Hans Arora

Intermediate-Term Outcomes for Men with Very Low/Low and Intermediate/High Risk Prostate Cancer Managed by Active Surveillance

Purpose: We compare intermediate term clinical outcomes among men with favorable risk and intermediate/high risk prostate cancer managed by active surveillance. Materials and Methods: A total of 635 men with localized prostate cancer have been on active surveillance since 2002 at a high volume academic hospital in the United States. Median followup is 50.5 months (IQR 31.1–80.3). Time to event analysis was performed for our clinical end points. Results: Of the cohort 117 men (18.4%) had intermediate/high risk disease. Overall 5 and 10‐year all cause survival was 98% and 94%, respectively. Cumulative metastasis‐free survival at 5 and 10 years was 99% and 98%, respectively. To date no cancer specific deaths had been observed. Overall freedom from intervention was 61% and 49% at 5 and 10 years, respectively. Overall cumulative freedom from failure of active surveillance, defined as metastasis or biochemical failure after local therapy with curative intent, was 97% and 91% at 5 and 10 years, respectively. Of the men 21 (9.9%) experienced biochemical failure after deferred treatment and the 5‐year progression‐free probability was 92%. Compared to men with favorable risk disease those with intermediate/high risk cancer experienced no difference in metastases, surveillance failure or curative intervention. However, patients at higher risk were at significantly increased risk for all cause mortality, likely reflecting patient selection factors. These conclusions may be limited by the small number of events and the duration of our study. Conclusions: Patients with localized prostate cancer who are on active surveillance demonstrated a low rate of active surveillance failure, prostate cancer specific mortality and metastases regardless of baseline risk.

Gut microbiome and chronic prostatitis/chronic pelvic pain syndrome

Analysis of the human microbiome continues to reveal new and previously unrealized associations between microbial dysbiosis and disease. Novel approaches to bacterial identification using culture-independent methods allow practitioners to discern the presence of alterations in the taxa and diversity of the microbiome and identify correlations with disease processes. While some of these diseases that have been extensively studied are well-defined in their etiology and treatment methods (colorectal cancer), others have provided much more significant challenges in both diagnosis and treatment. One such condition, chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), has several etiological and potentiating contributions from infection, inflammation, central nervous system (CNS) changes, stress, and central sensitization-all factors that play important roles in the crosstalk between the human body and its microbiome. No singular cause of CP/CPPS has been identified and it is most likely a syndrome with multifactorial causes. This heterogeneity and ambiguity are sources of significant frustration for patients and providers alike. Despite multiple attempts, treatment of chronic prostatitis with monotherapy has seen limited success, which is thought to be due to its heterogeneous nature. Phenotypic approaches to both classify the disease and direct treatment for CP/CPPS have proven beneficial in these patients, but questions still remain regarding etiology. Newer microbiome research has found correlations between symptom scores and disease severity and the degree of dysbiosis in urine and gut (stool) microbiomes in these patients as compared to un-afflicted controls. These findings present potential new diagnostic and therapeutic targets in CP/CPPS patients.

Development of a clinically relevant symptom index to assess patients with chronic orchialgia/chronic scrotal content pain

Background The purpose of this study was to develop a candidate symptom index for men with an established diagnosis of chronic orchialgia. Methods Based on interviews with patients and providers, we developed a 70-item questionnaire that focused on seven areas of orchialgia symptoms: pain, location, urinary symptoms, sexual dysfunction, medical history and quality of life (QOL) impact. The questionnaire was completed by patients at two medical centers. Cluster analysis was performed with the software package R (3.2.1). Results A total of 113 men completed the survey. Median symptom duration was 12 months (range, 3–336 months). Outside the testicle, pain was felt in the spermatic cord (66%), groin (66%), penis (24%), suprapubic region (38%), flank (31%), thigh (32%), abdomen (36%) and perineum (35%). Bother scores were high only for testicle and spermatic cord pain. Urinary frequency was common (54%) but not bothersome. Sexual dysfunction was common: 55% had erectile dysfunction, 56% had decreased libido and 39% had painful ejaculation with high bother for all. By cluster analysis, QOL parameters clustered tightly with minimal pain level, pain at night, burning pain, distribution to spermatic cord and groin, erectile dysfunction and premature ejaculation. Conclusions Men with chronic orchialgia have a high incidence of associated symptoms. Most bothersome symptoms with highest QOL impact include burning pain, pain at night, radiation to groin and spermatic cord, erectile dysfunction and low libido. Based on these findings, we have created a candidate orchialgia symptom index with domains of pain, sexual symptoms and QOL that will undergo prospective validation.

