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Introduction: A functional tool to optimize patient selection for magnetic resonance imaging (MRI)-guided prostate biopsy (MRGB) is an unmet clinical need. We sought to develop a prostate cancer risk calculator (PCRC-MRI) that combines MRI and clinical characteristics to aid decision-making for MRGB in North American men. Methods: Two prospective registries containing 2354 consecutive men undergoing MRGB (September 2009 to April 2019) were analyzed. Patients were randomized into five groups, with one group randomly assigned to be the validation cohort against the other four groups as the discovery cohort. The primary outcome was detection of clinically significant prostate cancer (csPCa) defined as Gleason grade group greater than or equal to 2. Variables included age, ethnicity, digital rectal exam (DRE), prior biopsy, prostate-specific antigen (PSA), prostate volume, PSA density, and MRI score. Odds ratios were calculated from multivariate logistic regression comparing two models: one with clinical variables only (clinical) against a second combining clinical variables with MRI data (clinical+MRI). Results: csPCa was present in 942 (40%) of the 2354 men available for study. The positive and negative predictive values for csPCa in the clinical+MRI model were 57% and 89%, respectively. The area under the curve of the clinical+MRI model was superior to the clinical model in discovery (0.843 vs. 0.707, p<0.0001) and validation (0.888 vs. 0.757, p<0.0001) cohorts. Use of PCRC-MRI would have avoided approximately 16 unnecessary biopsies in every 100 men. Of all variables examined, Asian ethnicity was the most protective factor (odds ratio [OR] 0.46 [0.29–0.75]) while MRI score 5 indicated greatest risk (OR15.8 [10.5–23.9]). Conclusions: A risk calculator (PCRC-MRI), based on a large North American cohort, is shown to improve patient selection for MRGB, especially in preventing unnecessary biopsies. This tool is available at https://www.uclahealth.org/urology/prostate-cancer-risk-calculator and may help rationalize biopsy decision-making.

You have accessJournal of UrologyProstate Cancer: Localized: Active Surveillance I (PD17)1 Sep 2021PD17-02 MRI-GUIDED BIOPSY IN ACTIVE SURVEILLANCE OF PROSTATE CANCER Adam Kinnaird, Nitin Yerram, Luke O'Connor, Wayne Brisbane, Vidit Sharma, Ryan Chuang, Rajiv Jayadevan, Michael Ahdoot, Michael Daneshvar, Alan Priester, Merdin Delfin, Elizabeth Tran, Danielle Barsa, Anthony Sisk, Robert Reiter, Ely Felker, Steve Raman, Lorna Kwan, Peter Choyke, Maria Merino, Bradford Wood, Baris Turkbey, Peter Pinto, and Leonard Marks Adam KinnairdAdam Kinnaird More articles by this author , Nitin YerramNitin Yerram More articles by this author , Luke O'ConnorLuke O'Connor More articles by this author , Wayne BrisbaneWayne Brisbane More articles by this author , Vidit SharmaVidit Sharma More articles by this author , Ryan ChuangRyan Chuang More articles by this author , Rajiv JayadevanRajiv Jayadevan More articles by this author , Michael AhdootMichael Ahdoot More articles by this author , Michael DaneshvarMichael Daneshvar More articles by this author , Alan PriesterAlan Priester More articles by this author , Merdin DelfinMerdin Delfin More articles by this author , Elizabeth TranElizabeth Tran More articles by this author , Danielle BarsaDanielle Barsa More articles by this author , Anthony SiskAnthony Sisk More articles by this author , Robert ReiterRobert Reiter More articles by this author , Ely FelkerEly Felker More articles by this author , Steve RamanSteve Raman More articles by this author , Lorna KwanLorna Kwan More articles by this author , Peter ChoykePeter Choyke More articles by this author , Maria MerinoMaria Merino More articles by this author , Bradford WoodBradford Wood More articles by this author , Baris TurkbeyBaris Turkbey More articles by this author , Peter PintoPeter Pinto More articles by this author , and Leonard MarksLeonard Marks More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001999.