Introduction The American Urological Association (AUA)/Society of Urology Oncology (SUO) guidelines recommend a repeat transurethral resection of bladder tumor (TURBT) for high-risk, non-invasive (HR Ta) nonmuscle invasive bladder cancer (NMIBC) patients. The evidence base for this recommendation is weak (grade C) and fraught with methodological shortcomings, such as the lack of adjuvant intravesical Bacillus Calmette Gurein (BCG) and single-center study designs. We sought to evaluate the effect of repeat TURBT on recurrence-free survival at a population level in HR Ta NMIBC patients who completed BCG induction therapy. Methods High-grade Ta NMIBC patients who underwent TURBT for a ≥5cm tumor were identified within the SEER-Medicare database from 2000 to 2015. All patients completed induction BCG and were stratified into two groups: repeat TURBT within eight weeks of initial TURBT and a group without repeat TURBT (control group). The primary endpoint was the 3-year high-risk recurrence rate. Results A cohort of 591 patients was identified, with 88 (14.9%) undergoing a repeat TURBT within eight weeks of initial TURBT and 503 (85.1%) without a repeat TURBT. Patient demographic and clinical characteristics were similar overall. No significant difference in the 3-year recurrence rate was noted (repeat TURBT group 20.5% vs. control group 14.7%, p=0.17). After adjusting for demographic and clinical characteristics, no association between repeat TURBT and 3-year high-risk recurrence was observed (HR (95% CI): 1.34 (0.79, 2.25); p=0.28) (Figure 1). A Kaplan Meier with Logrank test (KM) showed no significant difference in 3-year recurrence-free survival between the repeat TURBT and control groups (p = 0.19) (Figure 2). Conclusions In patients with large volume HG Ta NMIBC with completion of induction BCG therapy repeat TURBT was not associated with decreased high-risk recurrence-free survival. While repeat TURBT does likely identify residual disease in a subsection of this population, the implementation of a high-quality initial resection in conjunction with the treatment benefit of BCG therapy may nullify the therapeutic benefit of repeat TURBT. These data underscore the need for additional studies evaluating the utility of repeat TURBT in HR Ta NMIBC, ideally in a cooperative group setting.

Introduction Renal angiomyolipoma (AML) is one of the most common solid benign renal tumors. Although most of these tumors are often discovered incidentally during radiological imaging, symptomatic presentations such as flank pain, gross hematuria, or retroperitoneal hemorrhage may also exist. AMLs are often imaged intensively and treated empirically when they reach between the sizes 4-6cm. When to intervene remains controversial. Our aim was to investigate the growth rate, examine radiographic features, and evaluate trends in clinical presentation. Methods This is multicenter single institution retrospective study. We reviewed all patients diagnosed with renal AML between three Mayo Clinic sites (Rochester, Arizona, Jacksonville) between 1997-2021. Only patients with 3 or more abdominal scans with at least 2 years between first and last scans and at least 36 months follow-up were selected. A thorough review was performed of radiologic reports, images, and charts. Patient demographics, tumor characteristics, and type of imaging modalities were recorded. We also looked at intervention rates, tumor size, and growth rates. A t-test and chi-square test were used to compare differences between renal AML < 4 and > 4 cm. Results 960 patients were initially identified. Following exclusion criteria 863 patients were identified. The majority of patients were female (81.6%). 723 presented with an initial mass < 4 cm and 136 >4 cm. 63 patients had tuberous sclerosis. 197 (22.8%) required intervention and 52 (6.1%) patients bled. When comparing the two groups (initial size < 4cm and >4 cm) patients with an initial mass >4cm were more likely to bleed, have tuberous sclerosis, or receive intervention. Percent growth changes between the two groups over 6, 12, 24, 36, and 48 months were not significantly different. Conclusions To our knowledge this is the largest series on AMLs. Our single-institution multicenter series on AMLs confirms that the majority of AMLs are small (<4 cm), and grow at a slow pace. Our study also shows that larger AMLs (>4 cm) do not grow at a faster rate. However, larger AMLs are more likely to bleed and require intervention. We believe further studies focusing on radiographic characteristics may help guide which lesions need earlier intervention.

