Introduction Adjuvant treatment of stage II nonseminomatous germ cell tumors (NSGCT) following retroperitoneal lymph node dissection (RPLND) requires careful consideration of the risks and benefits of adjuvant versus salvage systemic therapy. While early adjuvant chemotherapy improves recurrence-free survival, its impact on overall survival compared to treatment in the salvage setting is disputed. Methods Patients with tumor marker-negative clinical stage II NSGCT (TANYN1-3M0S0) were identified within the NCDB testis cancer dataset from 2004 to 2021. Inclusion criteria were patients who underwent RPLND, had confirmed nodal disease on final pathological staging, and received postoperative chemotherapy. Mean time to chemotherapy by pathological nodal stage was compared using an analysis of variance (ANOVA) with post-hoc pairwise t-tests. A multivariable Cox proportional hazards regression model, incorporating patient comorbidities, tumor characteristics, and an interaction term for chemotherapy receipt at any time, was used to assess overall survival stratified by pathologic nodal stage. Results A total of 186 patients with marker-negative clinical stage II disease who underwent RPLND with pathologically confirmed nodal disease were identified. Patient demographics, presented in Table 1, show nominal differences in patient characteristics and general concordance between clinical and pathological nodal staging. Figure 1A indicates a trend towards earlier chemotherapy for patients with pN3 disease (median 7.5 weeks) compared to those with pN1 (11.2 weeks) and pN2 disease (10.2 weeks), although this did not reach statistical significance (p=0.056). With a median follow-up of 86 months, mortality was rare, occurring in only 7 patients (3 pN1, 2 pN2, 2 pN3). The 10-year overall survival curves showed no significant difference (Figure 1B), and early chemotherapy timing did not predict survival (HR 0.99, 95% CI 0.87-1.135) when accounting for chemotherapy receipt at any time. Conclusions The timing of chemotherapy does not appear to impact overall survival in patients when controlling for chemotherapy receipt at any time. Therefore, a delay in administration of systemic therapy following RPLND, in this patient population at high risk for developing chemotherapy-associated adverse effects, should be considered. Further research is needed to determine the impact on specific high-risk populations, such as patients with pN3 disease, who were underrepresented in this study.

Introduction Adjuvant chemotherapy is recommended following retroperitoneal lymph node dissection (RPLND) for non-seminomatous germ cell tumors (NSGCT) based on pathologic nodal involvement. However, the benefit of adjuvant versus salvage treatment is disputed based on concerns that upfront therapy potentially overtreats many patients with pathologic stage II disease. Here, we investigate overall survival in clinical stage I NSGCT patients upstaged to node-positive disease at RPLND, comparing outcomes between those who received adjuvant chemotherapy and those who did not. Methods Patients with clinical stage I NSGCT (TANYN0M0S0) were identified within the NCDB testis cancer dataset from 2004 to 2021. Descriptive statistics were used to compare demographics and clinical characteristics between patients undergoing surgery versus surveillance. Overall survival was analyzed using Cox proportional hazards regression, focusing on differences in survival outcomes among patients upstaged at RPLND based on chemotherapy receipt. Results Out of 3610 men with clinical stage I NSGCT, 615 (17%) underwent RPLND. The demographic and clinical characteristics of patients, stratified by management strategy, are summarized in Table 1. A significantly higher frequency of lymphovascular invasion in the orchiectomy specimen was observed in patients undergoing RPLND (p<0.05). Among those upstaged at RPLND (n=158, 26%), 87 (55%) received adjuvant chemotherapy. Ten-year survival rates were comparable between men who received chemotherapy and those managed with surveillance following RPLND (Figure 1). Notably, pN3 status was associated with a hazard ratio for death of 3.3, though this did not reach statistical significance (p=0.07). Conclusions In this large multi-institutional cohort, clinical stage I NSGCT patients upstaged to pN1-3 disease showed equivalent 10-year overall survival regardless of adjuvant chemotherapy receipt. Further research is necessary to identify patients who may benefit from adjuvant therapy versus those who could safely forgo it, particularly considering cases with pN3 status.