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The promise of prostate Active Surveillance (AS) is that cancers likely to metastasize will be recognized and eliminated before cancer-related disease can ensue. The objective was to determine if prostate biopsy guided by magnetic resonance imaging (MRGB) may improve detection of high-grade cancers during AS. METHODS: From two prospective studies, a sub-cohort of 519 men with low-risk prostate cancer was selected for analysis. All men were diagnosed with Gleason Grade Group 1 (GG1) cancer and underwent confirmatory MRBG (targeted and systematic cores), followed by MRGB surveillance, typically every 12 to 24 months. The primary outcome was tumor upgrading ≥GG3. Secondary outcomes were upgrading ≥GG2 and biopsy type (targeted or systematic) identifying the upgrade. Cox proportional hazard regression was used. RESULTS: After a median follow-up of 4.8 years (IQR 3.1-6.5) after confirmatory MRGB, the primary outcome occurred in 92 men (18%). Upgrading-free probabilities at 2, 5, and 7 years were 0.95, 0.85, and 0.77, respectively. Cancer detected in a targeted core at confirmatory MRBG increased risk of tumor upgrading during AS (HR, 2.7; 95%C.I., 1.2-6.0), while cancer detected by systematic cores did not (Figure 1). In men who upgraded ≥GG3 during AS, upgrading was detected by targeted cores only in 27%, systematic cores only in 25%, and both in 47% (p=0.02). Upgrading ≥GG2 occurred in 164 men (37%). In 63 men undergoing prostatectomy, upgrading from MRGB was found in 5 (8%). CONCLUSIONS: In patients undergoing surveillance with MRI-guided and systematic biopsies, cancer detected in biopsies of MRI-visible lesions, but not systematic samples, indicated risk of subsequent upgrading. Source of Funding: This research was supported in part by R01CA218547, R01CA195505, the Intramural Research Program of the National Cancer Institute, the Center for Interventional Oncology, intramural NIH Grants Z1A CL040015, 1ZIDBC011242, and UL1TR000124 from University of California, Los Angeles Clinical and Translational Science Institute © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e284-e285 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Adam Kinnaird More articles by this author Nitin Yerram More articles by this author Luke O'Connor More articles by this author Wayne Brisbane More articles by this author Vidit Sharma More articles by this author Ryan Chuang More articles by this author Rajiv Jayadevan More articles by this author Michael Ahdoot More articles by this author Michael Daneshvar More articles by this author Alan Priester More articles by this author Merdin Delfin More articles by this author Elizabeth Tran More articles by this author Danielle Barsa More articles by this author Anthony Sisk More articles by this author Robert Reiter More articles by this author Ely Felker More articles by this author Steve Raman More articles by this author Lorna Kwan More articles by this author Peter Choyke More articles by this author Maria Merino More articles by this author Bradford Wood More articles by this author Baris Turkbey More articles by this author Peter Pinto More articles by this author Leonard Marks More articles by this author Expand All Advertisement PDF downloadLoading ...

PURPOSE:The underlying premise of prostate cancer active surveillance (AS) is that cancers likely to metastasize will be recognized and eliminated before cancer-related disease can ensue. Our study was designed to determine the prostate cancer upgrading rate when biopsy guided by magnetic resonance imaging (MRGBx) is used before entry and during AS. MATERIALS AND METHODS:The cohort included 519 men with low- or intermediate-risk prostate cancer who enrolled in prospective studies (NCT00949819 and NCT00102544) between February 2008 and February 2020. Subjects were preliminarily diagnosed with Gleason Grade Group (GG) 1 cancer; AS began when subsequent MRGBx confirmed GG1 or GG2. Participants underwent confirmatory MRGBx (targeted and systematic) followed by surveillance MRGBx approximately every 12 to 24 months. The primary outcome was tumor upgrading to ≥GG3. RESULTS:Upgrading to ≥GG3 was found in 92 men after a median followup of 4.8 years (IQR 3.1-6.5) after confirmatory MRGBx. Upgrade-free probability after 5 years was 0.85 (95% CI 0.81-0.88). Cancer detected in a magnetic resonance imaging lesion at confirmatory MRGBx increased risk of subsequent upgrading during AS (HR 2.8; 95% CI 1.3-6.0), as did presence of GG2 (HR 2.9; 95% CI 1.1-8.2) In men who upgraded ≥GG3 during AS, upgrading was detected by targeted cores only in 27%, systematic cores only in 25% and both in 47%. In 63 men undergoing prostatectomy, upgrading from MRGBx was found in only 5 (8%). CONCLUSIONS:When AS begins and follows with MRGBx (targeted and systematic), upgrading rate (≥GG3) is greater when tumor is initially present within a magnetic resonance imaging lesion or when pathology is GG2 than when these features are absent.

