Joshua S. Jue

Re-examining Prostate-specific Antigen (PSA) Density: Defining the Optimal PSA Range and Patients for Using PSA Density to Predict Prostate Cancer Using Extended Template Biopsy

OBJECTIVE To compare the predictive accuracy of prostate-specific antigen (PSA) density vs PSA across different PSA ranges and by prior biopsy status in a prospective cohort undergoing prostate biopsy. MATERIALS AND METHODS Men from a prospective trial underwent an extended template biopsy to evaluate for prostate cancer at 26 sites throughout the United States. The area under the receiver operating curve assessed the predictive accuracy of PSA density vs PSA across 3 PSA ranges (<4 ng/mL, 4-10 ng/mL, >10 ng/mL). We also investigated the effect of varying the PSA density cutoffs on the detection of cancer and assessed the performance of PSA density vs PSA in men with or without a prior negative biopsy. RESULTS Among 1290 patients, 585 (45%) and 284 (22%) men had prostate cancer and significant prostate cancer, respectively. PSA density performed better than PSA in detecting any prostate cancer within a PSA of 4-10 ng/mL (area under the receiver operating characteristic curve [AUC]: 0.70 vs 0.53, P < .0001) and within a PSA >10 mg/mL (AUC: 0.84 vs 0.65, P < .0001). PSA density was significantly more predictive than PSA in detecting any prostate cancer in men without (AUC: 0.73 vs 0.67, P < .0001) and with (AUC: 0.69 vs 0.55, P < .0001) a previous biopsy; however, the incremental difference in AUC was higher among men with a previous negative biopsy. Similar inferences were seen for significant cancer across all analyses. CONCLUSION As PSA increases, PSA density becomes a better marker for predicting prostate cancer compared with PSA alone. Additionally, PSA density performed better than PSA in men with a prior negative biopsy.

Kidney Autotransplantation: Between the Past and the Future

Purpose of ReviewThe practice of kidney autotransplantation (KAT) has become an increasingly favorable approach in the treatment of certain renovascular, ureteral, and malignant pathologies. Current KAT literature describes conventional open procedures, which are associated with substantial risks. We sought to compare previously reported outcomes, evaluate common surgical indications, and assess associated risks and benefits of current KAT methods. A thorough evaluation and review of the literature was performed with the keywords “autologous transplantation” and “kidney.”Recent FindingsEarly outcomes of robotic KAT are encouraging and have been associated with fewer complications and shorter hospital stay, but require robotic technique proficiency.SummaryKAT is an important method to manage selected complex urological pathologies. Robotic KAT is promising. Nevertheless, future studies should utilize larger patient cohorts to better assess the risks and benefits of KAT and to further validate this approach.

Trends in Utilization of Robotic and Open Partial Nephrectomy for Management of cT1 Renal Masses

BACKGROUND Partial nephrectomy is widely used for surgical management of small renal masses. Use of robotic (RPN) versus open partial nephrectomy (OPN) among various populations is not well characterized. OBJECTIVE To analyze trends in utilization of RPN and disparities that may be associated with this procedure for management of cT1 renal masses in the USA. DESIGN, SETTING, AND PARTICIPANTS Patients who underwent RPN or OPN for clinical stage T1N0M0 renal masses in the USA from 2010 to 2013 were identified in the National Cancer Data Base. A total of 23 154 patients fulfilled the inclusion criteria. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Univariable and multivariable logistic regression analyses were performed to evaluate differences in receiving RPN or OPN across various patient groups. RESULTS AND LIMITATIONS Utilization of RPN increased from 41% in 2010 to 63% in 2013. Black patients (adjusted odds ratio [aOR] 0.91, 95% confidence interval [CI] 0.84-0.98) and Hispanic patients (aOR 0.85, 95% CI 0.77-0.95) were less likely to undergo RPN. RPN was less likely to be performed in rural counties (aOR 0.80, 95% CI 0.66-0.98) and in patients with no insurance (aOR 0.52, 95% CI 0.44-0.61) or patients covered by Medicaid (aOR 0.81, 95% CI 0.73-0.90). There was no significant difference in RPN utilization between academic and non-academic facilities. Patients with higher clinical stage (aOR 0.58, 95% CI 0.55-0.62) and comorbidities (aOR 0.79, 95% CI 0.71-0.88) were also less likely to undergo RPN. CONCLUSIONS Utilization of RPN has continued to increase over time; however, there are significant disparities in its utilization according to race and socioeconomic status. Black and Hispanic patients and patients in rural communities and with limited insurance were more likely to be treated with OPN instead of RPN. PATIENT SUMMARY The use of robotic surgery in partial nephrectomy for management of small renal masses has increased over time. We found a significant disparity across different racial and socioeconomic groups in use of robotic partial nephrectomy compared to open surgery. Patients living in rural areas, with limited insurance, and multiple medical comorbidities were more likely to undergo open than robotic partial nephrectomy.

A successful case of salvage kidney transplantation using the recipient gonadal vein to bypass a major outflow obstruction

Renal transplantation is the treatment of choice for chronic kidney disease and has been shown to have better outcomes than dialysis in multiple studies.1 In the standard procedure, the donor renal artery and vein are anastomosed to the external iliac vessels of the recipient. In cases of an unusable vein, such as thrombosis of the iliac vein or inferior vena cava (IVC), renal transplantation becomes extremely difficult. These issues were originally considered contraindications to renal transplant, but several case reports have demonstrated ways to circumvent the obstructed veins by using other systemic or portal veins in the area. We present an unusual case of kidney transplantation on a right external iliac vein (EIV) that contained a chronic thrombus extending to the common iliac vein (CIV) and infrarenal IVC, hence, partially obstructing the right EIV. It was identified intraoperatively after a standard initial anastomosis. The transplanted kidney was salvaged by utilizing the recipient right gonadal vein to bypass the iliac outflow obstruction.