Introduction Cystic renal cell carcinoma (cRCC) is a rare subset of renal cell carcinoma (RCC), accounting for approximately 2.5-5% of all RCC cases. While cystic renal masses often carry benign or low-grade malignancies, large cystic lesions with central necrosis can often mask as more indolent biology. Indeed, preoperative differentiation of cRCC from more aggressive variants based on modern imaging remains a clinical challenge. Methods A single institution database of 4,340 kidney lesions treated with either active surveillance or intervention between 2000-2020 was queried for radiographic cystic renal masses ≥ 7 cm. The association between CT radiographic tumor characteristics and high-grade pathology was evaluated. Similarly, we looked at radiographic features and their associations with overall survival (OS) and recurrence free survival (RFS). Radiographic features considered were peripheral thickening, fluid heterogeneity, calcifications, septations, and density mass >20 HU. Results We identified 387 radiographically confirmed cystic lesions in 367 patients. Fifty lesions in 49 patients were noted to be ≥ 7 cm. Of the lesions that underwent intervention (72%, n=36), 33.3% (n=12) were benign and 66.7% (n=24) were malignant. Fluid heterogeneity and cystic density >20 HU were associated with malignancy (P<0.05). High grade pathology was demonstrated in 29.7% (n=11) of malignant lesions and were significantly associated with fluid heterogeneity (P<0.05) (Table 1). Regarding overall survival, 30.6% (n=15) died during the follow up period, with 12.2% (n=6) experiencing cancer-related mortality. Recurrence occurred in 8.2% (n = 4) of the patients, all of which had density > 20 HU. Of the radiographic features examined, density > 20 HU showed a statistically significant difference in terms of OS and RFS (Figure 1). Conclusions Cystic indolent RCC imposters such as solid renal lesions with central necrosis highlight the discordance between radiographic and pathologic characterization. In large cystic lesions (≥ 7 cm), fluid heterogeneity and density > 20HU can serve as a predictor of adverse pathology to appropriately identify patients for intervention. Future work is needed to prevent both over and under treatment of these cystic renal masses.

Adrenal surgery has evolved significantly over the years, with advancements in surgical techniques and perioperative management enhancing patient outcomes. Understanding the intricate anatomy and surgical landmarks of the adrenal glands is essential for safe and effective surgery, particularly in avoiding complications. The choice between open, laparoscopic, and robotic adrenalectomy depends on various factors, including tumor characteristics, patient comorbidities, and surgeon expertise. Each modality offers distinct advantages, while open approaches are preferred for large tumors suspected to be ACC and minimally invasive approaches remain the standard for most other adrenal lesions.3 Perioperative management, particularly in patients with hormone-secreting tumors, is critical to minimizing complications and ensuring rapid recovery.3 Proper preoperative optimization, intraoperative vigilance, and postoperative care are key components in achieving favorable outcomes.75 Despite the advancements in surgical technology, complications such as bleeding, injury to adjacent organs, and adrenal insufficiency must remain top of mind and require careful management.23,75 Shifts in adrenalectomy toward high-volume surgical centers have been associated with improved perioperative morbidity and mortality; however, they may also have opened the door for inequities in access to care.22 As the field evolves, future advancements may include the refinement of techniques such as single-site adrenalectomy, improved imaging and diagnostic tools, and more personalized approaches to adrenal surgery. The ongoing development of less invasive procedures and optimized perioperative protocols offers great potential for further enhancing outcomes in adrenal pathologies. A multidisciplinary approach, involving collaboration among urologists, endocrinologists, anesthesiologists, and other specialists, is essential for achieving the best results in adrenal surgery. By continuing to innovate and adhere to best practices, adrenal surgery will continue to offer life-saving benefits to patients with adrenal gland disorders.

