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.

You have accessJournal of UrologyPediatrics: Urinary Tract Infection & Vesicoureteral Reflux1 Apr 2018MP69-16 CHARACTERISTICS AND MORBIDITY OF BACTEREMIA OF UROLOGIC ORIGIN IN THE PEDIATRIC PATIENT Jesse Jacobs, Kevin Ginsburg, Kahlil Saad, and George Steinhardt Jesse JacobsJesse Jacobs More articles by this author , Kevin GinsburgKevin Ginsburg More articles by this author , Kahlil SaadKahlil Saad More articles by this author , and George SteinhardtGeorge Steinhardt More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2240AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Bacteremia of urologic origin (BUO) is a common cause of sepsis in the adult population causing significant morbidity and mortality. We sought to review patient characteristics and morbidity of pediatric patients presenting with BUO. METHODS We retrospectively reviewed cases of pediatric patients with BUO at the Helen DeVos Children′s Hospital from 2010 to 2015. Study sample was obtained using combinations of the ICD-9 diagnostic code 599.0 (urinary tract infection, UTI), with 790.7 (bacteremia), 995.92 (severe sepsis), 995.91 (sepsis), and 591.10 (acute pyelonephritis). The electronic medical recorded was reviewed for relevant laboratory and clinic parameters. BUO was present if blood and urine cultures grew the same organism. If discordance between the blood and urine cultures existed, or the blood culture was negative, the patient was considered to have clinical pyelonephritis (CP). Neonatal patients were excluded. RESULTS We identified 121 pediatric patients with diagnosis codes consistent with BUO. Upon review of the chart, 87 patients met criteria for CP or BUO. Most patients were female (74.7%) with a median age of 3.0 years (IQR 0.25-10.0). Forty-four patients (50.6%) were classified as having BUO. Patients with underlying genitourinary (GU) structural abnormalities had similar proportions with BUO compared to children without GU abnormalities (53.8% vs 47.9%, p=0.668). E. coli was the causative agent in the majority of cases of CP (76.7%) and BUO (70.5%) p=0.628. There was a significant difference in mean length of intravenous antibiotic use in patients with BUO compared to CP (7.7 vs 5.1 days, p=0.023) and in the mean number of antibiotics used to treat the infection (1.9 vs 1.4, p=0.003). In the 44 children with BUO, children with GU structural abnormalities tended to be younger (2.6 vs 5.8 years), although this difference was not statistically significant (p=0.07). There was no difference in age, gender, length of stay (LOS), antibiotic usage, or rates of BUO compared to CP in patients diagnosed with a GU structural abnormality prior to admission, compared to those diagnosed during or after admission. CONCLUSIONS BUO in the pediatric patient is relatively rare, with only 44 cases across our 5-year study period. Underlying structural GU abnormalities did not significantly increase the risk for BUO compared to clinical pyelonephritis. Although LOS and other morbidity were similar, patients with BUO tended to be younger and require more IV antibiotic therapy. Further studies into the impact of GU structural abnormalities on the development of BUO is warranted. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e932 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Jesse Jacobs More articles by this author Kevin Ginsburg More articles by this author Kahlil Saad More articles by this author George Steinhardt More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyProstate Cancer: Localized: Active Surveillance I1 Apr 2018MP12-10 RATES AND VARIATION IN USE OF MRI, GENOMICS, AND PROSTATE BIOPSY AS CONFIRMATORY TESTS IN A LARGE ACTIVE SURVEILLANCE COHORT Kevin Ginsburg, Jesse Jacobs, Deborah Kaye, Ji Qi, Michael Cher, and For the Michigan Urological Surgery Improvement Collaborative Kevin GinsburgKevin Ginsburg More articles by this author , Jesse JacobsJesse Jacobs More articles by this author , Deborah KayeDeborah Kaye More articles by this author , Ji QiJi Qi More articles by this author , Michael CherMichael Cher More articles by this author , and For the Michigan Urological Surgery Improvement CollaborativeFor the Michigan Urological Surgery Improvement Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.397AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In order to