Purpose: To investigate effects of baseline and early longitudinal body composition changes on mortality and hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS). Materials and Methods: This is a case-control study with analysis of a TIPS registry (1995-2020) including data from patients with cirrhosis with computed tomography (CT) scans obtained within 1 month before and 3 months after TIPS. Core and muscle adiposity index (MAI) on CT were obtained. Multipredictor Cox proportional hazards models were used to assess the effect of body composition variables on mortality or HE. Results: In total, 280 patients (158 men; median age, 57.0 years; median Model for End-stage Liver Disease-sodium [MELD-Na] score, 14.0) were included. Thirty-four patients had post-TIPS imaging. Median baseline CMA was 68.3 cm2 (interquartile range, 57.7-83.5 cm2). Patients with higher baseline CMA had decreased risks of mortality (hazard ratio [HR]: 0.82; P = .04) and HE (HR: 0.82; P = .009). It improved prediction of mortality over MELD-Na and post-TIPS right atrial pressure alone (confidence interval = 0.729). An increase in CMA (HR: 0.60; P = .043) and mSAT (HR: 0.86; P = .022) or decrease in MAI (HR: 1.50; P = .049) from before to after TIPS was associated with a decreased risk of mortality. An increase in mSAT was associated with an increased risk of HE (HR: 1.11; P = .04). Conclusions: CMA on CT scan 1 month before TIPS placement predicts mortality and HE in patients with cirrhosis. Changes in body composition on CT measured 3 months after TIPS placement independently predict mortality and HE.

In this work, we introduce the first realistic digital phantoms for prostate ultrasound and photoacoustic (PA) imaging in the male pelvic region. Our model encompasses surrounding tissues or organs around the prostate, including fat, bones (including femoral heads), muscles, urinary bladder, rectum, anal canal, penile bulb, neurovascular bundles, and seminal vesicles. Each digital phantom set contains five parameters: speed of sound, density, acoustic attenuation, optical absorption, and reduced optical scattering. The anatomical structures were derived from open-source computed tomography (CT) and magnetic resonance imaging (MRI) data from the Gold Atlas Project. The acoustic parameters, including the speed of sound and attenuation of the prostate, were obtained from an ex vivo prostate study utilizing the QTscan ultrasound tomography (UST) platform at the National Institutes of Health. All other parameters were acquired from the literature. By employing atlas data from four pelvises and UST images of 62 ex vivo prostate specimens, we generated 248 sets of digital phantoms. Additionally, we demonstrate a practical application, showcasing the identification of the effective insonification window for prostate UST. The developed digital phantoms are made open source and can be found at https://github.com/ywu115/Prostate-digital-phantoms. They can be leveraged for imaging device design, image formation studies, image reconstruction validation, and diagnostic and treatment planning for numerous prostate studies using ultrasound and PA imaging. Since the digital phantoms cover the entire male pelvic region, they can potentially be extended to other applications, such as bladder cancer imaging, cyst detection in seminal vesicles, hernias, and treatment planning for point-of-care ultrasound.

Abstract Introduction Low serum testosterone (T) in the presence of clinical symptoms of hypogonadism is essential in determining who may benefit from T replacement therapy. However, clinical symptoms associated with hypogonadism are non-specific and challenging to discriminate from other etiologies. While low bone mineral density is an objective primary end-organ effect of low testosterone, DEXA scans are not recommended by national guidelines due to poor sensitivity and specificity, and the limitation that these changes likely manifest over a prolonged period of time. Notably, prior studies have demonstrated that perineal ultrasound of the bulbocavernosus muscle (BCM) can be an effective surrogate to evaluate end-organ activity of hypogonadism. However, it is unclear if low BCM area is secondary to or rather correlated with hypogonadism, and longitudinal studies assessing men in both the eugonadal and hypogonadal state are lacking. Objective To report an initial experience with measuring the androgen-sensitive BCM, ischiocavernosus muscle (ICM), and levator ani muscles (LAM) on MRI in men before and after androgen deprivation therapy (ADT) as a novel imaging marker for end-organ effects of hypogonadism. Methods Data was collected from treatment-naive patients with intermediate or high-risk localized prostate cancer enrolled in a clinical trial involving six months of neoadjuvant treatment with goserelin and enzalutamide prior to prostatectomy. Patients underwent 3-Tesla multiparametric MRI of the prostate prior to treatment and again immediately prior to prostatectomy. An expert genitourinary trained radiologist retrospectively assessed MR images and measured width of the bilateral BCM, ICM, and LAM on coronal T2W MRI (Figure 1). Paired t-tests were performed to evaluate changes in muscle width before and after ADT. Linear regression was performed to evaluate the relationship between change in total testosterone levels and change in muscle width. The lower detection limit of testosterone was 20 ng/dL, and T less than 20 ng/dL was set to 0 for statistical analysis. Results 38 patients with pre- and post-treatment MRIs were identified with a median time between scans of 6.85 months. Median age at start of trial was 62.5 years (IQR: 58-69). 28/38 patients had documented AUA/IPSS and SHIM questionnaires with median scores of 8 and 19.5, respectively. Mean total testosterone prior to androgen deprivation was 289.5 ng/dL (SD= 121.7). 34/38 patients reached castrate level (T less than 20 ng/dL) after treatment completion, with mean testosterone 4.7 ng/dL (SD= 15.4). Muscle width was significantly reduced in all three muscle groups following ADT (Table 1). Linear regression found that decreases in testosterone significantly predicted decreases in combined perineal muscle (BCM + ICM) width (β = 0.0056, p = 0.032). Conclusions Decreases in testosterone to castrate levels led to significant and rapid decreases in sizes of both perineal and pelvic muscles. This shows initial plausibility in using an image-based approach to assess a short- to intermediate-term objective marker of end-organ effects of hypogonadism. Future prospective studies with larger samples and refinement of MRI sequences may lead to a useful clinical tool in the diagnosis and clinical workup of hypogonadism, and help clinicians better understand who would benefit from testosterone supplementation. Disclosure No

muscle mass. This might be related to urinary incontinence.