PURPOSE:Contemporary biopsy methods were used to determine the success rate of hemigland cryoablation as a primary treatment for prostate cancer. Previous studies, often including men at low risk, have used magnetic resonance imaging guided biopsy to a variable extent. Here, we uniformly used the new diagnostic modality to study all men, each with clinically significant cancer, at baseline and at short and intermediate-term followup. MATERIALS AND METHODS:In an open label trial (NCT03503643) 61 men with unilateral cancer (all clinically significant, ie Grade Group 2 or greater) underwent primary hemigland cryoablation. Subjects were 80% Caucasian, average age 69 years, prostate specific antigen 6.6 ng/ml and prostate volume 38 cc. Biopsy was performed using magnetic resonance imaging/ultrasound fusion prior to treatment and at the followup intervals of near-term (6 months, in 61) and intermediate-term (18 months, in 27). All utilities of fusion biopsy, ie targeting of magnetic resonance imaging visible lesions, template systematic sampling, and in followup, tracking of prior positive sites, were used throughout the study to detect clinically significant cancer, the primary end point. RESULTS:Following treatment 82% of men (50 of 61) had no biopsy detectable clinically significant prostate cancer at 6-month near-term followup and 82% of men (22 of 27) reaching the 18-month intermediate-term remained biopsy negative. Combination of the 3 sampling methods provided maximal cancer detection. During followup a new focus of cancer was found in the contralateral prostate in only 1 of 27 men. No adverse events above Clavien-Dindo grade 2 were encountered. CONCLUSIONS:Hemigland cryoablation, when rigorously evaluated by all utilities of magnetic resonance imaging guided biopsy, appears to eliminate clinically significant cancer in 82% of men, a success rate that endures for at least 18 months.

You have accessJournal of UrologyProstate Cancer: Detection & Screening IV (MP56)1 Apr 2020MP56-09 A RISK CALCULATOR INCORPORATING MRI-GUIDED BIOPSY DATA TO PREDICT CLINICALLY SIGNIFICANT PROSTATE CANCER Adam Kinnaird*, Alan Priester, Ryan Chuang, Danielle Barsa, Merdie Delfin, Anthony Sisk, Ely Felker, Lorna Kwan, and Leonard Marks Adam Kinnaird*Adam Kinnaird* More articles by this author , Alan PriesterAlan Priester More articles by this author , Ryan ChuangRyan Chuang More articles by this author , Danielle BarsaDanielle Barsa More articles by this author , Merdie DelfinMerdie Delfin More articles by this author , Anthony SiskAnthony Sisk More articles by this author , Ely FelkerEly Felker More articles by this author , Lorna KwanLorna Kwan More articles by this author , and Leonard MarksLeonard Marks More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000925.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: MRI guidance provides increased accuracy of prostate biopsy, and use of the PIRADS score helps determine cancer likelihood. However, when used alone the PIRADS score, especially in the mid-ranges, is only moderately predictive of clinically-significant prostate cancer (csPCa). Thus, we aimed to create a predictive index which combines MRI and clinical characteristics, potentially allowing a patient to rationally answer the question, “Do I Need a Biopsy?” METHODS: Subjects were all men undergoing MRI-guided biopsy to rule out csPCa at UCLA (9/09-4/19), excluding only men with previously diagnosed PCa. Mean (SD) age was 64.8 (7.7). 66% were Caucasian. Biopsy strategy combined targeted and systematic sampling (JAMA Surg online 6-12-19). csPCa was defined as Grade Group ≥2. A prediction tool was created from a logistic regression model that included age, race, family history, abnormality on rectal exam, PSA, prostate volume, PSA density, previous negative biopsy, MRI score, and longest diameter of region of interest (ROI) on MRI. Clinical characteristics were chosen a priori based on previous research. ROC curves were generated to display the relative ability of each variable to predict csPCa. RESULTS: Of the 2643 men undergoing biopsy, 1605 were eligible for the study. csPCa was detected in 683 (43%). Odds ratios of clinical and radiological variables included in the creation of the risk calculator are listed in Table 1. The overall AUC of the prediction tool (Figure 1) was