improve risk stratification and promote the appropriate use of active surveillance (AS), the Michigan Urological Surgery Improvement Collaborative (MUSIC) encourages the use of at least one confirmatory test (prostate MRI, tumor genomics, or repeat biopsy) within 6 months of the diagnostic biopsy. We sought to determine the rate and variation in the use of confirmatory testing across the state of Michigan. METHODS We identified all patients in the MUSIC registry managed with AS from 2011 to present. A patient was considered to be on AS if the initial management strategy entered in the registry was AS, and there was no curative therapy within 6 months of the diagnostic biopsy. Patients that did not have a confirmatory test within 6 months of their initial diagnosis were excluded. RESULTS 4015 patients enrolled in AS during the study period. Of 999 patients undergoing a confirmatory test, 25.2% had biopsy, 27.3% had MRI, 37.6% had tumor genomics, and 9.8% had more than one. Compared to patients with public insurance, patients with private insurance were more likely to undergo MRI (30.2% v. 23.1%) and less likely to have tumor genomics (32.3% v 45.2%), p=0.0002. As patients aged from <50, 50-60, 60-70, and >70 years, we found a decline in MRI usage from 39.1%, to 30.7%, 27%, and 22%, and an increase in genomics use from 21.7%, to 30.0%, 38.5%, and 45.9%, respectively (p<0.05). Patients with very low and intermediate risk prostate cancer more often had tumor genomics while patients with low risk prostate cancer more often had MRI (p<0.0001). Additionally, patients with initial biopsy Gleason 6 more often had confirmatory biopsy (27.6%) and less often had tumor genomics (32.7%) as compared to men with initial biopsy Gleason 7 who more often had tumor genomics (56.7%) and less often had confirmatory biopsies (15.7%), p<0.0001. We noted significant variation in the relative use of confirmatory tests among the MUSIC practices (Figure 1). CONCLUSIONS There was significant variation in the relative utilization of the confirmatory tests in various patient groups, as well as variation in confirmatory test utilization at the practice level. The optimal confirmatory test for AS remains unknown. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e139 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Kevin Ginsburg More articles by this author Jesse Jacobs More articles by this author Deborah Kaye More articles by this author Ji Qi More articles by this author Michael Cher More articles by this author For the Michigan Urological Surgery Improvement Collaborative More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyProstate Cancer: Localized: Active Surveillance III1 Apr 2018PD20-03 RATES OF UPGRADING AND PROGRESSION TO TREATMENT IN PATIENTS ON ACTIVE SURVEILLANCE DEPEND ON CHOICE OF CONFIRMATORY TEST AT THE TIME OF DIAGNOSIS Kevin Ginsburg, Jesse Jacobs, Deborah Kaye, Ji Qi, Michael Cher, and For the Michigan Urological Surgery Improvement Collaborative Kevin GinsburgKevin Ginsburg More articles by this author , Jesse JacobsJesse Jacobs More articles by this author , Deborah KayeDeborah Kaye More articles by this author , Ji QiJi Qi More articles by this author , Michael CherMichael Cher More articles by this author , and For the Michigan Urological Surgery Improvement CollaborativeFor the Michigan Urological Surgery Improvement Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1007AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES For patients with newly diagnosed Gleason 6 or low volume Gleason 7 prostate cancer (PC) considering active surveillance (AS), the Michigan Urological Surgery Improvement Collaborative (MUSIC) encourages the use of a confirmatory test (prostate MRI, tumor genomics, or repeat biopsy) within 6 months of the original diagnostic biopsy. We sought to determine associations between the confirmatory test and subsequent biopsy outcomes and progression to curative treatment during the surveillance period. METHODS We identified all patients in the MUSIC registry managed with AS from 2011 to present. A patient was considered to be on AS if the initial management strategy entered in the registry was AS, and there was no curative therapy within 6 months of the diagnostic biopsy. Patients that did not have a confirmatory test within 6 months of their initial diagnosis were excluded. We assessed the proportion