Bruce Kava

Incidence and clinical significance of false-negative sextant prostate biopsies

PURPOSE Since most patients do not undergo repeat sextant prostate biopsies after a biopsy is positive for prostate cancer, the true incidence of false-negative biopsies is not well defined. We assess the incidence and clinical significance of false-negative sextant prostate biopsies in patients undergoing radical prostatectomy. MATERIALS AND METHODS A total of 118 patients with biopsy proved prostate cancer underwent repeat sextant prostate biopsy before enrollment in a prospective randomized trial of radical prostatectomy with or without neoadjuvant hormonal therapy. Clinical parameters were assessed to determine potential sources of bias. Pathological parameters and prostate specific antigen relapse-free survival rates were compared to determine the clinical significance of false-negative biopsies. RESULTS Of the 118 patients 27 (23%) had a negative repeat sextant biopsy. Except for initial clinical stage, no differences were noted in the clinical or pathological parameters, or prostate specific antigen relapse rates in patients with negative versus positive repeat biopsies. CONCLUSIONS Our findings suggest that this 23% incidence of false-negative biopsies represents significant cancer. This relatively high incidence is important to consider in treatment modalities in which prostate biopsy may be performed to determine response to therapy.

Bland thrombus association with tumour thrombus in renal cell carcinoma: analysis of surgical significance and role of inferior vena caval interruption

Study Type – Therapy (case series)

Results of laparoscopic pelvic lymphadenectomy in patients at high risk for nodal metastases from prostate cancer

AbstractBackground: Laparoscopic pelvic lymphadenectomy (LPLND) can be performed safely and with minimal morbidity in the staging of prostate cancer. Its utility in evaluating patients at high risk for metastatic disease before primarily nonsurgical treatment modalities was evaluated. Methods: Twenty-four consecutive patients who underwent LPLND between June 1993 and July 1996 were studied. These patients were considered poor surgical candidates based on several risk factors, as follows: elevation of serum PSA >20 in 19 patients (79%); elevation of serum acid phosphatase in 4 patients (17%); digital rectal examination findings indicative of extraprostatic extension or seminal vesical involvement in 14 patients (58%); and poorly differentiated tumors on prostate biopsy in 19 patients (79%). Nineteen patients (79%) had two or more of these risk factors. Median PSA for the entire series of patients was 35.2 ng/mL (range 7.9 to 133 ng/mL), and median Gleason score was 7 (range 5 to 9). Preoperative CT or MRI was negative for pelvic lymph node metastases in 17 of 23 patients (79%), and bone scan was negative in all 24 patients. Results: Unilateral (n=2) or bilateral (n=22) LPLND was performed in all patients. Six patients (25%) had lymph node metastases detected laparoscopically. Five of the six patients had palpable extraprostatic extension (T3a/b) or invasion of a seminal vesical (T3c), and in four of these patients the site of the metastatic lymph nodes was ipsilateral to the palpable prostate abnormality. None of the risk factors was independently predictive of lymph node metastases within this series of patients. An average of 10.8±6.5 lymph nodes was removed at a mean operative time of 174±10 minutes for patients undergoing bilateral LPLND. Estimated blood loss was minimal for 20 of 22 patients (92%) undergoing LPLND alone, and there were no complications requiring open exploration. Mean postoperative hospital stay was 1.2±0.5 days for patients undergoing LPLND alone. Conclusions: LPLND can be used efficiently to identify patients with nodal metastases from select high-risk patients. This, in turn, can exclude such patients from noncurative local and regional therapy.

Orthotopic ileal neobladder reconstruction for bladder cancer: is adjuvant chemotherapy safe?

OBJECTIVE We examined our database of patients undergoing radical cystectomy (RC) with orthotopic neobladder (NB) to determine whether adjuvant chemotherapy in this group is safe. MATERIALS AND METHODS We performed a retrospective analysis of patients who underwent radical cystectomy and urinary diversion between 1992 and 2004. Relevant clinical and therapeutic data were entered into a database. High-risk bladder cancer patients who underwent NB were identified. They were stratified into 2 groups, those who received adjuvant chemotherapy and those who did not. The incidence of complications between the 2 groups was analyzed and compared. RESULTS Over the 12-year period, 136 patients underwent RC and NB construction for bladder cancer. Of these, 83 patients were at high risk for recurrence. Nineteen patients received adjuvant chemotherapy and 64 did not. The complication rate in the adjuvant chemotherapy group was 53% and it was 23% in those who did not receive chemotherapy. There were no perioperative or treatment related death. There were 2 patients with grade 4 toxicity in the adjuvant chemotherapy group. There was a statistical difference between these two groups with regard to the incidence of complications. However, none of these complications was life-threatening, required only conservative treatment and caused no long-term disability. CONCLUSIONS Adjuvant chemotherapy is a safe treatment for patients undergoing RC and NB substitution. Hence, the option of orthotopic NB should not be denied in selected bladder cancer patients with high risk for recurrent disease.