superior to AUC of MRI score alone (0.874 vs. 0.792; p<0.0001). Inclusion of the MRI-visible lesion’s longest diameter into the model, regardless of MRI score, improved prediction of csPCa at MRI-guided biopsy. CONCLUSIONS: A risk calculator has been created for prediction of csPCa (AUC = 0.874), based on MRI and clinical data and confirmed by MRI-guided biopsy. The tool can help rationalize biopsy decisions, beyond other inputs currently available. Multi-site prospective testing of the tool is in progress. Source of Funding: R01CA218547, R01CA195505 © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e850-e851 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Adam Kinnaird* More articles by this author Alan Priester More articles by this author Ryan Chuang More articles by this author Danielle Barsa More articles by this author Merdie Delfin More articles by this author Anthony Sisk More articles by this author Ely Felker More articles by this author Lorna Kwan More articles by this author Leonard Marks More articles by this author Expand All Advertisement PDF downloadLoading ...

The value of multi-parametric magnetic resonance imaging in the detection of clinically-significant prostate cancer is increasingly well-established, and has been adopted in current diagnostic pathways and clinical guidelines. Concurrently, the role of conventional ultrasound-guided systematic prostate biopsy is increasingly questioned. In this brief review, we evaluate the continued value of systematic biopsy including a review of prospective studies on targeted and systemic biopsies in the same patients. We also address current limitations of multi-parametric magnetic resonance imaging of the prostate.

INTRODUCTION AND OBJECTIVE:Hemi-gland cryoablation (HGCryo) aims to eliminate clinically-significant disease (csCaP) while minimizing adverse after-effects. MRI-guided biopsy (MRGB) has been used t...

You have accessJournal of UrologyProstate Cancer: Epidemiology & Natural History II (MP64)1 Apr 2020MP64-10 MRI-GUIDED BIOPSY TO EVALUATE PROSTATE CANCER SEVERITY IN AFRICAN-AMERICAN MEN Jorge Ballon, Ryan Chuang*, Adam Kinnaird, Rajiv Jayadevan, Steve Zhou, Danielle Barsa, Lorna Kwan, and Leonard Marks Jorge BallonJorge Ballon More articles by this author , Ryan Chuang*Ryan Chuang* More articles by this author , Adam KinnairdAdam Kinnaird More articles by this author , Rajiv JayadevanRajiv Jayadevan More articles by this author , Steve ZhouSteve Zhou More articles by this author , Danielle BarsaDanielle Barsa More articles by this author , Lorna KwanLorna Kwan More articles by this author , and Leonard MarksLeonard Marks More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000939.010AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The mortality rate of prostate cancer has long been considered higher among African-American (AA) men. Most diagnostic information has been obtained by ultrasound-guided prostate biopsy. To study the possibility that MRI-guided biopsy might provide histologic clarification of the apparent disparity, we studied use of the new modality in AA and other men at three time points in prostate cancer care: 1) at diagnosis, 2) during active surveillance, and 3) at final pathology after radical prostatectomy. METHODS: Subjects were 1002 consecutive men who underwent MRI-guided biopsy combining both systematic and lesion-targeted sampling between 2009-2018. Pathologic upgrading was defined as an increase in Gleason Grade group (GG) at structured follow-up biopsy during active surveillance (AS) or at whole-mount sectioning (prostatectomy). Statistical significance (p<0.05) was assessed using the Mann-Whitney-U test for continuous data, the Chi-square test (or Fisher's exact if necessary) for categorical data, and the Kaplan-Meier estimator to calculate progression-free survival probabilities. RESULTS: AA men (N=57) had higher rates of prostate cancer at diagnostic biopsy than other men (N=945) (79% AA vs 66% others; p=0.05). GG was similar in both groups: AA vs Other: GG <2, 25% vs 20%; GG3, 12% vs 10%; GG >4, 9% vs 9% (p=0.76). Upgrading at prostatectomy was found in 3/29 (10%) AA men and 32/262 (12%) other men (p=0.45). Among low-risk men in AS, Gleason upgrading during a median follow up of 4 years was found in 5/16 (31%) AA men and 93/274 (34%) other men (p=0.80). CONCLUSIONS: In our cohort studied with contemporary MRI-guided biopsy, aggressiveness of prostate cancer (judged histologically) was the same for both groups at initial biopsy, at prostatectomy, and during AS. Unlike similar investigations that used only ultrasound-guided biopsy, a method little changed from the 1980s, we found with the improved technology, no significant histologic differences between AA and other men at three important points in prostate cancer care. This suggests that differences previously observe were not based on physiology alone. Furthermore, these data indicate that after MRI-guided biopsy, entry into AS programs for AA men with prostate cancer is appropriate when low-risk pathology is determined using MRI-guided biopsy. Source of Funding: R01CA218547, R01CA195505 © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e966-e967 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jorge Ballon More articles by this author Ryan Chuang* More articles by this author Adam Kinnaird More articles by this author Rajiv Jayadevan More articles by this author Steve Zhou More articles by this author Danielle Barsa More articles by this author Lorna Kwan More articles by this author Leonard Marks More articles by this author Expand All Advertisement PDF downloadLoading ...

Purpose: Magnetic resonance imaging guided biopsy which reveals no cancer may impart reassurance beyond that offered by ultrasound guided biopsy. However, followup of men after a negative magnetic resonance imaging guided biopsy has been mostly by prostate specific antigen testing and reports of followup tissue confirmation are few. We investigated the incidence of clinically significant prostate cancer in such men who, because of persistent cancer suspicion, subsequently underwent a repeat magnetic resonance imaging guided biopsy. Materials and Methods: Subjects were all men with a negative initial magnetic resonance imaging guided biopsy who underwent at least 1 further magnetic resonance imaging guided biopsy due to continued clinical suspicion of clinically significant prostate cancer (September 2009 to July 2019). Biopsies were magnetic resonance imaging-ultrasound fusion with targeted and systematic cores. Regions of interest from initial magnetic resonance imaging and any new regions of interest at followup magnetic resonance imaging guided biopsy were targeted. The primary end point was detection of clinically significant prostate cancer (Gleason Grade Group 2 or greater). Results: Of 2,716 men 733 had a negative initial magnetic resonance imaging guided biopsy. Study subjects were 73/733 who underwent followup magnetic resonance imaging guided biopsy. Median (IQR) age and prostate specific antigen density were 64 years (59-67) and 0.12 ng/ml/cc (0.08-0.17), respectively. Baseline PI-RADS (R) scores were 3 or greater in 74%. At followup magnetic resonance imaging guided biopsy (median 2.4 years, IQR 1.3e3.6), 17/73 (23%) were diagnosed with clinically significant prostate cancer. When followup magnetic resonance imaging revealed a lesion (PI-RADS 3 or greater), clinically significant prostate cancer was found in 17/53 (32%). When followup magnetic resonance imaging was negative (PI-RADS less than 3), cancer was not found (0/ 20) (p <0.01). Overall 54% of men with PI-RADS 5 at followup magnetic resonance imaging guided biopsy were found to have clinically significant prostate cancer. Conclusions: Men with negative magnetic resonance imaging following an initial negative magnetic resonance imaging guided biopsy are unlikely to harbor clinically significant prostate cancer and may avoid repeat biopsy. However, when lesions are seen on followup magnetic resonance imaging, repeat magnetic resonance imaging guided biopsy is warranted.

A 35-year-old female presented to the emergency department with fevers and flank pain and was found on computed tomography to have a retained ureteral stent that was placed during emergent ureteral repair eight years prior. The stent was only faintly visible on computed tomography and was completely radiolucent on fluoroscopy. We believe that the stent's radiopaque coating degraded and was lost after years of exposure to urine. This case suggests that a stent may become undetectable on standard imaging if left in place for a long enough period of time.