You have accessJournal of UrologyCME1 Apr 2023PD38-12 NATURAL HISTORY OF SMALL INDEX LESIONS ON MULTIPARAMETRIC MRI: IMPLICATIONS FOR ACTIVE SURVEILLANCE Anjali Pillai, Zoe Blake, Daniel R. Nemirovsky, Jacob J. Enders, Neil Mendhiratta, Alexander P. Kenigsberg, Michael B. Rothberg, Jibriel Noun, Daniel Nethala, Sandeep Gurram, Bradford J. Wood, Baris Turkbey, and Peter A. Pinto Anjali PillaiAnjali Pillai More articles by this author , Zoe BlakeZoe Blake More articles by this author , Daniel R. NemirovskyDaniel R. Nemirovsky More articles by this author , Jacob J. EndersJacob J. Enders More articles by this author , Neil MendhirattaNeil Mendhiratta More articles by this author , Alexander P. KenigsbergAlexander P. Kenigsberg More articles by this author , Michael B. RothbergMichael B. Rothberg More articles by this author , Jibriel NounJibriel Noun More articles by this author , Daniel NethalaDaniel Nethala More articles by this author , Sandeep GurramSandeep Gurram More articles by this author , Bradford J. WoodBradford J. Wood More articles by this author , Baris TurkbeyBaris Turkbey More articles by this author , and Peter A. PintoPeter A. Pinto More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003336.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Multiparametric magnetic resonance imaging (mpMRI) has demonstrated utility as an adjunct to active surveillance (AS). However, the optimal time interval between sequential MRIs is not standardized. This aims to analyze index lesion growth rates to potentially inform modern AS imaging practice. METHODS: A prospectively maintained database of patients on AS at our institution was queried for patients with ≥2 mpMRIs with no index lesion or index lesions ≤7 mm, as well as a subset of patients with no index lesion or index lesions ≤5 mm. Both cohorts were limited to patients with paired MRI-targeted biopsy showing benign or Gleason grade group (GG) 1 disease. For MRIs preceding PI-RADS scoring, an internal Likert suspicion scoring system was converted into PI-RADS scores. Imaging intervals were calculated between serial mpMRIs and growth rate was calculated with two-tailed t-tests to assess differences between initial and most recent lesion sizes measured on mpMRI. RESULTS: Between 2003-2021, patients on AS with ≥2 mpMRIs with small index lesions measuring ≤7 mm (n=123) or <5 mm (n=65) were identified (Table 1). Lesions in both the ≤7 mm (p=.015) and ≤5 mm (p=.003) cohorts demonstrated a significant change between first and last mpMRI. For the ≤7 mm cohort, average overall growth rate was 0.44±2.4 mm/year over a mean imaging interval of 1.27±0.09 years. For the ≤5 mm cohort, the average overall growth rate was 0.70±3.05 mm/year over a mean imaging interval of 1.31±0.13 years. There were 11 lesions that grew over 5 mm in the first year after initial mpMRI, however, univariate analysis of age, PSA, PI-RADS, and GG did not identify these variables as significant predictors of growth. The majority of lesions (84.6%) grew <1 mm/year (Figure 1). CONCLUSIONS: Small MRI lesions in patients on AS demonstrate minimal growth between follow up mpMRIs. This may indicate that these lesions can be followed longer surveillance intervals. Further studies are needed to prospectively identify the small subset of lesions that demonstrate more rapid growth. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e998 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Anjali Pillai More articles by this author Zoe Blake More articles by this author Daniel R. Nemirovsky More articles by this author Jacob J. Enders More articles by this author Neil Mendhiratta More articles by this author Alexander P. Kenigsberg More articles by this author Michael B. Rothberg More articles by this author Jibriel Noun More articles by this author Daniel Nethala More articles by this author Sandeep Gurram More articles by this author Bradford J. Wood More articles by this author Baris Turkbey More articles by this author Peter A. Pinto More articles by this author Expand All Advertisement PDF downloadLoading ...

Background: Cribriform (CBFM) pattern on prostate biopsy has been implicated as a predictor for high-risk features, potentially leading to adverse outcomes after definitive treatment. This study aims to investigate whether the CBFM pattern containing prostate cancers (PCa) were associated with false negative magnetic resonance imaging (MRI) and determine the association between MRI and histopathological disease burden.Methods: Patients who underwent multiparametric magnetic resonance imaging (mpMRI), combined 12-core transrectal ultrasound (TRUS) guided systematic (SB) and MRI/US fusion-guided biopsy were retrospectively queried for the presence of CBFM pattern at biopsy. Biopsy cores and lesions were categorized as follows: C0 = benign, C1 = PCa with no CBFM pattern, C2 = PCa with CBFM pattern. Correlation between cancer core length (CCL) and measured MRI lesion dimension were assessed using a modified Pearson correlation test for clustered data. Differences between the biopsy core groups were assessed with the Wilcoxon-signed rank test with clustering.Results: Between 2015 and 2022, a total of 131 consecutive patients with CBFM pattern on prostate biopsy and pre-biopsy mpMRI were included. Clinical feature analysis included 1572 systematic biopsy cores (1149 C0, 272 C1, 151 C2) and 736 MRI-targeted biopsy cores (253 C0, 272 C1, 211 C2). Of the 131 patients with confirmed CBFM pathology, targeted biopsy (TBx) alone identified CBFM in 76.3% (100/131) of patients and detected PCa in 97.7% (128/131) patients. SBx biopsy alone detected CBFM in 61.1% (80/131) of patients and PCa in 90.8% (119/131) patients. TBx and SBx had equivalent detection in patients with smaller prostates (p = 0.045). For both PCa lesion groups there was a positive and significant correlation between maximum MRI lesion dimension and CCL (C1 lesions: p < 0.01, C2 lesions: p < 0.001). There was a significant difference in CCL between C1 and C2 lesions for T2 scores of 3 and 5 (p <= 0.01, p <= 0.01, respectively) and PI-RADS 5 lesions (p <= 0.01), with C2 lesions having larger CCL, despite no significant difference in MRI lesion dimension.Conclusions: The extent of disease for CBFM-containing tumors is difficult to capture on mpMRI. When comparing MRI lesions of similar dimensions and PIRADS scores, CBFM-containing tumors appear to have larger cancer yield on biopsy. Proper staging and planning of therapeutic interventions is reliant on accurate mpMRI estimation. Special considerations should be taken for patients with CBFM pattern on prostate biopsy.