240 Background: Debate remains about the value of Prostate-specific antigen (PSA) based prostate cancer screening among men aged 55-69 (USPSTF Grade C). However, no professional society or guideline recommends PSA based prostate cancer screening in men younger than age 40. This study aims to understand the risk of PSA testing exposure in young men, and we hypothesize that substantial low-value testing occurs in this population. Methods: We performed a retrospective analysis of claims data from the MarketScan database to identify men aged 18 to 39 without prostate cancer who received a PSA test from 2008 to 2017. For the primary analysis, men were required to be continuously in the database for least 5 years. Age groups were stratified to include: men less than 25, 25-29, 30-34, and 35-39 years. Secondary analysis did not limit subjects to those with 5 years of continuous data and explored the association of Charlson Comorbidity Index (CCI), lower urinary tract symptoms, erectile dysfunction, depression/anxiety, prostate cancer screening, infertility, and hypogonadism with PSA testing in young men. We used logistic regression to determine which of the factors were associated with PSA testing in young men. Results: We identified claims for 40,164,773 adult men who met study criteria. Of these men, 3,230,748 were continuously in the Marketscan database for at least 5 years. The cumulative risk for receiving a PSA over 5 years for men under 40 is 2.5%. Stratified by age, men aged 35-39 are at highest risk (Table). Logistic multivariable regression showed that, relative to all men between 18 and 40, patients in this age group who received a PSA were more likely to be diagnosed with hypogonadism (OR 20.55, 95% CI 20.39-20.71) or lower urinary tract symptoms (OR 9.34, 95% CI 9.26-9.41). Higher CCIs appeared to correlate with a decreased rate of PSA testing. This population was not significantly more likely to be diagnosed with infertility, depression, or anxiety. Conclusions: PSA screening for men under 40 is not uncommon, especially when associated with concomitant genitourinary symptoms. At a population level, this represents substantial low-value testing. Interventions aimed at clarifying the relationship between common urologic conditions and prostate cancer, the extremely low incidence of prostate cancer in this age group, and the lack of guidelines supporting this practice may help decrease low-value PSA testing. Funding: Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under Award Number K08CA234431. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.[Table: see text]

INTRODUCTION:Obesity in prostate cancer survivors may increase mortality. Better characterization of this effect may allow better counseling on obesity as a targetable lifestyle factor to reduce mortality in prostate cancer survivors. The purpose of this study was to determine whether pre- and post-diagnostic obesity and weight change affect all-cause mortality, cardiovascular disease specific mortality, and prostate cancer specific mortality in patients with nonmetastatic prostate cancer. PATIENTS AND METHODS:We performed a retrospective cohort analysis of 5,077 patients diagnosed with localized prostate cancer from 1997 to 2017 with median follow-up of 15.5 years. The Utah Population Database linked to the Utah Cancer Registry was used to identify patients at a variety of treatment centers. RESULTS:Pre-diagnosis obesity was associated with a 62% increased risk of cardiovascular disease specific mortality and a 34% increased risk of all-cause mortality (HR 1.62, 95% CI 1.05-2.50; HR 1.34, 95% CI 1.07-1.67, respectively). Post-diagnosis obesity increased the risk of cardiovascular disease specific mortality (HR 1.83, 95% CI 1.31-2.56) and all-cause mortality (HR 1.37, 95% CI 1.16-1.64) relative to non-obese men. We found no association between pre-diagnostic obesity or post-diagnostic weight gain and prostate cancer specific mortality. CONCLUSION:Our study strengthens the conclusion that pre-, post-diagnostic obesity and weight gain increase cardiovascular disease and all-cause mortality but not prostate cancer specific mortality compared to healthy weight men. An increased emphasis on weight management may improve mortality for prostate cancer survivors who are obese.

Artificial intelligence (AI) is the integration of human tasks into machine processes. The role of AI in kidney cancer evaluation, management, and outcome predictions are constantly evolving. We performed a narrative review utilizing PubMed electronic database to query AI as a method of analysis in kidney cancer research. Key search-words included: Artificial Intelligence, Supervised/Unsupervised Machine Learning, Deep Learning, Natural Language Processing, Neural Networks, radiomics, pathomics, and kidney or renal neoplasms or cancer. 72 clinically relevant and impactful studies related to imaging, histopathology, and outcomes were recognized. We anticipate the incorporation of AI tools into future clinical decision-making for kidney cancer.