Do Renin-Angiotensin Blockers Affect Renal Function and Cardiac Outcomes in Patients Undergoing Partial Nephrectomy?

Purpose: Currently no data exist to guide renal surgeons on the perioperative use of renin‐angiotensin blockers despite potential cardiorenal benefits. We aimed to assess the impact of resuming renin‐angiotensin blockers on postoperative renal function and adverse cardiac events following partial nephrectomy. Materials and Methods: This is an observational analysis of patients who underwent robot‐assisted laparoscopic partial nephrectomy from 2006 to 2014 at a single institution. The Wilcoxon rank sum and chi‐square tests, and logistic regression were used to assess the risk of adverse renal and cardiac events stratified by history and pattern of renin‐angiotensin blockade perioperatively. Results: We identified 900 patients with a median followup of 16.3 months (IQR 1.4–39.1). There were no significant differences in severe renal dysfunction at last followup on univariate analysis or adverse cardiac events at 30 days on multivariate analysis in patients stratified by a history of renin‐angiotensin blockade. Of the 338 patients 137 (41.9%) resumed renin‐angiotensin blockade immediately after surgery, which did not result in any significant difference in the postoperative glomerular filtration rate (p >0.05). Resuming renin‐angiotensin blockade at discharge home was associated with a decreased risk of heart failure within 30 days of surgery (0.3% vs 11.8% of cases) and stage IV/V chronic kidney disease at last followup (2.6% vs 25.5%, each p <0.001). Conclusions: Renin‐angiotensin blockers appear safe to continue immediately after renal surgery. Discharge home with angiotensin converting enzyme inhibitors/angiotensin receptor blockers was associated with a decreased risk of heart failure and severe renal dysfunction. However, this risk may be overstated as a result of the small number of patients discharged without resuming the home medication.

Kidney, Ureteral, and Bladder Cancer: A Primer for the Internist

Malignancies of the urinary tract (kidney, ureter, and bladder) are distinct clinical entities. Hematuria is a unifying common presenting symptom for these malignancies. Surgical management of localized disease continues to be the mainstay of treatment, and early detection is important in the prognosis of disease. Patients often require life-long follow-up and assessment for recurrence.

Prognostic Significance of a Negative Confirmatory Biopsy on Reclassification Among Men on Active Surveillance

OBJECTIVE To examine the association between absence of disease on confirmatory biopsy and risk of pathologic reclassification in men on active surveillance (AS). MATERIALS AND METHODS Men with grade groups 1 and 2 disease on AS between 2002 and 2015 were identified who received a confirmatory biopsy within 1 year of diagnosis and ≥3 biopsies overall. The primary outcomes were pathologic reclassification by grade (any increase in primary Gleason pattern or Gleason score) or volume (>33% of sampled cores involved or increase in the number of cores with >50% involvement). The effect of a negative confirmatory biopsy survival was evaluated using Kaplan-Meier analysis and a Cox proportional hazards modeling. RESULTS Out of 635 men, 224 met inclusion criteria (median follow-up: 55.8 months). A total of 111 men (49.6%) had a negative confirmatory biopsy. Decreased grade reclassification (69.7% vs 83.9%; P = .01) and volume reclassification (66.3% vs 87.4%; P = .004) was seen at 5 years for men with a negative confirmatory biopsy compared with those with a positive biopsy. On adjusted analysis, a negative confirmatory biopsy was associated with a decreased risk of grade reclassification (hazard ratio, 0.51; 95% confidence interval, 0.28-0.94; P = .03) and volume reclassification (hazard ratio, 0.32; 95% confidence interval, 0.17-0.61; P = .0006) at a median of 4.7 years. CONCLUSION Absence of cancer on the confirmatory biopsy is associated with a significant decrease in rate of grade and volume reclassification among men on AS. This information may be used to better counsel men on AS.