You have accessJournal of UrologyCME1 Apr 2023MP11-17 SIGNET RING CELLS ON PROSTATE BIOPSY IN THE SETTING OF PRIMARY ACINAR ADENOCARCINOMA Daniel Nemirovsky, Zoe Blake, Alexander Kenigsberg, Neil Mendrihatta, Jacob Enders, Michael Rothberg, Antoun Toubaji, Sandeep Gurram, and Peter Pinto Daniel NemirovskyDaniel Nemirovsky More articles by this author , Zoe BlakeZoe Blake More articles by this author , Alexander KenigsbergAlexander Kenigsberg More articles by this author , Neil MendrihattaNeil Mendrihatta More articles by this author , Jacob EndersJacob Enders More articles by this author , Michael RothbergMichael Rothberg More articles by this author , Antoun ToubajiAntoun Toubaji More articles by this author , Sandeep GurramSandeep Gurram More articles by this author , and Peter PintoPeter Pinto More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003226.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Signet ring cells (SRC) on pathology are typically associated with gastric carcinoma, but are also rarely seen in other malignancies, including prostate cancer (PCa). Though primary SRC adenocarcinoma of the prostate is a well-described aggressive malignancy, there is a paucity of literature describing the oncologic significance of SRC on prostate biopsy in patients with primary acinar adenocarcinoma. In this study, we aimed to describe the clinicopathologic characteristics and outcomes of these patients. METHODS: A prospectively collected database of patients with PCa was queried for presence of SRC on prostate biopsy. Patients with primary SRC adenocarcinoma were excluded. Demographics, imaging, pathological and treatment data were collected. Patients who received radical prostatectomy (RP) without neoadjuvant therapy were examined for adverse features, including extraprostatic extension (EPE), seminal vesicle invasion (SVI), lymphovascular invasion (LVI), as well as post-RP biochemical recurrence (BCR). RESULTS: Between 2014-2022, 46 patients with SRC on biopsy were found. Clinicopathologic data is displayed in Table 1. Patients had a mean of 2.2 cores with SRC on biopsy, and 40/46 (87.0%) of these cores were GG ≥4. Oncologic outcomes are shown in Table 2. Every lesion containing SRC was MRI-visible, 93.3% of which were PIRADS 4 or 5. Of 14 patients with available whole-mount pathology data after RP, 12/14 (85.7%) had Gleason grade group ≥ 3 disease. 5/14 (35.7%) patients had EPE, 4/14 (28.6%) had SVI, and 3/14 (21.4%) had LVI. 3/14 (21.4%) patients experienced BCR post-RP, with a median time to BCR of 12 months (3-28). CONCLUSIONS: Signet ring cells on biopsy were typically identified in the setting of MRI-visible high-grade acinar adenocarcinoma and frequently associated with adverse features on whole mount pathology. While the biological significance of signet ring features in prostate cancer remains to be elucidated, clinical and pathologic correlates suggest an association with high risk disease and should prompt further study of this entity. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e131 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Nemirovsky More articles by this author Zoe Blake More articles by this author Alexander Kenigsberg More articles by this author Neil Mendrihatta More articles by this author Jacob Enders More articles by this author Michael Rothberg More articles by this author Antoun Toubaji More articles by this author Sandeep Gurram More articles by this author Peter Pinto More articles by this author Expand All Advertisement PDF downloadLoading ...