of patients with Gleason Score ≥7 on later surveillance biopsy (>6 months after initial diagnosis) as well as rates of progression to treatment. RESULTS 4015 patients enrolled in AS during the study period. Of 999 AS patients with a confirmatory test, the confirmatory test was repeat biopsy in 25.2%, MRI in 27.3%, tumor genomics in 37.6%, and more than one test in 9.8%. Among 242 patients with GS 6 on the diagnostic biopsy and had a surveillance biopsy, a total of 25.6% were upgraded to GS 7 on surveillance biopsy. Upgrading on the later surveillance biopsy was 21.6% when the confirmatory test was MRI, 16.4% when the confirmatory test was repeat biopsy and 35.3% when the confirmatory test was tumor genomics, p=0.0052. Of all 999 patients on surveillance with a confirmatory test, 127 (12.7%) progressed to treatment during the study period. Progression to treatment was most common among patients whose confirmatory test was repeat biopsy (19.4%) as compared to MRI (13.2%) and tumor genomics (7.98%), p=0.0002 (Figure 1). CONCLUSIONS The various confirmatory tests are associated with different proportions of upgrading on surveillance biopsy and different rates of progression to treatment. The ideal confirmatory test in AS is unknown, and further investigation into the relationship of confirmatory testing to metastasis free survival and disease specific survival should be investigated. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e402 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Kevin Ginsburg More articles by this author Jesse Jacobs More articles by this author Deborah Kaye More articles by this author Ji Qi More articles by this author Michael Cher More articles by this author For the Michigan Urological Surgery Improvement Collaborative More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

INTRODUCTION AND OBJECTIVES: We aim to present longterm outcomes of patients with ureterocele, treated by an innovative technique.To date the optimal surgical technique for ureterocele complex remains unclear and treatment options are extremely variable in this regard.These techniques mostly share major drawbacks including de novo vesicoureteral reflux (VUR) into ureterocele moiety and mandatory secondary surgery.A feasible and minimally invasive method for treatment of ureterocele using concomitant ureterocele double puncture and intraureterocele fulguration has been previously introduced (Kajbafzadeh et al.J Urol 2007; 177: 1118-23).Herein, we present long-term outcomes of this technique.METHODS: After obtaining institutional ethical approval, a retrospective chart review was performed to gather records of patients undergone this technique between 1999 and 2014.Patients with history of previous ureterocele surgery or follow up period of less than two years were excluded from the study.In this technique, after maintaining two punctures into the poles of ureterocele using the stylet of a 3Fr ureteral stent and cutting current, a Double-J stent was inserted into the both punctured sites.Afterwards, fulguration of anterior and posterior ureterocele walls at multiple sites was performed under direct vision in order to create anterior and posterior wall surface welding of urine channel.RESULTS: During the study period, 48 patients (51 ureteroceles) underwent this technique.From these, 31 (64.6%)patients were female.Two patients had single system ureteroceles.Three patients (6.2%) underwent bilateral ureterocele double puncture.Mean (range) age at the time of surgery was 2.9 (2 months -13 years) years.The mean follow up period was 6.1 (2-15.2) years.Mode of presentation was febrile UTI (52%).Ureterocele was successfully decompressed in all except two kids (success rate¼96%).Secondary ureterocele surgery was performed successfully in two aforementioned patients.De novo VUR was diagnosed in another two patients in upper pole ureter (one grade II, one grade III) which was endoscopically treated with success in both cases.No febrile UTI was encountered postoperatively.CONCLUSIONS: The present study suggests that double puncture ureterocele surgery is highly successful in decompressing ureterocele without incurring major complications, further partial nephroureterectomy or common sheet double ureteric reimplatation.We believe that, this technique could serve as a promising minimally invasive alternative in ureterocele management.