The incidence of low serum testosterone has been increasing in men of all ages across a period which also corresponds to an increasing prevalence of kidney stones. Currently, the relationship between testosterone and kidney stones is unclear. Using the TriNetX Research Network, we performed a retrospective cohort study to evaluate the risk of developing an initial kidney stone in men based on their total testosterone level. Men aged >= 18 were divided into a low testosterone (<300 ng/dL) and normal testosterone (>= 300 ng/dL) cohort. Men were excluded if they had a history of a kidney stone encounter diagnosis before testosterone measurement and a history of testosterone therapy prescription at any point. Propensity score matching was employed with an absolute standardized mean difference of less than 0.1 used as an indicator of successful matching. Our main outcome of interest was risk of developing an initial kidney stone in men aged >= 18 and within age-based subgroups. In men 18 and older, low testosterone was associated with a higher risk of one or more kidney stone encounter diagnoses (HR 1.12, 95% CI [1.09-1.15]). When stratified by age, no significant association between low testosterone and kidney stone encounter diagnoses was seen in men aged 18-24 (HR 1.09, 95% CI [0.85-1.39]). The highest risk was observed in men with low testosterone aged 34-44 (HR 1.29, 95% CI [1.17-1.38]). In this study, low serum testosterone was associated with an increased risk of initial kidney stone diagnosis in adult men without testosterone therapy prescriptions at any point in their life. Stratifying by age, the increased risk appears to begin in men aged 25, with the highest observed risk in men aged 33-44.

Specific issues affect the treatment of urological cancer and survivorship in gay and bisexual men. Creating an accepting and inclusive environment for these patients in our men’s health clinics can help to improve the quality of life for men from sexual minority groups undergoing cancer treatment.

We read the article by Thompson and colleagues 1 Thompson R.H. Lohse C.M. Leibovich B.C. et al. Predictors of Excellent Urology Residents at the Time of the Urology Match. Urol. 2023 Nov 7; Google Scholar with great interest given the competitive nature of urology residency and desire of all programs to match high quality candidates who will achieve success as residents and, later, independent physicians. The timing is quite apropos with resident interviews currently in full swing. The manuscript utilized a logistic regression model trained to predict resident excellence, as based on scoring from the current and prior program directors. Based on their multivariable model, no negative interview comments and honors in all core clinical clerkships were independently associated with an excellent score Surprisingly, doing an away rotation and being ranked in the top 5 on the match list were not predictive of excellence. We applaud the authors for attempting to hone the recruitment process but have concerns about meaningful external implementation (contrary to the author's suggestion in the discussion section) and caution other programs from following with a similar approach. Reply by AuthorsUrologyPreviewTo provide a numerical assessment of resident quality, the program director (PD) and former PD independently rated graduates on a scale of 1 to 10, with the overarching objective of quantifying the degree to which the PD would want a similar resident in the future. The PD and former PD weighed the listed surgical skills, communication skills, judgement, and clinical skills, but also took into account other features including empathy, grit, perseverance, and humility that contributed to the global score. Full-Text PDF

Hypogonadism is understudied in men requiring solid organ transplants, particularly among lung transplant recipients. Improvement in serum testosterone levels has been reported in kidney and liver transplantation. Using the TriNetX Research Network, we performed a retrospective cohort study to evaluate the incidence of peri-transplant hypogonadism and the natural course of serum testosterone following successful lung transplantation. Men aged ≥ 18 with a lung transplant and total testosterone drawn within one year pre- and post-transplant were included. Men with receipt of testosterone therapy were excluded. A low testosterone (<300 ng/dL) and normal testosterone (≥300 ng/dL) cohort was created before employing descriptive and analytic statistics to investigate the incidence of peri-transplant hypogonadism and the change in serum testosterone levels following lung transplantation. In our entire cohort, lung transplantation was not associated with a significant increase in post-transplant serum testosterone (329.86 ± 162.56 ng/dL pre-transplant and 355.13 ± 216.11 ng/dL post-transplant, p = 0.483). The number of men with low testosterone decreased by 9.8% following lung transplantation but was not significant, p = 0.404. In this pilot study, no significant change in the number of hypogonadal men nor serum testosterone levels was observed among men undergoing lung transplantation.