You have accessJournal of UrologyCME1 Apr 2023MP09-02 MULTIPARAMETRIC MRI-BASED RADIOMICS FEATURES OF PROSTATIC ADENOCARCINOMA WITH CRIBRIFORM ARCHITECTURE Zoe Blake, Mason Belue, Daniel Nemirovsky, Stephanie Harmon, Jacob Enders, Alexander Kenigsberg, Neil Mendhiratta, Enis Yilmaz, Yue Lin, Michael Rothberg, Antoun Toubaji, Maria Merino, Sandeep Gurram, Bradford Wood, Peter Choyke, Baris Turkbey, and Peter Pinto Zoe BlakeZoe Blake More articles by this author , Mason BelueMason Belue More articles by this author , Daniel NemirovskyDaniel Nemirovsky More articles by this author , Stephanie HarmonStephanie Harmon More articles by this author , Jacob EndersJacob Enders More articles by this author , Alexander KenigsbergAlexander Kenigsberg More articles by this author , Neil MendhirattaNeil Mendhiratta More articles by this author , Enis YilmazEnis Yilmaz More articles by this author , Yue LinYue Lin More articles by this author , Michael RothbergMichael Rothberg More articles by this author , Antoun ToubajiAntoun Toubaji More articles by this author , Maria MerinoMaria Merino More articles by this author , Sandeep GurramSandeep Gurram More articles by this author , Bradford WoodBradford Wood More articles by this author , Peter ChoykePeter Choyke More articles by this author , Baris TurkbeyBaris Turkbey More articles by this author , and Peter PintoPeter Pinto More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003224.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Cribriform (CBFM) pattern on prostate biopsy has been implicated as a predictor for high-risk features, potentially leading to adverse outcomes after definitive treatment. Literature on imaging characteristics of CBFM is sparse and mixed. This study aims to elucidate the multiparametric MRI (mpMRI) features of CBFM-containing cancers on prostate biopsy using radiomics. METHODS: Patients who underwent mpMRI, combined 12-core transrectal ultrasound (TRUS) guided systematic and MRI/US fusion-guided biopsy on a prostate cancer (PCa) clinical trial were retrospectively queried for the presence of CBFM pattern at biopsy. Biopsy cores were scored: C0=benign, C1=PCa with no CBFM pattern, C2=PCa with CBFM pattern. In addition to targeted lesion regions of interest (ROIs), patient-specific 12-core systematic TRUS biopsy sector maps were reconstructed and transposed on mpMRI slices for virtual core ROI creation (Figure 1). Radiomics features from each ROI were extracted using PyRadiomics package in Python. Radiomics and clinical feature analyses were done with Wilcoxon signed-rank test and Akaike Information Criterion. RESULTS: Between 2020-2022, 90 consecutive patients with CBFM pattern on prostate biopsy and paired mpMRI were identified. Radiomics/clinical feature analysis included 1080 transrectal systematic biopsy cores (677 C0, 191 C1, 212 C2) and 272 MRI-targeted biopsy cores (72 C0, 66 C1, 134 C2). On combined biopsy analysis, two DWI radiomics features capturing signal heterogeneity were predictive for CBFM classification (p<.01). On analysis of MRI-targeted biopsy only, overall PIRADS score (p=.037), DWI PIRADS score (p=.017), and target lesion dimension (p=.017) were predictive for CBFM classification (Table 1). CONCLUSIONS: CBFM pattern has visible radiomics features on mpMRI, most notably on DWI. Imaging findings suggestive of CBFM may play a role in risk stratification and patient counseling. Further studies are needed to evaluate these lesions and validate their imageability longitudinally and externally. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e103 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Zoe Blake More articles by this author Mason Belue More articles by this author Daniel Nemirovsky More articles by this author Stephanie Harmon More articles by this author Jacob Enders More articles by this author Alexander Kenigsberg More articles by this author Neil Mendhiratta More articles by this author Enis Yilmaz More articles by this author Yue Lin More articles by this author Michael Rothberg More articles by this author Antoun Toubaji More articles by this author Maria Merino More articles by this author Sandeep Gurram More articles by this author Bradford Wood More articles by this author Peter Choyke More articles by this author Baris Turkbey More articles by this author Peter Pinto More articles by this author Expand All Advertisement PDF downloadLoading ...

You have accessJournal of UrologyCME1 Apr 2023MP38-19 FOCAL THERAPY CANDIDACY: AN EVALUATION OF INITIAL AND CONTINUED ELIGIBILITY FOR FOCAL THERAPY IN AN ACTIVE SURVEILLANCE COHORT Alexander P. Kenigsberg, Daniel Nemirovsky, Neil Mendhiratta, Zoe Blake, Jacob J. Enders, Samuel A. Gold, Michael B. Rothberg, Daniel Nethala, Brad Wood, Baris Turkbey, Sandeep Gurram, and Peter A. Pinto Alexander P. KenigsbergAlexander P. Kenigsberg More articles by this author , Daniel NemirovskyDaniel Nemirovsky More articles by this author , Neil MendhirattaNeil Mendhiratta More articles by this author , Zoe BlakeZoe Blake More articles by this author , Jacob J. EndersJacob J. Enders More articles by this author , Samuel A. GoldSamuel A. Gold More articles by this author , Michael B. RothbergMichael B. Rothberg More articles by this author , Daniel NethalaDaniel Nethala More articles by this author , Brad WoodBrad Wood More articles by this author , Baris TurkbeyBaris Turkbey More articles by this author , Sandeep GurramSandeep Gurram More articles by this author , and Peter A. PintoPeter A. Pinto More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003276.19AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Focal Therapy (FT) for Gleason grade group (GG) 1 prostate cancer (PCa) is controversial, given almost all of these patients are suitable active surveillance (AS) candidates. Little is known about how many AS GG 1 patients retain focal therapy eligibility (FTE) over time. The objective of this study is to evaluate initial and long-term FTE for patients with GG1 disease. METHODS: A prospectively maintained AS cohort was retrospectively queried for patients initiated on AS between 2009 and 2020 with GG1 PCa. Patients with a unilateral, biopsy-concordant, MRI-visible PIRADS or PIRADS-equivalent 2-5 lesions amenable to hemiablation who had a PSA<20, <4 positive systematic biopsy cores were considered FTE. Patients who remained GG1 were considered to have maintained FTE. Those who progressed were reassessed at time of progression for FTE. Patients with ≥GG4 disease, bilateral GG≥2, or MRI-invisible GG≥2 lost FTE. Univariate and multivariate analyses were conducted to evaluate factors associated with FTE. RESULTS: 282 GG1 PCa patients were identified, 164 of whom (58%) were FT candidates, with a mean follow-up of 4.9 years (range 1.0-13.4 years). 81/164 (49%) progressed to GG≥2 or higher on a subsequent biopsy. At the time of PCa upgrading, 36/164 (22%) of the FT candidate cohort lost FTE. Baseline characteristics are shown in Table 1. Patients who lost FTE trended toward increased PSA (6.3 vs 5.3, p=0.062 and MRI lesions (2.6 vs 2.0, p=0.007), and were more likely to have transitional or central zone (TZ/CZ) lesions (30.6% vs 14.1%, p=0.022) relative to those who maintained FTE. On logistic regression (Table 2), the number of MRI lesions and TZ/CZ lesions were associated with FTE loss (p=0.033 and 0.047, respectively). CONCLUSIONS: While approximately half of GG1 FT candidates demonstrate disease progression, almost 80% maintain FTE. Given the demonstrated safety of AS and relatively small number of patients who lose FTE while on surveillance, routine FT for GG1 disease would result in a large number of unnecessary procedures. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e532 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alexander P. Kenigsberg More articles by this author Daniel Nemirovsky More articles by this author Neil Mendhiratta More articles by this author Zoe Blake More articles by this author Jacob J. Enders More articles by this author Samuel A. Gold More articles by this author Michael B. Rothberg More articles by this author Daniel Nethala More articles by this author Brad Wood More articles by this author Baris Turkbey More articles by this author Sandeep Gurram More articles by this author Peter A. Pinto More articles by this author Expand All Advertisement PDF downloadLoading ...