Background:Using a health systems approach to investigate low-value care (LVC) may provide insights into structural drivers of this pervasive problem. Objective:To evaluate the influence of service area practice patterns on low-value mammography and prostate-specific antigen (PSA) testing. Design:Retrospective study analyzing LVC rates between 2008 and 2018, leveraging physician relocation in 3-year intervals of matched physician and patient groups. Setting:U.S. Medicare claims data. Participants:8254 physicians and 56 467 patients aged 75 years or older. Measurements:LVC rates for physicians staying in their original service area and those relocating to new areas. Results:Physicians relocating from higher-LVC areas to low-LVC areas were more likely to provide lower rates of LVC. For mammography, physicians staying in high-LVC areas (LVC rate, 10.1% [95% CI, 8.8% to 12.2%]) or medium-LVC areas (LVC rate, 10.3% [CI, 9.0% to 12.4%]) provided LVC at a higher rate than physicians relocating from those areas to low-LVC areas (LVC rates, 6.0% [CI, 4.4% to 7.5%] [difference, -4.1 percentage points {CI, -6.7 to -2.3 percentage points}] and 5.9% [CI, 4.6% to 7.8%] [difference, -4.4 percentage points {CI, -6.7 to -2.4 percentage points}], respectively). For PSA testing, physicians staying in high- or moderate-LVC service areas provided LVC at a rate of 17.5% (CI, 14.9% to 20.7%) or 10.6% (CI, 9.6% to 13.2%), respectively, compared with those relocating from those areas to low-LVC areas (LVC rates, 9.9% [CI, 7.5% to 13.2%] [difference, -7.6 percentage points {CI, -10.9 to -3.8 percentage points}] and 6.2% [CI, 3.5% to 9.8%] [difference, -4.4 percentage points {CI, -7.6 to -2.2 percentage points}], respectively). Physicians relocating from lower- to higher-LVC service areas were not more likely to provide LVC at a higher rate. Limitation:Use of retrospective observational data, possible unmeasured confounding, and potential for relocating physicians to practice differently from those who stay. Conclusion:Physicians relocating to service areas with lower rates of LVC provided less LVC than physicians who stayed in areas with higher rates of LVC. Systemic structures may contribute to LVC. Understanding which factors are contributing may present opportunities for policy and interventions to broadly improve care. Primary Funding Source:National Cancer Institute of the National Institutes of Health.

OBJECTIVE To evaluate outcomes of robotic-assisted transplant ureteral repair (RATUR) for the managemultiple tertiary referral centers between January 2016 and December 2022. RATUR was performed utilizing a robotic-assisted transperitoneal approach. The primary outcome was stricture recurrence rate and secondary outcomes included postoperative complicate rate, determining factors impacting with allograft functional recovery, and rate of conversion to open surgery. Categorical and continuous variables are displayed as total number (Percentage) or median [Interquartile Range], respectively. Pearson correlation coefficient was utilized to assess categorical variable correlation with creatinine. RESULTS The median age was 56 years [44,66]. The female-to-male ratio was 1.1:1. Approximately 66% of patients were dialysis-dependent prior to kidney transplantation. TUS was identified at a median time of 4 months [2, 15.5] following kidney transplant. Median stricture length was 2 cm [1.22, 2.9 cm]. There were no TUS recurrences with a median follow-up of 36 months [24,48]. There were 3 Clavien grade 2 and 1 Clavien grade 3 complications (9.5%). No baseline characteristics or preoperative diagnostics were correlated with a long-term decline in renal allograft function. CONCLUSION RATUR has excellent and durable outcomes with low complication rates. These findings encourage the use of a minimally invasive definitive repair as a first-line treatment option for the management of TUS. UROLOGY 193: 186-191, 2024. (c) 2024 Elsevier Inc. All rights reserved.

BACKGROUND:Large language model (LLM) chatbots, a form of artificial intelligence (AI) that excels at prompt-based interactions and mimics human conversation, have emerged as a tool for providing patients with information about urologic conditions. We aimed to examine the quality of information related to benign prostatic hyperplasia surgery from four chatbots and how they would respond to sample patient messages. METHODS:We identified the top three queries in Google Trends related to "treatment for enlarged prostate." These were entered into ChatGPT (OpenAI), Bard (Google), Bing AI (Microsoft), and Doximity GPT (Doximity), both unprompted and prompted for specific criteria (optimized). The chatbot-provided answers to each query were evaluated for overall quality by three urologists using the DISCERN instrument. Readability was measured with the built-in Flesch-Kincaid reading level tool in Microsoft Word. To assess the ability of chatbots to answer patient questions, we prompted the chatbots with a clinical scenario related to holmium laser enucleation of the prostate, followed by 10 questions that the National Institutes of Health recommends patients ask before surgery. Accuracy and completeness of responses were graded with Likert scales. RESULTS:Without prompting, the quality of information was moderate across all chatbots but improved significantly with prompting (mean [SD], 3.3 [1.2] vs. 4.4 [0.7] out of 5; p < 0.001). When answering simulated patient messages, the chatbots were accurate (mean [SD], 5.6 [0.4] out of 6) and complete (mean [SD], 2.8 [0.3] out of 3). Additionally, 98% (39/40) had a median score of 5 or higher for accuracy, which corresponds to "nearly all correct." The readability was poor, with a mean (SD) Flesch-Kincaid reading level grade of 12.1 (1.3) (unprompted). CONCLUSIONS:LLM chatbots hold promise for patient education, but their effectiveness is limited by the need for careful prompting from the user and by responding at a reading level higher than that of most Americans (grade 8). Educating patients and physicians on optimal LLM interaction is crucial to unlock the full potential of chatbots.

