Brian Dinerman

Indications, Utilization and Complications Following Prostate Biopsy: New York State Analysis

Purpose: Uptake of active surveillance and changes in prostate cancer care may affect the utilization of and complications following prostate needle biopsy. We characterized recent trends and risk factors for prostate needle biopsy complications using a statewide, all‐payer cohort. Materials and Methods: We used SPARCS (New York Statewide Planning and Research Cooperative System) to identify prostate needle biopsies performed between 2011 and 2014 via the transrectal and the transperineal approach (9,472 and 421 patients, respectively). We characterized trends in utilization and complications using Poisson regression and the Cochrane‐Armitage test. We applied logistic regression to examine predictors of complications within 30 days of prostate needle biopsy. Results: Ambulatory use of prostate needle biopsy decreased with time (p <0.01). The most common indication for prostate needle biopsy was elevated prostate specific antigen in 53.2% of patients, followed by active surveillance for cancer in 26.7%, abnormal digital rectal examination in 2.6% and atypia in 1.6%. The prostate needle biopsy associated infection rate increased from 2.6% to 3.5% during the study period (p = 0.02). Among the 777 repeat prostate needle biopsies, the complication rate was comparable to that of initial prostate needle biopsy. Preprocedural rectal swab was done in less than 1% of prostate needle biopsies. On multivariable analysis, patient race, procedure year, diabetes (OR 1.92, 95% CI 1.29–2.86, p <0.01), transrectal approach (OR 3.48, 95% CI 1.27–9.54, p = 0.02) and recent hospitalization (OR 2.03, 95% CI 1.43–2.89, p <0.01) were significantly associated with infection. The median total charge for infectious complications was

Robotic-Assisted Abdomino-perineal Vesicourethral Anastomotic Reconstruction for 4.5 Centimeter Post-prostatectomy Stricture

4,129 (IQR 711–19,185). Conclusions: Across New York State, infectious complications after prostate needle biopsy have increased over time. With higher complications using the transrectal approach and minimal utilization of targeted antibiotic prophylaxis, further efforts should focus on the evaluation and implementation of these strategies to reduce post‐prostate needle biopsy complications nationally.

National Trends and Characteristics of Success in the Urology Match

We report surgical management of a disrupted radical prostatectomy vesicourethral anastomosis after bleeding from undiagnosed hemophilia that required re-exploration, pudendal artery embolization, and urinary diversion with nephrostomy and surgical drains. After referral, the 4.5 cm vesicourethral anastomotic defect was reconstructed with a robotic-assisted abdomino-perineal approach. Intra-abdominal robotic-assisted mobilization of the bladder and perineal mobilization of the urethra permitted a tension-free vesicourethral anastomosis while avoiding a pubectomy. Side docking of the Da Vinci Xi robot allows for simultaneous access to the perineum during pelvic minimally invasive surgery, enabling a novel approach to complex bladder neck reconstruction.

Intraductal Carcinoma of the Prostate: A Risk for Rapid Recurrence

Introduction We examined temporal trends in urology residency applicant statistics and characteristics through time. Methods Match statistics during 2006 to 2016 were obtained from the American Urological Association and examined through time. Additionally applicant self‐reported data were obtained from Urologymatch.com for those successfully matching in urology during the application cycles from 2014 to 2016. Variables including United States Medical Licensing Examination® Step 1 score, number of urology subinternships, research productivity, Alpha Omega Alpha Honor Medical Society status and application specific characteristics were trended through time. Univariable linear and logistic regression was used to determine statistical significance of trends. Results A total of 4,262 applicants entered the urology match between 2006 and 2016. The number of applicants increased by 19.1% yearly and the number of positions increased by 25.1% yearly during the study period. Of the applicants 2,934 (68.8%) successfully matched, with an annual match rate ranging from 60.9% to 79.1%. Of 874 applicants matched successfully between 2014 and 2016, 417 (47.7%) self‐reported complete match data. During the study period the mean ± SD number of programs applied to by matched applicants increased from 60.0 ± 18.2 to 65.2 ± 19.3 (p = 0.037). Mean ± SD number of subinternships completed increased from 2.6 ± 0.7 to 2.8 ± 0.6 (p = 0.004). Conclusions Urology has remained a highly competitive specialty with a competitive match rate and increasing number of applicants. These data may guide future applicants in achieving desired professional goals.