You have accessJournal of UrologyCME1 Apr 2023PD10-12 HISTOPATHOLOGIC AND MRI CORRELATES OF ANTERIOR INDEX LESIONS IN PROSTATE CANCER: IMPLICATIONS FOR POST-SURGICAL ONCOLOGIC OUTCOMES Zoe Blake, Katie Merriman, Daniel Nemirovsky, Jacob Enders, Alexander Kenigsberg, Mason Belue, Enis Yilmaz, Tim Phelps, Neil Mendhiratta, Michael Rothberg, Daniel Nethala, Antoun Toubaji, Maria Merino, Bradford Wood, Sandeep Gurram, Stephanie Harmon, Peter Choyke, Baris Turkbey, and Peter Pinto Zoe BlakeZoe Blake More articles by this author , Katie MerrimanKatie Merriman More articles by this author , Daniel NemirovskyDaniel Nemirovsky More articles by this author , Jacob EndersJacob Enders More articles by this author , Alexander KenigsbergAlexander Kenigsberg More articles by this author , Mason BelueMason Belue More articles by this author , Enis YilmazEnis Yilmaz More articles by this author , Tim PhelpsTim Phelps More articles by this author , Neil MendhirattaNeil Mendhiratta More articles by this author , Michael RothbergMichael Rothberg More articles by this author , Daniel NethalaDaniel Nethala More articles by this author , Antoun ToubajiAntoun Toubaji More articles by this author , Maria MerinoMaria Merino More articles by this author , Bradford WoodBradford Wood More articles by this author , Sandeep GurramSandeep Gurram More articles by this author , Stephanie HarmonStephanie Harmon More articles by this author , Peter ChoykePeter Choyke More articles by this author , Baris TurkbeyBaris Turkbey More articles by this author , and Peter PintoPeter Pinto More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003250.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The influence of anatomic location of prostate cancer (PCa) on biochemical recurrence (BCR) after radical prostatectomy (RP) is an active area of research. Some evidence suggests that anterior lesions are more commonly associated with extra prostatic extension (EPE) due to lack of a distinct capsule in the anterior portion of the prostate, and are more prone to metastasize due to proximity of the Batson venous plexus. We sought to evaluate whether anterior index lesion location is associated with increased rates of EPE, BCR or lymph node invasion (LNI). METHODS: Clinical, imaging, and histopathological data were retrospectively analyzed for patients with PCa who underwent MRI prior to RP between 2008 and 2022. Anterior lesion location, as well as zonal anatomy, was determined by an expert genitourinary radiologist. Correlation with EPE, LNI, and BCR were analyzed using Wilcoxon rank sum and chi-squared tests. BCR-free survival (RFS) was analyzed using Kaplan-Meier (KM) survival curves. RESULTS: 662 RP patients were identified with median follow up of 19 months (IQR 11-35). Anterior lesions were not associated with an increased rate of MRI-detected EPE (p>0.995), pathology-confirmed EPE (p=0.119), LNI (p=0.059), or BCR (p=0.203) (Table 1). A sub-group analysis of anterior lesions by zonal anatomy revealed that transition zone (TZ) lesions were associated with higher rates of MRI-detected EPE than peripheral zone (PZ) lesions (25/144 [19.4%] vs 2/54 [3.7%], p=0.024) but not pathology-confirmed EPE (p=0.392), LNI (p=0.890), or BCR (p=0.525). Differences in RFS were not significant for anterior vs non-anterior lesions overall (p=0.27) or when zonally divided (p=0.11) (Figure 1). CONCLUSIONS: Anterior prostate lesions were not associated with increased rate of EPE, LNI, or difference in RFS, even when sub-stratifying lesions by zone. Thus, anterior vs non-anterior lesion location is unlikely to impact risk stratification or clinical decision making. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e331 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Zoe Blake More articles by this author Katie Merriman More articles by this author Daniel Nemirovsky More articles by this author Jacob Enders More articles by this author Alexander Kenigsberg More articles by this author Mason Belue More articles by this author Enis Yilmaz More articles by this author Tim Phelps More articles by this author Neil Mendhiratta More articles by this author Michael Rothberg More articles by this author Daniel Nethala More articles by this author Antoun Toubaji More articles by this author Maria Merino More articles by this author Bradford Wood More articles by this author Sandeep Gurram More articles by this author Stephanie Harmon More articles by this author Peter Choyke More articles by this author Baris Turkbey More articles by this author Peter Pinto More articles by this author Expand All Advertisement PDF downloadLoading ...