PURPOSE:This study aimed to investigate the prevalence of pathogenic germline variants (PGVs) in hereditary cancer genes utilizing a universal testing approach and to determine the rate of PGVs that would have been missed based on National Comprehensive Cancer Network (NCCN) guidelines in genitourinary (GU) malignancies. MATERIALS AND METHODS:A multisite, single-institution prospective germline genetic test (GGT) was universally offered to patients with new or active diagnoses of GU malignancies (prostate, bladder, and renal) from April 2018 to March 2020 at Mayo Clinic sites. Participants were offered GGT using a next-generation sequencing panel of > 80 genes. Demographic, tumor characteristics, and genetic results were evaluated. NCCN GU cancer guidelines were used to identify whether patients had incremental findings, defined as PGV-positive patients who would not have received testing based on NCCN guidelines. RESULTS:Of 3095 individuals enrolled in the study, 601 patients had GU cancer (prostate = 358, bladder = 106, and renal = 137). The mean enrollment age was 67 years (SD 9.1), 89% were male, and 86% of patients were non-Hispanic White. PGVs were identified in 82 (14%) of all GU patients. PGV prevalence breakdown by cancer type was: 14% prostate, 14% bladder, and 13% renal cancer. Nearly one-third of identified PGVs were high penetrance, and the majority of these (67%) were clinically actionable. Incremental PGVs were identified in 28 (57%) prostate, 15 (100%) bladder, and 14 (78%) renal cancer patients. Of the 82 patients with PGV findings, 29 (35%) had at least 1 relative undergo cascade testing for the familial variant(s) identified. CONCLUSIONS:More than 1 in 8 patients with GU malignancies were found to carry a PGV, with 67% of patients with high-penetrance PGVs undergoing clinically actionable changes. The majority of these PGVs would not have been identified based on current testing criteria. These findings support universal GGT for GU malignancies and underscore its potential to enhance risk assessment and guide precision interventions in urologic oncology.

Background: Postoperative stress urinary incontinence (SUI) after Holmium Laser Enucleation of the Prostate (HoLEP) has improved with the early apical release (EAR) technique. However, some patients develop SUI despite using EAR HoLEP. The aim of this study is to investigate whether a novel classification of the external sphincter is correlated with postoperative SUI. Methods: The data of 98 patients who underwent EAR HoLEP for benign prostatic hyperplasia were prospectively analyzed. We propose a novel endoscopic classification of external sphincter appearance after HoLEP graded from 0 (best preserved) to 3 (most degraded). Patients were followed for 6 months postoperatively and administered validated questionnaires. A logistic regression was performed to compare moderate SUI rates at sphincter grade 3, controlling for age, obesity, catheter dependency, and grams resected at 6 weeks and 3 months. Results: The sphincter grades included 6 grade 0, 47 grade 1, 30 grade 2, and 15 grade 3. Patients were divided into a group without SUI (n = 51), and a group with SUI (n = 47) at 6 weeks postoperatively by International Consultation on Incontinence Questionnaire (ICIQ). Patients with reported SUI on ICIQ were more likely to have sphincter grades ≥2 at 6 weeks (p= 0.001) and 3 months (p < 0.0001). At 6 months, persistent SUI was associated with sphincter grade 3 (p < 0.0001). Logistic regression demonstrated that sphincter grade 3 was associated with clinically significant SUI at 3 months (p < 0.01). Conclusions: Lower sphincter grades are associated with improved return of continence after EAR HoLEP.