Objective The aim of this study was to quantify radiomic changes in prostate cancer (PCa) progression on serial MRI among patients on active surveillance (AS) and evaluate their association with pathologic progression on biopsy. Methods This retrospective study comprised N = 121 biopsy-proven PCa patients on AS at a single institution, of whom N = 50 at baseline conformed to the inclusion criteria. ISUP Gleason Grade Groups (GGG) were obtained from 12-core TRUS-guided systematic biopsies at baseline and follow-up. A biopsy upgrade (AS+) was defined as an increase in GGG (or in number of positive cores) and no upgrade (AS−) was defined when GGG remained the same during a median period of 18 months. Of N = 50 patients at baseline, N = 30 had MRI scans available at follow-up (median interval = 18 months) and were included for delta radiomic analysis. A total of 252 radiomic features were extracted from the PCa region of interest identified by board-certified radiologists on 3T bi-parametric MRI [T2-weighted (T2W) and apparent diffusion coefficient (ADC)]. Delta radiomic features were computed as the difference of radiomic feature between baseline and follow-up scans. The association of AS+ with age, prostate-specific antigen (PSA), Prostate Imaging Reporting and Data System (PIRADS v2.1) score, and tumor size was evaluated at baseline and follow-up. Various prediction models were built using random forest (RF) classifier within a threefold cross-validation framework leveraging baseline radiomics ( C br ), baseline radiomics + baseline clinical ( C brbcl ), delta radiomics ( C Δr ), delta radiomics + baseline clinical ( C Δrbcl ), and delta radiomics + delta clinical ( C ΔrΔcl ). Results An AUC of 0.64 ± 0.09 was obtained for C br , which increased to 0.70 ± 0.18 with the integration of clinical variables ( C brbcl ). C Δr yielded an AUC of 0.74 ± 0.15. Integrating delta radiomics with baseline clinical variables yielded an AUC of 0.77 ± 0.23. C ΔrΔcl resulted in the best AUC of 0.84 ± 0.20 ( p < 0.05) among all combinations. Conclusion Our preliminary findings suggest that delta radiomics were more strongly associated with upgrade events compared to PIRADS and other clinical variables. Delta radiomics on serial MRI in combination with changes in clinical variables (PSA and tumor volume) between baseline and follow-up showed the strongest association with biopsy upgrade in PCa patients on AS. Further independent multi-site validation of these preliminary findings is warranted.

, IPPL was found to be associated with urinary incontinence at 3 months (OR [ 1.09 [1.01-1.29] p [ 0.049). CONCLUSIONS: Preoperative measurement of IPPL is asso- ciated with postoperative urinary incontinence after HoLEP. Further anatomic features such as MUL, MUA, and LAT, which have been associated with incontinence after robotic prostatectomy, do not have an effect on postoperative incontinence after HoLEP in our study, suggesting such anatomical variations may play less of a role in post-operative incontinence. Further studies are needed to assess the impact of anatomical dimensions on surgical outcomes after HoLEP.