PD22-10 PENILE PROSTHESIS IN SOLID ORGAN TRANSPLANT RECIPIENTS – A MATCHED COHORT STUDY

device infections. The coatings primarily target coagulasenegative Staphylococcus species. Traditionally, these organisms have been implicated in the majority of implant infections. We desired to ascertain the spectrum of bacterial species responsible for implant infections in the era following the widespread adoption of infection-retardant coated devices METHODS: The study cohort was derived from two prospective databases of patients undergoing penile implant surgery from two highvolume centers between February, 2004 and July, 2016. Included were those patients undergoing primary implant placement, revision surgery, and external referrals for management of an infected implant. Descriptive data included: patient age, comorbidities, first-time or revision surgery, and the organisms causing infection. Over the last 10 years, both centers have pursued an aggressive policy of performing salvage surgery. Patients who are not candidates for salvage surgery include those with systemic toxicity, purulence, cellulitis, a systemic inflammatory response, and significant soft tissue or urethral destruction. RESULTS: The cohort consisted of 39 patients, including 12 (2.8%) infections following 430 primary implant surgeries, 20 (5.5%) infections following 365 revision surgeries and 6 patients with infected implants referred from external sources (3 primary and 3 revision). Average patient age was 64.2 +/6.7 years. Table 1 depicts the spectrum of organisms encountered. There were no differences between the groups in terms of comorbidities. Based upon the criteria above, only 18 (46%) patients were candidates for salvage surgery, of which 12 (67%) were successful. CONCLUSIONS: The spectrum of bacterial species causing penile implant infections has changed in the era of infection-retardant coated devices. Contemporary infections are much more likely to be caused by Staph. aureus, and nearly 50% of infections are caused by gram negative bacteria. The aggressive nature of these bacteria limits the number of patients who are candidates for salvage surgery, and reduces the likelihood of an infected patient undergoing successful salvage surgery.

The enigma of men with interstitial cystitis/bladder pain syndrome

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a common and frequently misdiagnosed disorder in men. Hallmark symptoms are the presence of chronic discomfort attributed to the urinary bladder associated with bladder filling and relieved with bladder emptying, often associated with irritative voiding symptoms, in the absence of any other identifiable cause. It is often grouped with another common clinical entity, chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Men with IC/BPS often suffer from a delay in diagnosis and subsequent treatment, often being categorized as having prostatitis, benign prostatic hyperplasia, or epididymitis before the correct diagnosis is reached. The etiology of IC/BPS is poorly understood, and its pathogenesis may involve multiple pathways leading to a common clinical entity. Diagnostic criteria continue to evolve over time as the understanding of IC/BPS improves, and a clinical diagnosis with properly performed history and physical exam is suitable for diagnosis after other processes such as infection, radiation, or pharmaceutical exposure are appropriately excluded. No set pathological findings, biomarkers, or phenotypic descriptions have been universally accepted as a result of conflicting studies. Guidelines for diagnostic and treatment options are limited by available data, and few studies incorporate substantial numbers of male patients. Reported outcomes for common therapies are mixed or have not yet been subjected to study in rigorous placebo-controlled clinical trials in men. Lessons learned from the treatment of CP/CPPS can be applied to IC/BPS, by favoring a phenotypically directed, multimodal approach rather than a stepwise algorithm as advocated by current practice guidelines.