INTRODUCTION:Through PPACA (Patient Protection and Affordable Care Act) many adults have or will gain health insurance via Medicaid expansion. To understand how this policy change may potentially impact patients with kidney cancer we examined the relationship between insurance status and cancer related outcomes.METHODS:Using SEER (Surveillance, Epidemiology and End Results) data we identified 18,632 patients 26 to 64 years old with kidney cancer from 2007 to 2009. For each patient we classified insurance status as no insurance, Medicaid or private insurance. After adjusting for patient and county characteristics we measured the association of insurance status with cancer stage, treatment and 1-year mortality using multinomial logistic regression with clustering or generalized estimating equations as appropriate.RESULTS:In our study cohort 937 (5.0%) and 2,027 patients (10.9%) had no insurance and Medicaid, respectively. These patients were more likely to be younger, nonwhite, unmarried and residing in areas with lower income, education or employment (p <0.001). On adjusted analyses uninsured and Medicaid patients more often presented with advanced disease (21.3% vs 19.6% vs 11.0%) but less frequently received treatment (86.2% vs 87.9% vs 93.4%, each p <0.001) compared with privately insured patients. These adults also died of kidney cancer more often (13.6% vs 12.5% vs 6.4%, p <0.001) likely due to differences in stage and receipt of cancer directed therapy.CONCLUSIONS:Uninsured and Medicaid patients suffer disproportionately from kidney cancer with equal magnitude. Given the reliance on Medicaid, even as insurance coverage expands differences in outcomes will likely persist, underscoring the need for additional efforts that address disparities in kidney cancer care.

You have accessJournal of UrologyMale Voiding/Sexual Dysfunction/BPH/ Incontinence/Infection/Infertility1 Apr 2016V3-11 SURGICAL MANAGEMENT OF EJACULATORY DUCT OBSTRUCTION DUE TO PROSTATIC UTRICULAR CYST Phil Bach, Filipe Tenorio Lira Neto, Ryan Chuang, Bobby Najari, Richard Lee, Philip Li, and Marc Goldstein Phil BachPhil Bach More articles by this author , Filipe Tenorio Lira NetoFilipe Tenorio Lira Neto More articles by this author , Ryan ChuangRyan Chuang More articles by this author , Bobby NajariBobby Najari More articles by this author , Richard LeeRichard Lee More articles by this author , Philip LiPhilip Li More articles by this author , and Marc GoldsteinMarc Goldstein More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1531AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Azoospermia is present in 10-15% of infertile men and can be divided into two broad categories: obstructive azoospermia (OA) and non-obstructive azoospermia. OA accounts for approximately 40% of azoospermia cases and can be caused by a blockage anywhere along the male reproductive tract. 5% of OA cases are secondary to ejaculatory duct obstruction, which may be caused by a variety of congenital or acquired etiologies. The mainstay of management for ejaculatory duct obstruction is transurethral resection of the ejaculatory ducts (TURED). We present the case and surgical management of a man with primary infertility secondary to ejaculatory duct obstruction caused by a prostatic utricular cyst. METHODS A 38 year old man with primary infertility presented with low semen volume, severe oligospermia and highly elevated sperm DNA fragmentation. He had an unremarkable physical exam, normal hormone levels, and a midline utricular cyst on both transrectal ultrasound and MRI, suggestive of ejaculatory duct obstruction. In the operating room, we successfully retrieved abundant highly motile sperm from both testes and vasa deferens. Next, to assess patency, we injected indigo carmine into the right vasotomy site and noted the dye coming out of the left vasotomy site, suggesting that both vasa deferens emptied into a common, obstructed cavity. A vasogram with water soluble contrast subsequently revealed bilaterally patent vasa deferens emptying into an obstructing midline utricular cyst. A TURED was carefully performed using a 24-Fr resectoscope while indigo carmine was instilled into both vasa deferens. Once inside the cyst, both ejaculatory ducts were visualized and a number of small stones were flushed out. A Foley catheter was placed for 24 hours and the patient instructed to ejaculate frequently to maintain patency of the freshly resected cyst. RESULTS Following the resection, indigo carmine could be seen flowing freely from a widely patent outflow tract. The patient tolerated the procedure well and was discharged home without complications. The sperm retrieved from the testes and vasa deferens had significantly lower DNA fragmentation than the ejaculated sperm and is currently being used for in vitro fertilization. Results from a follow-up semen analysis are pending. CONCLUSIONS While uncommon, ejaculatory duct obstruction due to midline utricular cyst is highly amenable to surgical management with TURED. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e470 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Phil Bach More articles by this author Filipe Tenorio Lira Neto More articles by this author Ryan Chuang More articles by this author Bobby Najari More articles by this author Richard Lee More articles by this author Philip Li More articles by this author Marc Goldstein More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Introduction: Postprostatectomy incontinence significantly impairs quality of life. Although bladder neck intussusception has been reported to accelerate urinary recovery after open radical retropubic prostatectomy, its adaption to robotic surgery has not been assessed. Accordingly, we describe our technique and compare outcomes between men treated with and without bladder neck intussusception during robot-assisted laparoscopic prostatectomy.Materials and methods: We performed a comparative trial of 48 men undergoing robot-assisted laparoscopic prostatectomy alternating between bladder neck intussusception (n = 24) and nonintussusception (n = 24). Intussusception was completed using 3-0 polyglycolic acid horizontal mattress sutures anterior and posterior to the bladder neck. We assessed baseline characteristics and clinicopathologic outcomes. Adjusting for age, body mass index, race, and D'Amico risk classification, we prospectively compared urinary function at 2 days, 2 weeks, 2 months, and last follow-up using the urinary domain of the Expanded Prostate Cancer Index Short Form.Results: Baseline patient characteristics and clinicopathologic outcomes were similar between treatment groups (P > 0.05). Median catheter duration (8 vs. 8 d, P = 0.125) and rates of major postoperative complications (4.2% vs. 4.2%, P = 1.000) did not differ. In adjusted analyses, Expanded Prostate Cancer Index Short Form urinary scores were significantly higher for the intussusception arm at 2 weeks (65.4 vs. 46.6, P = 0.019) before converging at 2 months (69.1 vs. 68.3, P = 0.929) after catheter removal and at last follow-up (median = 7 mo, 80.5 vs. 77.0; P = 0.665).Conclusions: Bladder neck intussusception during robot-assisted laparoscopic prostatectomy is feasible and safe. Although the long-term effects appear limited, intussusception may improve urinary function during the early recovery period. (C) 2016 Published by Elsevier Inc.

INTRODUCTION:While improving patient outcomes and controlling costs have become primary pursuits in health care, priority areas for value creation remain unclear. In urology operative morbidity serves as a major barrier to high value care. To guide improvement efforts we assessed the prevalence and cost of inpatient complications among patients undergoing major surgery for urological cancer.METHODS:Using the Nationwide Inpatient Sample from 2009 to 2011 we identified hospital admissions for cancer related prostatectomy, nephrectomy and cystectomy among adults age 18 years or older. We then measured the occurrence of inpatient complications, medical and surgical, and used multivariable, mixed effect models to estimate the associated marginal cost.RESULTS:Among weighted samples of 229,743 prostatectomies, 111,683 nephrectomies and 31,213 cystectomies, inpatient complications occurred in 9.4% (95% CI 8.6-10.2), 32.0% (95% CI 30.7-33.4) and 57.7% (95% CI 54.7-60.6) of hospital admissions, respectively. For these respective samples an adverse event added $4,947 (95% CI 4,523-5,454), $6,782 (95% CI 6,336-7,293) and $10,756 (95% CI 9,999-11,759) to the cost of inpatient care. While surgical events occurred most frequently, medical complications generated $1,699 (95% CI 994-2,423), $2,052 (95% CI 1,545-2,662) and $4,852 (95% CI 3,519-6,531) more in expense per episode for prostate, kidney and bladder cancer cases, respectively.CONCLUSIONS:Many patients undergoing major surgery for urological cancer experience a complication, adding substantially to health care costs. As urologists seek to generate value in urological cancer care, the prevention and management of complications, especially medically driven events, represent an immediate opportunity for quality improvement and cost savings.