Population-based study of the incidence and survival for intraductal carcinoma of the prostate

Intraductal carcinoma of the prostate (IDC-P), recently defined by the World Health Organization in 2016, is a distinct histologic entity associated with an aggressive clinical course, including increased risk of biochemical recurrence, metastasis, and mortality. Differential diagnosis includes intraductal spread of urothelial carcinoma, prostatic ductal carcinoma, and high-grade prostatic intraepithelial neoplasia. BRCA mutations are associated with an increased risk of IDC-P. The presence of IDC-P on initial biopsy or radical prostatectomy should trigger aggressive treatment and should be considered a contraindication to active surveillance, regardless of tumor volume.

MP69-12 UNDERUTILIZATION OF PALLIATIVE SERVICES IN ADVANCED GENITOURINARY MALIGNANCIES

PURPOSE The degree to which intraductal carcinoma of the prostate (IDC-P) affects clinical course remains poorly understood owing to small sample sizes from single-center studies. We sought to determine prognostic factors and outcomes associated with IDC-P in radical prostatectomy (RP) specimens. MATERIALS AND METHODS This is a retrospective study of RP during 2004 to 2013 using Surveillance, Epidemiology, and End Results to compare IDC-P with non-IDC-P. The effect of IDC-P on overall and disease-specific survival was assessed using Cox regression with a median follow-up of 4.8 years (interquartile range [IQR]: 2.6-7.0y; P = 0.01). Median prostate-specific antigen at diagnosis in IDC-P vs. non-IDC-P was similar (P = 0.23) at 6.2 (IQR: 4.6-13.0) vs. 6.1ng/ml (IQR: 4.6-9.8). RESULTS We identified 159,777 RP from 2004 to 2013, and 242 (0.002%) had IDC-P pathologic features. IDC-P was associated with a greater likelihood of extraprostatic stage, pT3/T4, 45.9% vs. 21.6% (P<0.001), higher grade, GS≥ 7, 79.3% vs. 62.7% (P<0.001), lymph node metastases, 5.8% vs. 2.4% (P<0.001), and positive surgical margins, 25.6% vs. 19.5% (P = 0.02). IDC-P was associated with a 3-fold increase in prostate cancer-specific mortality relative to non-IDC-P (hazard ratio = 3.0, 95% CI: 1.5-5.7; P<0.01). Limitations include retrospective design and potential underreporting of IDC-P that leads to underestimation of the true effect size. CONCLUSIONS The significance of IDC-P features has been recently recognized by the World Health Organization and it is associated with high-grade, extraprostatic features, and worse prostate cancer-specific mortality. Understanding its prognostic significance better guides adjuvant therapies and clinical trials.