25 Background: Previous studies have shown that individuals with cancer who live in rural areas have worse cancer-specific outcomes compared to their urban counterparts. Differences in access to high-quality cancer care and adequate social support may explain some of the observed disparity. Rural patients with relatives in urban areas may have better access to care via an increased ability to navigate the healthcare system than their rural counterparts without relatives in urban areas. In this study, we examine the possibility of a family-based social capital effect on genitourinary cancer survival. We hypothesized that rural patients who have family members living in urban areas have survival outcomes similar to their urban counterparts. Methods: We performed a retrospective cohort analysis of individuals diagnosed with genitourinary cancers, including prostate, bladder, kidney, penile, and testicular cancers. We constructed familial networks using the Utah Population Database (UPDB). Patients were classified as living in either rural or urban areas based on the rural-urban commuting area (RUCA) codes associated with their zip code of residence at the time of cancer diagnosis. Adult first degree relatives (siblings, parents, children) were identified and classified as urban or rural based on the zip code or county of residence at the time of the patients’ diagnosis or, when unavailable, the county or zip code of residence before or after diagnosis. Overall survival (OS) was analyzed using Cox proportional hazards models. Results: We identified 24,746 individuals diagnosed with genitourinary cancer between 1968-2018. Median follow-up was 8.72 years. After adjusting for sex, age, race, cancer type, health improvement index (HII), and Simpson’s diversity index, urban patients had the best OS at 5 and 10 years (reference group). Rural cancer patients without an urban first degree relative had the worst outcomes with OS hazard ratios at five and ten years of 1.4 (CI 1.23-1.58) and 1.4 (CI 1.26-1.55), respectively. Having an urban first degree relative ameliorated much of the urban-rural disparity with five- and ten-year OS hazard ratios of 1.19 (CI 1.07-1.31) and 1.12 (CI 1.03-1.21), respectively. Conclusions: Individuals diagnosed with cancer who live in rural areas have worse survival as compared to their urban counterparts, but this relationship appears to be heavily influenced by the presence or absence of relatives who live in urban areas. Further research is needed to better understand the mechanisms through which having an urban family member may contribute to improved cancer outcomes for rural patients. This may help in the crafting of policies that can reduce urban-rural cancer disparities. Funding: Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health (K08CA234431 & P30CA042014-31S2). The content does not represent the views of the National Institutes of Health.

Introduction: Bacillus Calmette-Guerin (BCG) is the most effective therapy available to treat high-risk nonmuscle invasive bladder cancer (NMIBC) patients. However, for patients with immunomodulating conditions BCG is a relative contraindication due to efficacy and safety concerns. To our knowledge, no population-level study evaluating the efficacy and safety profile of BCG for immunomodulated patients exists. Methods: NMIBC patients aged 66 years or older were identified in the Surveillance, Epidemiology, and End Results (SEER) - Medicare database from 1975-2013. All patients completed adequate BCG (at least 5 plus 2 treatments completed within 12 months of diagnosis). Two groups were defined: an immunomodulated population identified by immunomodulating conditions such as solid-organ transplantation, HIV, and autoimmune conditions, and an immunocompetent group. The primary endpoint was 5-year progression-free survival defined as progression to systemic chemotherapy, checkpoint inhibitors, radical or partial cystectomy, metastasis, or cancer-specific death. A safety analysis was performed as a secondary outcome. Results: In a total of 4,277 patients with NMIBC who completed adequate BCG, 606 (14.2%) were immunomodulated. The immunomodulated group was older at diagnosis (P < 0.001), more likely to be female (P < 0.001), more likely to live in a metropolitan area (P < 0.001), and had higher Charlson comorbidity scores (P < 0.001). There were no differences in progression to chemotherapy (P = 0.17), checkpoint inhibitors (P > 0.99), radical cystectomy (P = 0.40), partial cystectomy (P = 0.93), metastasis (P = 0.19), cancer-specific death (P = 0.18) or 5-year total bladder cancer progression (P = 0.30) between the groups. For the safety analysis, rates of disseminated BCG were similar between immunomodulated and immunocompetent patients (0.7% vs. <1.8%, P = 0.51). On multivariable analysis 5-year total bladder cancer progression (HR 1.07 [CI 0.88-1.30]) was similar between the groups. Conclusion: Rates of bladder cancer progression and disseminated BCG complications 5-years after BCG therapy were similar regardless of immunomodulation status. These findings suggest that BCG intravesical therapy can be offered to immunomodulated patients with high-risk NMIBC although theoretical infectious complication risks remain. (c) 2023 Elsevier Inc. All rights reserved.

BackgroundThe psychological and cardiovascular health impacts on family members of patients who have been diagnosed with cancer have not been well characterized. The purpose of this study is to determine whether a family member's cancer diagnosis influences the risk of psychological illness and cardiovascular disease in first-degree relatives and spouses of patients affected by cancer.MethodsThis retrospective cohort analysis evaluated the risk of psychological illness and cardiovascular disease in first-degree relatives and spouses of patients diagnosed with a genitourinary cancer between 1990 and 2015 compared to relatives of those not diagnosed with a genitourinary cancer. The Utah Population Database was used and familial linkage was determined. Follow-up included 1-, 3-, and 5-year intervals. Patients residing outside of Utah and first-degree relatives and spouses with psychological or cardiovascular disease diagnosed before a family member's cancer diagnosis were excluded.ResultsA total of 49,284 patients with a genitourinary cancer were identified with 77,938 first-degree relatives and spouses. A matched control group included 246,775 patients with 81,022 first-degree relatives and spouses. Via Cox proportional hazards models, a 10% increased risk of developing a psychological illness (hazard ratio [HR], 1.10; 95% CI, 1.00-1.20) and a 28% increased risk of developing cardiovascular disease (HR, 1.28; 95% CI, 1.17-1.41) at 1 year after a family member's cancer diagnosis were found.ConclusionsThis study provides population-level evidence to support the hypothesis that cancer diagnoses will lead to adverse health outcomes for family members of patients with cancer. Increased clinical attention and support are needed to reduce the harm to families caused by cancer. The purpose of this study is to determine whether a family member's cancer diagnosis influences the risk of psychological illness and cardiovascular disease in first-degree relatives and spouses of patients affected by cancer.