Optimizing patient's selection for prostate biopsy: A single institution experience with multi-parametric MRI and the 4Kscore test for the detection of aggressive prostate cancer

Objectives To evaluate the performance of mpMRI and the 4Kscore test together for the detection of significant prostate cancer. Material and methods We selected a consecutive series of men who were referred for evaluation of prostate cancer at an academic institution and underwent mpMRI and the 4Kscore test. The primary outcome was the presence of Gleason 7 or higher cancer on biopsy of the prostate. We used logistic regression and Decision Curve Analysis to report the discrimination and clinical utility of using mpMRI and the 4Kscore test for prostate cancer detection. We modeled the probability of harboring a Gleason 7 or higher prostate cancer based on the 4Kscore test and mpMRI findings. Finally, we examined various combinations and sequences of mpMRI and the 4Kscore test and assessed the impact on biopsies avoided and cancers missed. Results Among 300 men who underwent a 4Kscore test and mpMRI, 149 (49%) underwent a biopsy. Among those, 73 (49%) had cancer, and 49 (33%) had Gleason 7 cancer. The area under the curve (AUC) for using the 4Kscore test and mpMRI together 0.82 (0.75–0.89) was superior to using the 4Kscore 0.70 (0.62–0.79) or mpMRI 0.74 (0.66–0.81) individually (p = 0.001). Similarly, decision analysis revealed the highest net benefit was achieved using both tests. Conclusions The 4Kscore test and mpMRI results provide independent, but complementary, information that enhances the prediction of higher-grade prostate cancer and improves patient’s selection for a prostate biopsy. Prospective trials are required to confirm these findings.

Malakoplakia of the prostate diagnosed on multiparametric-MRI ultrasound fusion guided biopsy: A case report and review of the literature

Malakoplakia is an unusual chronic inflammatory condition described by Michaelis and Gutmann in 1902 and further characterized by von Hansemann in 1903.1 Microscopically, there are sheets of macrophages containing round concentrically basophilic intracytoplasmic inclusions (targetoid appearance) named Michaelis-Gutmann bodies; which contain calcium salts, iron, intact and degenerating bacteria within phagolysosomal bodies. A strong association with infectious process is well known, and a defective intraphagolysosomal digestive activity of macrophages and monocytes leading to inadequate killing of ingested bacteria is hypothesized. Gram-negative bacteria such as Escherichia coli and Klebsiella pneumonia are often isolated from malakoplakia lesions. However, association with immunosuppression has been linked too.1, 2 Being first described from a bladder biopsy specimen, this is still the most common site of involvement. Yet, in recent years, cases of the disease affecting extravesical sites such as prostate, skin, bone, uterus and lungs, have been reported with increasing frequency.2 Malakoplakia involvement of the prostate was initially described by Carruthers in 1959, and up to date, this location is considered extremely rare.3, 4 We describe a case of prostatic malakoplakia, diagnosed on multiparametric MRI (mpMRI) ultrasound fusion guided biopsy in a patient with clinically suspected prostate cancer (PCa).

MP09-10 TAMSULOSIN PRESCRIBING PATTERNS BASED ON A UNITED STATES HEALTH PLAN CLAIMS DATABASE

METHODS: We conducted a Cochrane review based on an a priori, protocol that included published and unpublished randomized controlled trials (RCTs) in any language. We excluded trials of children or adults with primary or secondary enuresis or underlying medical disorders. Primary outcomes were the number of nocturnal voids, quality of life (QoL), and major adverse events (AEs); secondary outcomes were duration of first sleep episode, time to first void, minor AEs, and treatment withdrawal due to AEs. We performed meta-analysis using RevMan 5.3 and rated the quality of evidence using GRADE. RESULTS: Of 271 studies identified through our search, we included 10 studies. Desmopressin was associated with a small decrease in the number of nocturnal voids (mean difference [MD] -1.1, 95% confidence interval [CI] -1.4 to -0.9; low quality evidence) and similar rates of major AEs (risk ratio [RR] 0.9, 95% CI 0.1 to 9.0; very low quality of evidence). We found no evidence for QoL. Compared to alpha-blockers, there was a similar reduction in the number of nocturnal voids (MD -0.2, 95% CI 01.2 to 0.7; very low quality evidence) and similar quality of life (MD -0.2, 95% CI -0.4 to 0.1; moderate quality of evidence). Rates of major AEs were similar (RR not estimable; low quality evidence). CONCLUSIONS: Current best evidence from RCTs in men with the chief complaint of nocturia suggests that desmopressin may result in a small reduction in the number of nocturnal voids with similar major AE rates compared to placebo. We are uncertain whether it reduces the number of nocturnal voids similarly to alpha-blockers. Additional welldesigned studies using active controls are needed.