MP16-19 NEOADJUVANT AND ADJUVANT CHEMOTHERAPY FOLLOWING NEPHROURETERECTOMY: CHANGES IN UTILIZATION AND OUTCOMES

INTRODUCTION AND OBJECTIVES: Testicular malignancies are the most common solid tumor in men 15-34 years and affect approximately 8400 men in the United States each year. Almost half can be classified as non-seminomatous germ cell tumors (NSGCT). Treatment options for stage I include surveillance, chemotherapy, or retroperitoneal lymph node dissection (RPLND). Our study aimed to examine demographic and socioeconomic trends around treatment patterns. METHODS: Using the National Cancer Database, we retrospectively examined 55,756 patients between January 1, 2004 and December 31, 2013. Data was extracted on 7,657 individuals with ICD histology diagnosis for stage I NSGCT. We obtained data on various demographic and socioeconomic variables including race, education, income, location and health insurance. We used multivariable logistic regression models to estimate odds ratios with 95% confidence intervals. RESULTS: Throughout 2004-2013 fewer patients received RPLND (OR 0.65 [0.55-0.76] p<0.01), and more received chemotherapy (OR 1.26 [1.10-1.43] p<0.01). Compared to other treatments, RPLND was less commonly seen in non-academic centers (OR 0.47 [0.33-0.66] p<0.01), more commonly in the highest volume institutions compared to the lowest volume institutions (OR 4.57 [2.47-8.46] p<0.01), and more commonly seen in those with low income (OR 1.24 [1.06-1.46] p<0.01). Patients living in rural counties compared to metro counties were more likely to receive chemotherapy (OR 1.72 [1.08-2.75] p1⁄40.03). As distance from hospital increased, individuals were more likely to receive any form of treatment versus observation for their disease (OR 1.51 for the greatest vs. the lowest quartile [1.31-1.74] p<0.01). Low income and Medicaid predicted greater chance for any treatment (OR 1.17 [1.04-1.32] p1⁄40.01 and OR 1.45 [1.20-1.74] p<0.01, respectively). No trends were seen for race or education status. CONCLUSIONS: Our study illustrates that fewer patients are undergoing RPLND, which may be due to increased surveillance. RPLND is more commonly practiced at higher volume and academic centers. Education and race do not predict choice of treatment, whereas distance, income and insurance type do predict increased likelihood for receiving treatment overall.

V9-07 MICROSURGICALLY-ASSISTED INGUINAL HERNIA REPAIR

INTRODUCTION AND OBJECTIVES: Novel antibodies against immune checkpoint proteins, which led to unleash anti-tumor T cell responses, results in durable long-lasting responses but only in a fraction of patients. RFA of tumors can enhance systemic antitumor immunity through a series of mechanisms. Nevertheless, antitumor immunity induced by RFA is mostly weak and not sufficient enough to eradicate metastatic tumors completely or prevent disease progression durably. We hypothesized that these two different treatment strategies could act synergistically. The purpose of this study is to evaluate whether the combination of RFA and anti-PD-1 antibody could result in both primary tumor control and prevention of lung metastasis in a murine model bearing renal adenocarcinoma. METHODS: Balb/c mice were injected with Renca cells into their left kidney to establish the orthotopical model of renal cancer. One week later, the mice were injected intravenously with Renca cells, which afterwards would spread into various organs particularly into the lung. Then, the mice were treated with IgG alone, anti-PD-1 monoclonal antibodies (mAbs), surgical resection/RFA of the kidney tumor, or surgical resection / RFA + anti-PD-1. anti-PD-1 mAbs were administered by intravenous injection (i.v) every other day for three times. The antitumor effect of the treatment was evaluated by counting the numbers of the tumors in the lung, weighing the lungs and observing the survival time, and the immunological responses were assessed using peripheral blood immune parameters and analyzing the infiltration of CD+4 or CD+8 T cells into the tumors. RESULTS: Treatment of mice bearing kidney tumors with RFA and anti-PD-1 mAbs resulted in significantly greater growth suppression of primary kidney tumors and prolonged survival compared with mice treated with the other modalities. ELISA analysis showed that mice treated with RFA and i.v anti-PD-1 mAbs had higher level of IFN-g, TNF-a in the peripheral blood after treatment compared with the other groups. In the combination therapy group, growth of lung metastases was prevented with fewer numbers of lung metastases and lighter weight of lung. The combined therapy of RFA and anti-PD-1 antibodies significantly increased T-cell infiltration, especially the effector T cells, which upregulated the effector T cells to regulatory T cells ratio. CONCLUSIONS: The combination of RFA and anti-PD-1 mAbs resulted in stronger antitumor immunity and prolonged survival in this preeclinical model of advanced RCC.