OBJECTIVE To report an initial experience with a novel, "fully" transperineal (TP) prostate fusion biopsy using an unconstrained ultrasound transducer placed on the perineal skin to guide biopsy needles inserted via a TP approach. METHODS Conventional TP prostate biopsies for detection of prostate cancer have been performed with transrectal ultrasound, requiring specialized hardware, imposing limitations on needle trajectory, and contributing to patient discomfort. Seventy-six patients with known or suspected prostate cancer underwent 78 TP biopsy sessions in an academic center between June 2018 and April 2022 and were included in this study. These patients underwent TP prostate fusion biopsy using a grid or freehand device with transrectal ultrasound as well as TP prostate fusion biopsy using TP ultrasound in the same session. Per-session and per-lesion cancer detection rates were compared for conventional and fully TP biopsies using Fisher exact and McNemar's tests. RESULTS After a refinement period in 30 patients, 92 MRI-visible prostate lesions were sampled in 46 subsequent patients, along with repeat biopsies in 2 of the 30 patients from the refinement period. Grade group >= 2 cancer was diagnosed in 24/92 lesions (26%) on conventional TP biopsy (17 lesions with grid, 7 with freehand device), and in 25/92 lesions (27%) on fully TP biopsy (P = 1.00), with a 73/92 (79%) rate of agreement for grade group >= 2 cancer between the two methods. CONCLUSION Fully TP biopsy is feasible and may detect prostate cancer with detection rates comparable to conventional TP biopsy. UROLOGY 181: 76-83, 2023. Published by Elsevier Inc.

fi ed by tracking, with 11/83 (13.3%) identi fi ed only on tracking biopsy. Of the 110 total upgrading events between the three repeat tracked biopsy sessions, 41/110 (37.3%) were captured on tracking, with 16/110 (14.5%) discovered solely by tracking. The median number of biopsy cores for systematic, MRI-targeted, and tracked approaches were 12, 4 (IQR: 2-4), and 2 (IQR: 2-4), respectively. CONCLUSIONS: In this series, a signi fi cant portion of upgrading events for patients on AS were uniquely identi fi ed on tracked biopsy and would have otherwise been missed on repeat systematic and MRI-targeted biopsy. Notably, given the low number of additional biopsy cores required for tracking, this approach may be an appropriate and low-risk supplement to standard AS protocols.

While the causative factors of smoking and hypertension leading to cardiovascular disease (CVD) are well understood, those involved with diet-induced CVD are not. One metabolite regulated by diet that is involved with cardio-protection and vasodilation is the gasotransmitter hydrogen sulfide (H 2 S). However, the molecular inhibition of H 2 S-generating enzymes via CVD-inducing diets is not fully understood, nor is it known if this is the causative event leading to CVD. Enzymatic H 2 S production in mammalian tissues and cells is primarily via the transsulfuration enzymes cystathionine β-synthase (CBS) and cystathionine γ-lyase (CGL). A high fat Western diet contributes to CVD through gut microbiome metabolic pathways and subsequent host enzymes converting choline and carnitine into the metabolites trimethylamine (TMA) and trimethylamine-N-oxide (TMAO). We hypothesized that TMA and TMAO lower H 2 S production by directly interacting with CGL to reduce enzymatic activity and that these gut-related metabolites’ inhibition account for some of the CVD risks. Results: Using a lead acetate assay, we discovered that these metabolites reduce enzymatic H 2 S production in a CGL-dependent manner from tissues ex vivo as well as from purified human CGL in vitro to a similar extent as propargylglycine (PAG), a known CGL suicide inhibitor that also happens to be a bacterial metabolite. We found that in vivo , hepatic and renal H 2 S production increased in antibiotic treated mice surface plasma resonance (SPR) and micro-scale thermophoresis (MST) assays revealed direct and specific physical interactions between TMA and TMAO with CGL. Additionally, pre-incubation with PAG blocked the binding of TMAO with CGL, indicating that the mechanism and location of inhibition are shared. Conclusion: Diet-induced gut metabolites TMA and TMAO bind CGL enzyme and suppress enzymatic production of cardioprotective H 2 S.

You have accessJournal of UrologyCME1 May 2022MP43-07 NEGATIVE PROSTATE MRI AS A PREDICTOR OF DISEASE STABILITY IN PATIENTS ON ACTIVE SURVEILLANCE Jacob Enders, Michael Rothberg, Zach Kozel, Michael Daneshvar, Luke O'Connor, Alex Wang, Cheyenne Williams, Nitin Yerram, Sandeep Gurram, Maria Merino, Baris Turkbey, Bradford Wood, and Peter Pinto Jacob EndersJacob Enders More articles by this author , Michael RothbergMichael Rothberg More articles by this author , Zach KozelZach Kozel More articles by this author , Michael DaneshvarMichael Daneshvar More articles by this author , Luke O'ConnorLuke O'Connor More articles by this author , Alex WangAlex Wang More articles by this author , Cheyenne WilliamsCheyenne Williams More articles by this author , Nitin YerramNitin Yerram More articles by this author , Sandeep GurramSandeep Gurram More articles by this author , Maria MerinoMaria Merino More articles by this author , Baris TurkbeyBaris Turkbey More articles by this author , Bradford WoodBradford Wood More articles by this author , and Peter PintoPeter Pinto More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002609.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Active surveillance (AS) for prostate cancer (PCa) increasingly relies on regularly scheduled imaging with multiparametric MRI (mpMRI) and subsequent prostate biopsy. However, MRI scans are costly and time-consuming, and transrectal biopsies can cause significant patient morbidity due to infection. As such, patients may benefit from avoiding biopsy when the results are unlikely to change clinical management. We sought to identify patients in our AS cohort undergoing annual mpMRI and subsequent MRI-US fusion systematic and targeted biopsy who had no lesions detected on MRI and examine rates and risk factors for disease upgrading. METHODS: A prospectively maintained retrospective database of patients with biopsy-proven PCa on AS at our institution was queried to find patients with no distinct lesion on surveillance mpMRI who underwent subsequent MRI-US fusion biopsy from 2007 to 2019. Patient demographics and information from prostate mpMRI and biopsy were collected, with clinically significant prostate cancer (csPCa) defined as Gleason grade group 2 or higher. A logistic regression model was constructed to examine risk factors for upgrading to csPCa at biopsy using JMP v16.0 (SAS Institute, NC). RESULTS: 466 patients on AS with at least one surveillance mpMRI were identified. Patients underwent an median of 4 MRIs across a median duration on AS of 3.4 years. The median age was 65.0 years (IQR: 60 – 69), median PSA was 5.4 ng/mL (IQR: 3.3 – 7.8), and median PSA density was 0.086 ng/mL/cc (IQR: 0.057 – 0.113). 120/466 (25.7%) patients had at least one surveillance mpMRI showing no distinct lesions in the prostate. Of these, 73/120 (60.8%) patients underwent at least one subsequent biopsy. Across 95 biopsy sessions in these 73 patients, 33/95 (34.7%) showed equal-grade and 47/95 (49.5%) showed lower-grade cancers compared to previous pathology. 10/95 (10.5%) biopsies in 9/73 (12.4%) patients showed upgrading to csPCa. A multivariate logistic regression model showed increased PSA density was a significant predictor of upgrading to csPCa at biopsy (OR: 4.2 for increase of 0.100 ng/mL/cc, 95% CI: 1.5-11.9, p <0.01). CONCLUSIONS: Negative mpMRI while on AS for prostate cancer resulted in equal grading or downgrading in the vast majority of patients undergoing subsequent biopsy. Patients with a negative mpMRI were more likely to be upgraded to csPCa with increasing PSA density. Thus, patients with a negative mpMRI, especially in the setting of a low PSA density, may be able to defer biopsy given the low likelihood for disease upgrading. Source of Funding: The National Institute of Health (NIH) Medical Research Scholars Program, Foundation for the NIH, NIH Intramural Research Program © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e743 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jacob Enders More articles by this author Michael Rothberg More articles by this author Zach Kozel More articles by this author Michael Daneshvar More articles by this author Luke O'Connor More articles by this author Alex Wang More articles by this author Cheyenne Williams More articles by this author Nitin Yerram More articles by this author Sandeep Gurram More articles by this author Maria Merino More articles by this author Baris Turkbey More articles by this author Bradford Wood More articles by this author Peter Pinto More articles by this author Expand All Advertisement PDF DownloadLoading ...

