin More articles by this author Paul Russo More articles by this author Expand All Advertisement PDF downloadLoading ...

Following 20 years of decline, prostate cancer mortality has plateaued while the incidence of advanced-stage disease is rising. 1 Negoita S Feuer EJ Mariotto A et al. Annual report to the nation on the status of cancer, part II: recent changes in prostate cancer trends and disease characteristics: recent changes in prostate cancer trends. Cancer. 2018; 124: 2801-2814https://doi.org/10.1002/cncr.31549 Crossref PubMed Scopus (143) Google Scholar This may be in part due to the 2012 United States Preventive Services Task Force recommendation against routine prostate-specific antigen (PSA) screening. 2 Moyer VA Screening for prostate cancer: U.S. preventive services task force recommendation statement. Ann Intern Med. 2012; 157: 120https://doi.org/10.7326/0003-4819-157-2-201207170-00459 Crossref PubMed Scopus (1634) Google Scholar The United States Preventive Services Task Force has since updated its recommendation in 2018, stating that men aged 55-69 should make screening decisions after a conversation with their physician by engaging in a shared decision-making (SDM) process. 3 Grossman DC Curry SJ et al. US Preventive Services Task ForceScreening for prostate cancer: US preventive services task force recommendation statement. JAMA. 2018; 319: 1901https://doi.org/10.1001/jama.2018.3710 Crossref PubMed Scopus (76) Google Scholar The SDM process seeks to weigh patient values against the potential harms of overdiagnosis and overtreatment. However, the quality of SDM can vary significantly, particularly in the setting of time constraints, language barriers, or health literacy limitations, potentially leaving patients uncertain about the implications of pursuing or foregoing screening. 4 Mulhem E Fulbright N Duncan N Prostate cancer screening. Am Fam Physician. 2015; 92: 683-688 PubMed Google Scholar

INTRODUCTION We summarize the 2018 AUA (American Urological Association) Quality Improvement Summit, Opioid Stewardship in Urology, highlighting appropriate urological opioid use as well as reviewing programs that have been successful in reducing opioid prescribing. The AUA brought together nearly 100 attendees from across the United States, including clinicians who specialize in urology and other specialties, as well as researchers, government officials and others. METHODS The 2018 AUA Quality Improvement Summit was a 1-day meeting held at AUA headquarters in Linthicum, Maryland. Talks and panels highlighted opioid stewardship programs and emphasized research on the nature and management of postoperative pain. RESULTS The impact of the opioid epidemic is profound and the contribution of postoperative prescribing is noteworthy (eg 6% of opioid naïve patients demonstrate new persistent use habits after surgery and up to 70% of opioid pills prescribed after surgery go unused). Speakers raised awareness of these facts and detailed opportunities to improve, including prudent prescribing, opioid reclamation, use of nonopioid alternatives, and outreach and education. CONCLUSIONS The 2018 AUA Quality Improvement Summit provided a platform for urologists to discuss the opioid epidemic and to learn strategies for combatting this issue from multidisciplinary experts. Physician led opioid stewardship and research, facilitated by this Summit, may enhance the quality and safety of medical care and improve the lives of patients, their families and their communities.

Active surveillance (AS) has emerged as the preferred management strategy for many men with prostate cancer (PC); however, insufficient longitudinal monitoring may increase the risk of poor outcomes. We sought to determine rates of patients becoming lost to follow-up (LTFU) and associated risk factors in a large AS cohort. The Michigan Urologic Surgery Improvement Collaborative (MUSIC) maintains a prospective registry of PC patients from 44 academic and community urology practices. Over a 6-yr period (2011-2017), we identified patients managed with AS. LTFU was defined as any 18-mo period where no pertinent surveillance testing was entered in the registry. With a median surveillance period of 32 mo, the estimated 2-yr LTFU-free probability calculated by Kaplan-Meier method was 90% (95% confidence interval [CI]=89-92%). Both African American race (hazard ratio [HR]: 2.77, 95% CI=1.81-4.24) and Charlson comorbidity index ≥1 (HR: 1.55, 95% CI=1.08-2.23) were independently associated with increased risk of LTFU. There was variability in rates of estimated 2-yr LTFU-free survival across MUSIC practices, ranging from 52% (95% CI=21-100%) to 99% (95% CI=97-100%), with a median of 96% (interquartile range: 94-98%), although this did not reach statistical significance (p=0.076). These data reveal opportunities for urology practices to identify systems to reduce rates of LTFU and improve the long-term safety of AS. PATIENT SUMMARY: With a median observation period of 32 mo, an estimated 10% of patients will be lost to follow-up at the 2 yr time point while on AS. African American men and generally unhealthy patients were at increased risk, and there was variability from one urology practice to another. There is ample opportunity to improve the quality of the performance of AS.

Purpose of review Physician-led quality improvement collaboratives have emerged across surgical disciplines as a means to measure and subsequently improve the quality and cost of care. In this review, we will provide an overview of recent successes within quality improvement collaboratives, as well as discuss future opportunities for such initiatives. Recent findings Successful quality improvement collaboratives have coupled data registries with a collegial environment to achieve data-driven improvements in care across diverse practice settings. Such efforts have a track record for accomplishing specific patient safety gains, and have more recently addressed complex care scenarios where data and consensus building have been leveraged to clarify optimal care pathways. Collaboratives are currently exploring mechanisms to meaningfully impact increasingly complex elements of care delivery, such as individual surgeon performance. Summary Quality improvement collaboratives are in a unique position to understand patterns in care across populations, lead evidence-based assessments of variation in quality, and to attempt to intervene to improve outcomes based on the data they accumulate. As healthcare increasingly shifts to emphasize quality of care, physician-led collaboratives represent an important mechanism to drive improvement.