Objectives To investigate the difference in postoperative incontinence and quality of life comparing standard vs early apical release (EAR) Holmium Laser Enucleation of the Prostate (HoLEP). Methods A retrospective review was performed to identify patients who underwent HoLEP from December 2021 to December 2022 at a single teritary referral center with two participating consultant urologists. Patients were assessed with questionnaires and evaluated clinically. We performed propensity score matching with a logistic regression and a 1:1 matching method. A propensity score adjusted logistic regression (PSRM) was performed to compare the pads per day between surgical techniques controlling for age, prostate size, preoperative survey data, uroflow and post void residual. Results 114 patients underwent HoLEP, of which 60 patients were treated with EAR and 54 patients with standard technique. EAR technique demonstrated shorter operative times (p= 0.046). The EAR cohort demonstrated improved AUASS (p = 0.034, p= 0.001), QOL (p= 0.001, p<0.001), and continence rates (p<0.001, p<0.001) at 6 and 12 weeks postoperatively. PSRM showed that the standard HoLEP increased the risk of requiring >2 pads per day 4.2x (p= 0.031, HR 95%, CI = 1.16, 15.35) and 8.3x (p<0.001, HR 95% CI 3.17, 21.6) at 6 and 12 weeks postoperatively. Conclusions Early apical release technique promoted earlier return of continence and improved quality of life within 6 weeks of surgery. Data Availability The data demonstrating the study’s results is accessible from the corresponding author in an anonymized format upon reasonable request for the purpose of review.

You have accessJournal of UrologyReconstruction: Ureteral Reconstruction (Including Pyeloplasty) and Bladder Reconstruction (Including Trauma-Related Fistula) II (PD44)1 May 2024PD44-07 COMPARISON OF OPEN AND ROBOTIC TRANSPLANT URETERAL REIMPLANT Kian Ahmadieh, Sayi Boddu, Victoria Edmonds, Mouneeb Choudry, Grace Madura, Nicolette Payne, Daniel Heidenberg, and Scott Cheney Kian AhmadiehKian Ahmadieh , Sayi BodduSayi Boddu , Victoria EdmondsVictoria Edmonds , Mouneeb ChoudryMouneeb Choudry , Grace MaduraGrace Madura , Nicolette PayneNicolette Payne , Daniel HeidenbergDaniel Heidenberg , and Scott CheneyScott Cheney View All Author Informationhttps://doi.org/10.1097/01.JU.0001008800.83683.92.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteral stricture is a potential complication after kidney transplant with possible precipitating factors including devascularization of the ureter, urine leak, and pelvic hematoma. Surgical repair of transplant ureteral strictures are classically performed with an open approach, though robotic techniques have emerged. Minimal data exists comparing open and robotic transplant ureteral reimplants. The objective of our study was to compare patient perioperative metrics and clinical outcomes after open vs. robotic ureteral reimplantation for transplant ureteral stricture disease. METHODS: All patients who underwent ureteral reimplantation of a transplanted kidney at three tertiary care centers were retrospectively reviewed over a 10-year-period. Inclusion criteria included patients who underwent ureteral reimplantation for delayed ureteral strictures with at least one year of follow up data. We compared patient demographics, perioperative metrics, and postoperative clinical outcomes between open and robotic ureteral reimplantation. RESULTS: A total of 89 patients underwent transplant ureteral reimplantation (47 open vs. 42 robotic). Patients in each cohort had similar baseline characteristics (Table 1). Time to recognition of ureteral stricture were similar in the open and robotic groups (7 mo vs 4 mo, p=0.224), with similar stricture length (3 cm vs 2 cm, p=0.21). Open reimplantation had shorter operative times than robotic (161min vs 271min, p<.001). There was no statistically significant difference between groups in length of stay, 30-day post-surgical complications, or improvement in creatinine post reimplantation (Table 2). Stricture recurrence was similar in both the open and robotic cohorts (3.9% vs 4.4 %, p=1). CONCLUSIONS: Robotic and open transplant ureteral reimplantation techniques demonstrate similar postoperative clinical outcomes. Patients in both groups had similar postoperative complications and rates of stricture recurrence. Shared decision making and surgeon technical experience should guide surgical planning. Source of Funding: None © 2024 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 211Issue 5SMay 2024Page: e907 Advertisement Copyright & Permissions© 2024 by American Urological Association Education and Research, Inc.Metrics Author Information Kian Ahmadieh More articles by this author Sayi Boddu More articles by this author Victoria Edmonds More articles by this author Mouneeb Choudry More articles by this author Grace Madura More articles by this author Nicolette Payne More articles by this author Daniel Heidenberg More articles by this author Scott Cheney More articles by this author Expand All Advertisement PDF downloadLoading ...