MP51-20 PROSTATE SPECIFIC COMMUNICATIONS: WHAT THE NEXT GENERATION OF UROLOGY TRAINEES ARE TELLING PATIENTS ABOUT PROSTATE CANCER SCREENING, DIAGNOSIS, AND TREATMENT DURING A VIRTUAL OBJECTIVE STRUCTURED CLINICAL ENCOUNTER.

METHODS: 18 medical students were enrolled in a study on a VR DaVinic surgical skills curriculum. They were randomized into three groups: Group A (n1⁄46, control), no performance feedback; Group B (n1⁄46, standard formative expert feedback), Group C (n1⁄46, summative expert feedback using multicomponent video feedback of the VR task þ webcam feedback of master controls and foot pedal). Each trainee completed each task six times. 4 tasks (Peg Board 2, Camera targeting 2, Ring walk 3 & Suture sponge 3) were chosen. Simulator-measured performance metrics included differences in total score, time and economy of motion over the five trials. Data were analyzed using SPSS version 15. RESULTS: A learning curve was observed across the five trials in all groups. A significant difference was seen between the three groups for change in overall score across the five trials. Ergonomic metric assessment showed that Groups B and C performed better than Group A (P .002 and P .000, respectively) and that the multicomponent feedback was more effective in tasks involving the use of multiple controls (Camera targeting & Ring walk). CONCLUSIONS: Multi-component summative feedback (combination of task, master control, and camera pedal) is effective in significantly shortening the learning curve in the robotic training process, especially in complex tasks.

PD22-08 TIMES ARE A CHANGING: DEFINING THE SPECTRUM OF BACTERIA CAUSING INFLATABLE PENILE PROSTHESIS INFECTIONS IN THE ERA OF INFECTION-RETARDANT COATED DEVICES.

(Group B) of rear-tip extender use during IPP replacement. Collected variables include the need for revision surgery, whether or not RTEs were used, and the date of revision surgery. Primary endpoints included prevalence of RTE usage from 2000 to 2015, as well as comparison of revision rates between Group A and Group B. RESULTS: There were 35,046 (53.5%) patients in Group A and 30,402 (46.5%) patients in Group B. Between 2000 and 2015 there was a statistically significant increase in the percentage of IPP placements utilizing RTEs from 6-8% of IPP procedures in 2000 to 82% and 93% of IPP placements in 2014 and 2015, respectively (P < 0.0001, see figure 1). Revision rates for both Group A and Group B changed in a parabolic fashion between 2000 and 2015. Group A revision rates increased from less than 1% in 2000 to a peak of 3.7% in 2011, followed by a decrease to 2.4% in 2015. Similarly, Group B revision rates increased from less than 1% in 2000 to a peak of 3% in 2012, followed by a decrease to 0.5% in 2015 (see figure 2). Comparing the revision rate of the two groups over the 15-year period demonstrated a two-fold increase in the rate of revision with the use of RTE (Group A 1.34%, Group B 2.65, P < 0.0001) CONCLUSIONS: The use of RTEs has increased over the last 15 years, however there appears to be a higher rate of revision surgery if the implant utilizes RTE. Given the frequent use of RTE in IPP surgery, further studies to understand this association are needed.

Cancer detection between peripheral zone and transitional zone targeted biopsies: Preliminary results from a prospective cohort of men undergoing MRI-US fusion biopsy.

56 Background: Multiparametric MRI has emerged as a popular imaging modality to localize prostate cancer. Nevertheless, interpretation of MRI is subjective, with concerns for false positives, particularly in the transitional zone (TZ), where hyperplastic changes may be confused for suspicion of cancer. We analyzed a prospective cohort of men undergoing MRI-US fusion biopsy and compared cancer detection rate between lesions seen in the peripheral zone (PZ) and the TZ. Methods: 133 men with elevated PSA or positive DRE underwent MRI-US fusion biopsy with average of 2 cores taken per target for the detection of prostate cancer between October 2014 and July 2015. Each targeted lesion in the PZ and TZ was previously classified by radiologists according to the MRI PI-RADS score and grouped according to their level of suspicion as probably benign (1-2), indeterminate (3) or probably malignant (4-5). Histopathology from targeted cores were categorized as no cancer, non-significant cancer (Gleason 6) and significa...