PD47-03 FAMILY HISTORY AND INCREASED RISK OF CLINICALLY SIGNIFICANT PROSTATE CANCER IN THE PLCO CANCER SCREENING TRIAL

INTRODUCTION AND OBJECTIVES: Gender confirmation surgery is an essential component in the management of gender identity disorder. However, short vaginal length, vaginal stenosis, or complications in the perineal dissection are significant limitations of current techniques in male to female surgery. Here we describe our technique for the robot assisted penile inversion vaginoplasty that addresses these needs. METHODS: The patient is prepped and draped in low lithotomy position. The penis is degloved through a circumcision incision. The neurovascular bundle, urethra and corpora cavernosa are dissected out. A six cm bulbar perineal incision is then made, and the dissection is carried to the bulbar urethra. The dissected urethra, neurovascular bundle, glans and corpora are delivered through this incision. The bilateral corpora are transected at their most proximal limit and overswen. The penile skin is inverted and gently retracted to allow a two cm incision above the neovagina for the neoclitoris. Immediately below this, an incision for the neomeatus is made. The urethra is brought through this incision and sutured to the skin. The remaining urethral tissue is used as an inlay onto the incised dorsal epithelial surface of the penile skin. The robotic portion of the surgery uses 4 port incisions: periumbiical Gelport with two pre-placed robotic trocars, right and left lateral ports, and an assistant port in the upper right abdomen. The dissection is from the posterior prostate, staying above Denonviller’s fascia to reach the endopelvic fascia. Under direct vision, the endopelvics are opened sharply from below and opened to a width of two fingerbreadths. The neovagina is passed into robotic field and pexed to the anterior reflection of the posterior peritoneum. The peritoneal reflection is then closed. The neoclitoris is fashioned from the glans penis and approximated. Labia majora and minora are fashioned with local skin flaps. A foley catheter is left indwelling as well as a vaginal stent. RESULTS: The index case required 7 hours of surgical time with an estimated blood loss of 100 mL. The vaginal length was greater than 15 cm. The patient was discharged home on post-operative day three, with no complications. The patient endorses sensation at the neoclitoris and anterior neovagina, and finds the vaginal depth satisfactory CONCLUSIONS: Our novel method for robot assisted penile inversion vaginoplasty is an important step in optimizing outcomes for our patients. This technique achieves maximal vaginal length in a safe and reproducible manner.

MP86-09 INCREASED RESOURCE UTILIZATION IN MEN WITH METASTATIC PROSTATE DOES NOT RESULT IN IMPROVED SURVIVAL OR QUALITY OF LIFE

INTRODUCTION AND OBJECTIVES: A family history (FH) of prostate cancer (CaP) is associated with an increased risk of CaP. However, it remains unclear how this association impacts the need for screening. The aim of this study is to evaluate the impact of FH of the diagnosis of clinically significant CaP in a large national cohort. METHODS: The study included 73,045 men from the control and screening arms of the Prostate Lung Colorectal and Ovarian (PLCO) trial, which had complete information regarding FH and CaP diagnosis. Incidence of clinically significant cancer (CS; intermediate or high risk disease) was compared by FH. The relationship between number of relatives diagnosed and age at CaP diagnosis was evaluated. Multivariable logistic regression was used to estimate odds rato (OR) and 95% confidence intervals (CI). RESULTS: FH was associated with a significantly increased risk of both CaP [OR 1.6, (95% CI 1.5-1.8)] and CS-CaP [OR 1.7 (95% CI 1.5-1.8), respectively]. Furthermore, the impact of FH on CS-CaP increased with the number of family members with CaP; for participants with one relative, the OR was 1.6 (95% CI 1.5-1.8); for those with multiple relatives, the OR increased to 2.2 (95% CI 1.6-3.2). Men with younger relatives with prostate cancer (< 65 vs 65 years) were more likely to be diagnosed with CS-CaP, [OR 1.6, (95%CI 1.3-2.0)]. FH, number of affected relatives and age of relatives remained significant on multivariable analysis controlling for ages, race, smoking history, history of BPH, marital status employment status and study arm. CONCLUSIONS: Detailed FH, including the number of relatives and relatives0 age of at diagnosis significantly affect a man0s risk of CSCaP and should be taken into consideration during individualized counseling about the frequency and intensity of screening.