Background The American Urological Association (AUA)/Society of Urology Oncology (SUO) guidelines recommend a repeat transurethral resection of bladder tumor (TURBT) for high-risk, non-invasive (HR Ta) nonmuscle invasive bladder cancer (NMIBC) patients. The evidence base for this recommendation is weak (grade C) and fraught with methodological shortcomings, such as the lack of adjuvant intravesical Bacillus Calmette Guerin (BCG) and single-center study designs. Objective We sought to evaluate the effect of repeat TURBT on recurrence-free survival at a population level in HR Ta NMIBC patients who completed BCG induction therapy. Methods High-grade Ta NMIBC patients who underwent TURBT for a ≥5 cm tumor were identified within the SEER-Medicare database. All patients completed induction BCG and were stratified into two groups: repeat TURBT within eight weeks of initial TURBT and a group without repeat TURBT (control group). The primary endpoint was the 3-year high-risk recurrence rate. Results A cohort of 604 patients was identified, with 93 (15.4%) undergoing a repeat TURBT within eight weeks of initial TURBT and 511 (84.6%) without a repeat TURBT. Patient demographic and clinical characteristics were similar overall. No significant difference in the 3-year recurrence rate was noted (repeat TURBT: 20.4% vs. control group: 15.7%, p = 0.25). After adjusting for demographic and clinical characteristics, no association between repeat TURBT and 3-year high-risk recurrence was observed (HR (95% CI): 1.27 (0.76, 2.11); p = 0.36). Conclusion Although our study contains several major limitations, our results suggest that repeat TURBT in large volume HG Ta NMIBC treated with induction BCG therapy was not associated with improved high-risk recurrence-free survival.

Objective: To evaluate the interest of primary care clinicians in utilizing CDS for PSA screening. Evidence suggests that electronic clinical decision support (CDS) may decrease low-value prostate-specific antigen (PSA) testing. However, physician attitudes towards CDS for PSA screening are largely unknown. Methods: A survey was sent to 201 primary care clinicians, including both physicians and Advanced Practice Providers (APP), within a large academic health system. Eligible clinicians cared for male patients aged 40 to 80 years and ordered = 5 PSA tests in the past year. Respondents were stratified into 3 groups, appropriate screeners, low-value screeners, or rare-screeners, based on responses to survey questions assessing PSA screening practices. The degree of interest in electronic CDS was determined via a composite Likert score comprising relevant survey items. Results: Survey response rate was 29% (59/201) consisting of 85% MD/DO and 15% APP respondents. All clinicians surveyed were interested in CDS (P < 0.001) without significant difference between screener groups. Clinicians agreed most uniformly that CDS be evidence-based. Clinicians disagreed on whether CDS would decrease professional discretion over patient decisions. Conclusions: Primary care clinicians are interested in CDS for PSA screening regardless of their current screening practices. Prioritizing CDS features that clinicians value, such as ensuring CDS recommendations are evidence-based, may increase the likelihood of successful implementation, whereas perceived threat to autonomy may be a hinderance to utilization. (c) 2022 Elsevier Inc. All rights reserved.

Introduction: Encouraging the appropriate use of staging imaging in patients with newly diagnosed prostate cancer remains a challenge. Assessing the effects of national efforts may help guide future initiatives in curtailing low-value care. The purpose of this study was to determine the impact of the Choosing Wisely campaign on imaging utilization among men with prostate cancer. Methods: Surveillance, Epidemiology, and End Results - Medicare data were used to complete a longitudinal population-based study of men diagnosed with prostate cancer from 2007 to 2015. An interrupted time series analysis evaluated the impact of the Choosing Wisely campaign on trends of imaging utilization. Results: From 2007 to 2015 imaging utilization in low-risk patients decreased, with computed tomography (CT) usage declining from 45.0% to 34.4% (P < 0.001) and nuclear medicine bone scan (NMBS) from 27.8% to 11.7% (P < 0.001). Choosing Wisely likely contributed to an absolute reduction of 2.9% (P=0.03) in utilization of NMBS in the low-risk population. Imaging usage for all modalities increased in the high-risk population, but with 32.8% continuing to not receive guideline-supported imaging. Conclusions: In 2012, the Choosing Wisely campaign sought to decrease inappropriate staging imaging for men with low-risk prostate cancer and encourage stewardship of medical resources. Overall decreases in staging imaging trends suggest a move towards higher value care. However, this study found that the Choosing Wisely recommendations had a modest impact on utilization of NMBS, but not CT or PET scans. These results may help inform future efforts to promote guideline concordant imaging. (c) 2022 Elsevier Inc. All rights reserved.