Concurrent Robotic Pyelolithotomy and Partial Nephrectomy: Tips and Tricks

OBJECTIVE With the evolution of robot-assisted surgery in the urology field, this technology is being applied to treat many genitourinary conditions.1 Although incidence of urolithiasis and renal neoplasm has increased, encountering both entities in a single kidney is noteworthy. Our video exhibits the concurrent management of a renal calculus and an ipsilateral renal neoplasm using a robotic platform. MATERIALS AND METHODS A 53-year-old man was diagnosed with a 1.7-cm left renal pelvis calculus and a 4.7-cm enhancing ipsilateral upper pole renal mass (R.E.N.A.L score 8a) after an episode of flank pain. After reviewing preoperative imaging, a single-setting approach using a robotic platform was planned. Main steps of our robotic technique on the case included (1) kidney defatting and mobilization, (2) hilum and ureter dissection up to the renal pelvis, (3) intraoperative ultrasound for tumor demarcation and stone localization, (4) anterior robotic pyelolithotomy,2 (5) double J stent placement and pyelotomy closure, (6) excision of renal mass, and (7) renorrhaphy. Perioperative outcomes were recorded. RESULTS The operative time was 180 minutes and the estimated blood loss was 100 mL. Warm ischemia time was 17 minutes. There were no intra- or postoperative complications. The patient was discharged home on postoperative day 3. Final pathology reported a 3.4-cm mass consistent with a clear cell renal carcinoma, with a tumor, nodes, metastases (TNM) staging pT1aNx and negative surgical margin. The double J stent was removed after 4 weeks, and the patient remained asymptomatic at 1 month postoperatively. CONCLUSION Pyelolithotomy and robotic partial nephrectomy can be performed effectively when treating patients with concurrent kidney mass and renal stone using the same surgical access. This minimally invasive approach should be contemplated as an option when managing patients with both conditions in an ipsilateral kidney. Furthermore, it will diminish the necessity of various surgeries while preserving renal function and maintaining oncological outcomes. We underline that the association of both procedures increases the likelihood of technical complications and risk for clot-related or stone-related ureteral obstruction, infection, and urine leak.

Impact of 5α-Reductase Inhibitors on Disease Reclassification among Men on Active Surveillance for Localized Prostate Cancer with Favorable Features

Purpose: We determined the effect of 5&agr;‐reductase inhibitors on disease reclassification in men with prostate cancer optimally selected for active surveillance. Materials and Methods: In this retrospective review we identified 635 patients on active surveillance between 2002 and 2015. Patients with favorable cancer features on repeat biopsy, defined as absent Gleason upgrading, were included in the cohort. Patients were stratified by those who did or did not receive finasteride or dutasteride within 1 year of diagnosis. The primary end point was grade reclassification, defined as any increase in Gleason score or predominant Gleason pattern on subsequent biopsy. This was assessed by multivariable Cox proportional hazards regression analysis. Results: At diagnosis 371 patients met study inclusion criteria, of whom 70 (19%) were started on 5&agr;‐reductase inhibitors within 12 months. Median time on active surveillance was 53 vs 35 months in men on vs not on 5&agr;‐reductase inhibitors (p <0.01). Men on 5&agr;‐reductase inhibitors received them for a median of 23 months (IQR 6–37). On actuarial analysis there was no significant difference in grade reclassification for 5&agr;‐reductase inhibitor use in patients overall or in the very low/low risk subset. The overall percent of patients who experienced grade reclassification was similar at 13% vs 14% (p = 0.75). After adjusting for baseline clinicopathological features 5&agr;‐reductase inhibitors were not significantly associated with grade reclassification (HR 0.80, 95% CI 0.31–1.80, p = 0.62). Furthermore, no difference in adverse features on radical prostatectomy specimens was observed in treated patients (p = 0.36). Conclusions: Among our cohort of men on active surveillance 5&agr;‐reductase inhibitor use was not associated with a significant difference in grade reclassification with time.