INTRODUCTION:Medicare eligibility at 65 has been associated with increased diagnosis and survival for certain cancers due to greater health care utilization. We aim to assess for a similar "Medicare effect" for bladder and kidney cancers, which has not been previously established.METHODS:Patients diagnosed with bladder or kidney cancer from 2000-2018 at ages 60-69 years were identified with the Surveillance, Epidemiology, and End Results database. We used age-over-age percent change calculations to characterize trends in cancer diagnoses focusing on patients aged 65. Multivariable Cox models were used to compare cancer-specific mortality across ages at diagnosis.RESULTS:We identified 63,960 patients diagnosed with bladder cancer and 52,316 diagnosed with kidney cancer. Age-over-age change in diagnosis was highest for patients aged 65 compared to all other ages for both cancers (P < .01 for both). Stratified by stage, patients aged 65 had a higher age-over-age change than those aged 61-64 or 66-69 for in situ (P = .01, P < .01, respectively), localized (P = .03, P = .01), and regional (P = .02, P = .02) bladder cancer and localized (P = .01, P = .01) kidney cancer. Bladder cancer patients aged 65 had lower cancer-specific mortality than patients aged 66 (HR = 1.17, P = .01) and 69 (HR = 1.18, P = .01), while kidney cancer patients aged 65 had lower mortality than patients aged 64 (HR = 1.18, P < .01) and 66-69.CONCLUSIONS:The age of 65, marking the onset of Medicare eligibility, is associated with more diagnoses of bladder and kidney cancer. Patients diagnosed at age 65 demonstrate decreased bladder and kidney cancer-specific mortality.

BACKGROUND Accurate delineations of regions of interest (ROIs) on multi-parametric magnetic resonance imaging (mpMRI) are crucial for development of automated, machine learning-based prostate cancer (PCa) detection and segmentation models. However, manual ROI delineations are labor-intensive and susceptible to inter-reader variability. Histopathology images from radical prostatectomy (RP) represent the "gold standard" in terms of the delineation of disease extents, for example, PCa, prostatitis, and benign prostatic hyperplasia (BPH). Co-registering digitized histopathology images onto pre-operative mpMRI enables automated mapping of the ground truth disease extents onto mpMRI, thus enabling the development of machine learning tools for PCa detection and risk stratification. Still, MRI-histopathology co-registration is challenging due to various artifacts and large deformation between in vivo MRI and ex vivo whole-mount histopathology images (WMHs). Furthermore, the artifacts on WMHs, such as tissue loss, may introduce unrealistic deformation during co-registration. PURPOSE This study presents a new registration pipeline, MSERgSDM, a multi-scale feature-based registration (MSERg) with a statistical deformation (SDM) constraint, which aims to improve accuracy of MRI-histopathology co-registration. METHODS In this study, we collected 85 pairs of MRI and WMHs from 48 patients across three cohorts. Cohort 1 (D1 ), comprised of a unique set of 3D printed mold data from six patients, facilitated the generation of ground truth deformations between ex vivo WMHs and in vivo MRI. The other two clinically acquired cohorts (D2 and D3 ) included 42 patients. Affine and nonrigid registrations were employed to minimize the deformation between ex vivo WMH and ex vivo T2-weighted MRI (T2WI) in D1 . Subsequently, ground truth deformation between in vivo T2WI and ex vivo WMH was approximated as the deformation between in vivo T2WI and ex vivo T2WI. In D2 and D3 , the prostate anatomical annotations, for example, tumor and urethra, were made by a pathologist and a radiologist in collaboration. These annotations included ROI boundary contours and landmark points. Before applying the registration, manual corrections were made for flipping and rotation of WMHs. MSERgSDM comprises two main components: (1) multi-scale representation construction, and (2) SDM construction. For the SDM construction, we collected N = 200 reasonable deformation fields generated using MSERg, verified through visual inspection. Three additional methods, including intensity-based registration, ProsRegNet, and MSERg, were also employed for comparison against MSERgSDM. RESULTS Our results suggest that MSERgSDM performed comparably to the ground truth (p > 0.05). Additionally, MSERgSDM (ROI Dice ratio = 0.61, landmark distance = 3.26 mm) exhibited significant improvement over MSERg (ROI Dice ratio = 0.59, landmark distance = 3.69 mm) and ProsRegNet (ROI Dice ratio = 0.56, landmark distance = 4.00 mm) in local alignment. CONCLUSIONS This study presents a novel registration method, MSERgSDM, for mapping ex vivo WMH onto in vivo prostate MRI. Our preliminary results demonstrate that MSERgSDM can serve as a valuable tool to map ground truth disease annotations from histopathology images onto MRI, thereby assisting in the development of machine learning models for PCa detection on MRI.