collected. Cancer Detection Rate (CDR), clinically significant Cancer Detection Rate (csCDR), and clinically significant cancer detection rate in target only (csCDRt) were compared by technique type. Statistical analysis was performed using Chi-squared, Fisher's exact, and t-tests as appropriate. RESULTS: A total of 377 TRUSUN and 118 TPCF prostate biopsies were performed. TPCF detected more cancers of any grade (p[0.02), but there was no difference in csCDR or csCDRt. When stratified by lesion, there was no difference in cancer detection except in the PIRADS 5 group, where TPCF outperformed TRUSUN biopsy in detecting clinically significant prostate cancer (p[0.006). Further analysis of the PIRADS 5 group found no difference in baseline characteristics except for age (mean age 72.2y in TP group, 68.7y in TRUS p[0.008). CONCLUSIONS: TPCF prostate biopsy showed similar rates of csCDR and csCDRt as TRUSUN prostate biopsy. When analyzed by PI-RADS score, TPCF was found to have similar or, in the case of PIRADS 5 lesion, superior csCDRt. Subgroup analysis did not find significant group differences, aside from age, to explain this finding. This data suggests that TPCF is as effective at detecting clinically significant prostate cancer as TRUSUN.

You have accessJournal of UrologyCME1 May 2022V07-12 ROBOTIC PROSTATECTOMY WITH WIDE EXCISION FOR LOCALLY ADVANCED PROSTATE CANCER Jeffrey Vehawn, Mouneeb Choudry, Austen Slade, Jacob Ambrose, Alejandro Sanchez, and Christopher Dechet Jeffrey VehawnJeffrey Vehawn More articles by this author , Mouneeb ChoudryMouneeb Choudry More articles by this author , Austen SladeAusten Slade More articles by this author , Jacob AmbroseJacob Ambrose More articles by this author , Alejandro SanchezAlejandro Sanchez More articles by this author , and Christopher DechetChristopher Dechet More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002598.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Locally advanced prostate cancer (PCa) is considered as high-risk disease with a poor prognosis. In this setting, the European Association of Urology (EAU) and the National Compressive Cancer Network (NCC) guidelines recommend radical prostatectomy as part of multimodal therapy. In recent years several variations of the standard robotic-assisted radical prostatectomy (RARP) approach have been described. Our aim was to describe our modified RARP technique for locally advanced PCa patients and report perioperative and long-term oncological outcomes. METHODS: Our cohort was derived from a prospectively maintained institutional prostate cancer database. We identified 117 men with high-risk or locally advanced PCa treated with RARP (wide excision) and pelvic lymph node dissection between 2008-2018 by a single expert robotic surgeon at the Huntsman Cancer Institute. Only patients with a minimum of 2 years follow-up were included. Post-operative outcomes were analyzed in patients with complete follow-up data. Post-operative outcomes were measured using univariate cox-proportional hazard models, modeling for BCR survival in wide local excision patients. RESULTS: The median age of men was 66 (IQR: 60.1-69.9) with a median follow-up of 2.8 years (IQR: 2-5.53). Overall, 41% of men had a pathological T-stage of ≥pT3 and 38.5% of men had a N-stage of pN1. 81.2% and 73.5% of patients had capsular extension and capsular invasion, respectively, on preoperative MRI. 69.2% of patients had negative surgical margins. At 5-year follow-up, 64.1% of men achieved BCR-free survival. From our univariate analysis, grade group, pathologic T- and N-stage, and margin status were all independent predictors of BCR. CONCLUSIONS: In this study we presented a revised RARP approach for patients with locally advanced or high-risk prostate cancer. This technique is associated with good post-operative oncological outcomes and may assure biochemical control of the disease in complex PCa patients. Source of Funding: This research was funded by the Huntsman Cancer Institute at the University of Utah © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e662 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jeffrey Vehawn More articles by this author Mouneeb Choudry More articles by this author Austen Slade More articles by this author Jacob Ambrose More articles by this author Alejandro Sanchez More articles by this author Christopher Dechet More articles by this author Expand All Advertisement PDF downloadLoading ...