PURPOSE OF REVIEW:Multiparametric magnetic resonance imaging (mpMRI) has fundamentally changed how intraprostatic lesions are visualized, serving as a highly sensitive means for detecting clinically significant prostate cancer (csPCa) via image-targeted biopsy. However, limitations associated with mpMRI have led to the development of new imaging technologies with the goal of better characterizing intraprostatic disease burden to more accurately guide treatment planning and surveillance for prostate cancer focal therapy. Herein, we review several novel imaging modalities with an emphasis on clinical data reported within the past two years.RECENT FINDINGS:7T MRI, artificial intelligence applied to mpMRI, positron emission tomography combined with either computerized tomography or MRI, contrast-enhanced ultrasound, and micro-ultrasound are novel imaging modalities with the potential to further improve intraprostatic lesion localization for applications in focal therapy for prostate cancer. Many of these technologies have demonstrated equivalent or favorable diagnostic accuracy compared to contemporary mpMRI for identifying csPCa and some have even shown improved capabilities to define lesion borders, to provide volumetric estimates of lesions, and to assess the adequacy of focal ablation of planned treatment zones.SUMMARY:Novel imaging modalities with capabilities to better characterize intraprostatic lesions have the potential to improve accuracy in treatment planning, real-time assessment of the ablation zone, and posttreatment surveillance; however, many of these technologies require further validation to determine their clinical utility.

Study Design: Retrospective review of patients ages 10-18 who underwent posterior fusion for adolescent idiopathic scoliosis (AIS) at a single institution from 2014 to 2019. Objective: The aim was to evaluate a standardized Care Path to determine its effects on perioperative outcomes in patients undergoing spinal fusion for AIS. Summary of Background Data: AIS is the most common pediatric spinal deformity and thousands of posterior fusions are performed annually. Surgery presents several postoperative challenges, such as pain control, delayed mobilization, and opioid-related morbidity. Optimizing perioperative care of AIS is a high priority to reduce morbidity and improving health care efficiency. Materials and Methods: A total of 336 patients ages 10-18 were included in this study; 117 in the pre-Care Path cohort (2014-2015) and 219 in the post-Care Path cohort (2016-2019). Data compared included intraoperative details, length of stay, timing of mobilization, inpatient complications, emergency room (ER) visits, readmissions after discharge, postoperative complications, and reoperations. Results: The post-Care Path cohort had improved mobilization on postoperative day 0 (pre 16.7%, post 53.3%, P<0.00001), reduced length of stay (pre 4.14 days, post 3.36 days, P=0.00006), fewer total inpatient complications (pre 17.1%, post 8.1%, P=0.0469), and fewer instances of postoperative ileus (pre 8.5%, post 1.9%, P=0.0102). Within 60 days of surgery, the post-Care Path cohort had fewer ER visits (pre 12.8%, post 7.2%, P=0.0413), decreased postoperative infections (pre 5.1%, post 0.48%, P=0.00547), decreased readmissions (pre 6.0%, post 0.48%, P=0.0021), and decreased reoperations (pre 5.1%, post 0.96%, P=0.0195). There was a decrease in inpatient oral morphine equivalents in the Care Path cohort (pre 118.7, post 84.7, P=0.0003). Conclusions: Our Care Path for AIS patients demonstrated significant improvements in postoperative mobilization and decreases in length of stay, complications, infections, ER visits, readmissions, and reoperations.

You have accessJournal of UrologyCME1 May 2022MP32-11 FREE-HAND VERSUS GRID-ASSISTED TRANSPERINEAL ULTRASOUND MRI-FUSION PROSTATE BIOPSY: AN INITIAL EXPERIENCE Jacob Enders, Nicole Varble, Michael Rothberg, Zach Kozel, Sheng Xu, Patrick Gomella, Michael Daneshvar, Reza Seifabadi, Maria Merino, Baris Turkbey, Bradford Wood, and Peter Pinto Jacob EndersJacob Enders More articles by this author , Nicole VarbleNicole Varble More articles by this author , Michael RothbergMichael Rothberg More articles by this author , Zach KozelZach Kozel More articles by this author , Sheng XuSheng Xu More articles by this author , Patrick GomellaPatrick Gomella More articles by this author , Michael DaneshvarMichael Daneshvar More articles by this author , Reza SeifabadiReza Seifabadi More articles by this author , Maria MerinoMaria Merino More articles by this author , Baris TurkbeyBaris Turkbey More articles by this author , Bradford WoodBradford Wood More articles by this author , and Peter PintoPeter Pinto More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002581.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Transperineal (TP) prostate biopsy has been shown to reduce rates of bleeding, sepsis, and other infectious complications compared to the traditional transrectal (TR) approach. Recent efforts have focused on using free-hand TP ultrasound (US) rather than TRUS for TP biopsy, with the objective of facilitating prostate biopsies in patients with post-TRUS biopsy urosepsis or in those without a rectum. We sought to compare cancer detection and upgrading rates between free-hand TPUS TP biopsy versus grid-assisted TP biopsy with TRUS. METHODS: Patients with an indication for prostate biopsy were enrolled in an IRB-approved clinical trial at our institution and underwent multiparametric MRI (mpMRI) of the prostate prior to biopsy. Under monitored anesthesia care or deep sedation, patients were placed in the dorsal lithotomy position. Registration of 2D TPUS sweeps with mpMRI was performed and, using the UroNav platform (Invivo/Philips, Gainesville, FL), two biopsy cores per MR-visible target lesion were obtained via the free-hand TPUS TP biopsy and grid-assisted TP biopsy with TRUS guidance techniques. A modified Barzell scheme was then used for systematic TP biopsy. Clinically significant prostate cancer was defined as Gleason grade group 2 or higher. Concordance of pathology of targeted biopsy cores and rates of upgrading between free-hand and grid-assisted TP biopsy techniques were compared. RESULTS: 49 patients have undergone free-hand and grid-assisted TP biopsy at our institution. 33/49 patients (67.3%) with a median PSA of 7.3 ng/mL (IQR: 5.2 – 11.0) were positive for cancer on biopsy. The mean number of cores obtained from targeted lesions per patient was 5.0±2.2 for the grid-assisted technique and 3.8±2.1 with free-hand technique. 40% and 34% of targeted cores were positive on grid-assisted and free-hand TP biopsy, respectively. 17/49 patients (34.7%) had a higher grade cancer on grid-assisted than free-hand biopsy, and in 6 cases this discordance was clinically significant. There were zero infection-related complications following the procedure. CONCLUSIONS: Free-hand TP prostate biopsy with TPUS guidance allows for diagnosis of prostate cancer with comparable rates to the grid assisted TP biopsy technique with TRUS. This may facilitate biopsies in patients who have had prior post-TRUS biopsy urosepsis or in patients without a rectum. Further work is necessary to refine needle placement with the free-hand technique to ensure accurate lesion sampling and validate the technique in a larger patient cohort. Source of Funding: The National Institute of Health (NIH) Medical Research Scholars Program, Foundation for the NIH, NIH Intramural Research Program © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e535 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jacob Enders More articles by this author Nicole Varble More articles by this author Michael Rothberg More articles by this author Zach Kozel More articles by this author Sheng Xu More articles by this author Patrick Gomella More articles by this author Michael Daneshvar More articles by this author Reza Seifabadi More articles by this author Maria Merino More articles by this author Baris Turkbey More articles by this author Bradford Wood More articles by this author Peter Pinto More articles by this author Expand All Advertisement PDF downloadLoading ...

STUDY DESIGN:This was a retrospective consecutive cohort analysis.OBJECTIVE:This study aimed to examine the association between commonly prescribed medications and outcomes following posterior lumbar spine surgery.SUMMARY OF BACKGROUND DATA:Postoperative complications and prolonged length of stay significantly increase costs following posterior lumbar spine surgery and worsen patient outcomes. To control costs and complications, providers should focus on modifiable risk factors, such as preoperative medications. Antihypertensive and anticholinergic drugs are among the most commonly prescribed medications but can carry significant risks in the perioperative period.MATERIALS AND METHODS:This study was a retrospective cohort analysis of patients undergoing posterior lumbar spine surgery from January 2014 through December 2015 at a large tertiary care center. The variable selection followed by multivariable logistic and negative binomial regressions were performed. An α threshold of 0.0056 was used for significance after correction for multiple comparisons. A secondary analysis was performed to evaluate confounding or effect modifying variables.RESULTS:This study included 1577 patients. Postoperative urinary retention risk was increased in patients taking loop diuretics. Acute kidney injury risk was increased for patients on nondihydropyridine calcium-channel blockers. Surgical site infection risk was increased for patients on aldosterone receptor blockers. Urinary tract infection risk was increased for patients on anticholinergics for urinary incontinence. Length of stay was decreased for patients on angiotensin II antagonists and angiotensin-converting enzyme inhibitors.CONCLUSION:A care path should be established in the perioperative period for patients who are deemed to be at higher risk due to medication status to either modify medications or improve postoperative monitoring.LEVEL OF EVIDENCE:Level III.

Patients with symptomatic instability of the spine may be treated surgically with interbody fusion. Cost and complexity in this procedure arises owing to the implanted materials involved with facilitating fusion such as titanium or polyetheretherketone. Surface modifications have been developed to augment these base materials such as plasma-spraying polyetheretherketone with titanium or coating implants with hydroxyapatite. Although some evidence has been gathered on these novel materials, additional study is needed to establish the true efficacy of surface modifications for interbody fusion devices in improving long-term patient outcomes.