Infertility evaluation and access to assisted reproductive technologies among male military veterans: Analysis of the South Florida Veterans Affairs experience

Background Recent legislation extended coverage for assisted reproductive technologies (ART) to male veterans within the United States Veterans Affairs (VA) healthcare system. We sought to characterize the appropriateness of male infertility diagnosis and access to assisted reproductive technologies (ART) among men within the local VA healthcare system after passage of the new legislation. Methods We retrospectively identified male patients within the South Florida VA Network who underwent semen analysis (SA) or were diagnosed with infertility between January 1999 and June 2017. Men were classified by infertility diagnosis and sperm concentration/mL (normal, oligospermia <15, severe oligospermia <5 million, azoospermia). We compared the number of oligospermic men before versus after the legislation. Men who did not receive ART were characterized according to eligibility criteria of military service connection to the infertility diagnosis. Results Six hundred twenty-seven men underwent SA or were diagnosed with infertility. Among 474 men with SA, 206 (43.5%) were diagnosed with infertility and 268 (56.5%) were not. Additionally, 153 men received an infertility diagnosis without SA. More men had oligospermia and severe oligospermia after the legislation (1 vs. 6, 1 vs. 10). Of 10 men with severe oligospermia post-legislation, 7 did not proceed to ART consultation due to lack of military service connection to the infertility diagnosis. Conclusions A substantial proportion of veterans with abnormal sperm concentrations were not diagnosed with infertility, while others carrying an infertility diagnosis did not undergo SA. Most patients clinically eligible for ART did not proceed with further evaluation due to lack of military service connection to their infertility diagnosis.

Effect of prescription medications on erectile dysfunction

Erectile dysfunction (ED) affects about 50% of men in the USA and is primarily attributed to physiological (organic) and psychological causes. However, a substantial portion of men suffer from ED due to iatrogenic causes. Common medications such as antihypertensives, non-steroidal anti-inflammatory drugs and antacids may cause ED. Physicians should be aware of the various prescription medications that may cause ED to properly screen and counsel patients on an issue that many may feel too uncomfortable to discuss. In this review, we discuss the physiology, data and alternative therapies for the ED caused by medications.

Significance of positive semen culture in relation to male infertility and the assisted reproductive technology process

There are currently no WHO guidelines on the indications for semen culture; however, semen cultures are performed in the evaluation of male infertility and the assisted reproductive technology (ART) process. The relevance and significance of positive semen cultures is widely debated in the literature, with no current consensus on the usefulness of this test in relation to male infertility. We review the pathogenic mechanisms of potentially pathogenic bacteria, general bacteria, urethral flora, and skin flora on sperm parameters. We also present, possible routes of semen contamination, measures to reduce contamination, and the clinical significance of culture contamination. First, it is critical to distinguish round cells in semen as leukocytes from immature germ cells. Second, it is critical to distinguish leukocytospermia from infected semen in order to guide management.

PD40-02 RE-EXAMINING PSA DENSITY: DEFINING THE OPTIMAL PSA RANGE AND PATIENTS FOR USING PSA DENSITY TO PREDICT PROSTATE CANCER USING EXTENDED TEMPLATE BIOPSY

and Cochran’s and Mantel-Haenszel Chi-square test were used to analyze the relationship between all the features and PPI incidence and severity, respectively. A Kaplan-Meier curve was created to clarify recovery of incontinence after prostatectomy. Cox regression analysis was performed in the analysis of influence factors of PPI recovery. Nomograms were formulated based on the results of multivariate analysis and by using the package of rms in R version 2.14.1. RESULTS: All 364 patients had complete data and the medium follow-up time was 17 months. The total immediate incontinence rate was 61.8%. The incontinence rate was 10.4% at the 12th month after the surgery. Risk factors related to PPI incidence included smoking, hypertension, preoperative incontinence, preoperative dysuresia and chief surgeon. Risk factors related to PPI severity included age, preoperative PSA, neutrophil-to-lymphocyte ratio, postoperative urinary stricture and Gleason score. Risk factors related to PPI recovery included age, BMI, diabetes, hernia, biopsy approaches, prostate volume, preoperative incontinence, preoperative dysuresia, preoperative PSA, postoperative urinary stricture and PPI severity. Age, BMI and PPI severity were independent predictor of PPI recovery. CONCLUSIONS: Incontinence is a very common complication after radical prostatectomy, which adversely affects patients’ quality of life. According to the nomograms developed by this study, now it is possible to predict the incidence of PPI and PPI recovery probabilities, which offers a strong evidence to the establishment of personalized prostate cancer management.

PD66-09 UTILIZATION OF ROBOTIC VERSUS OPEN PARTIAL NEPHRECTOMY FOR MANAGEMENT OF CT1 AND CT2 RENAL MASSES

INTRODUCTION AND OBJECTIVES: Partial nephrectomy is widely utilized for surgical management of small renal masses. Robotic partial nephrectomy (RPN) has demonstrated improved postoperative morbidity and comparable oncologic outcomes compared to open partial nephrectomy (OPN). However, there is limited data regarding the utilization of RPN across different socio-economic strata and racial groups in the United States. We investigated trends and disparities in utilization of RPN for management of cT1 and cT2 renal masses. METHODS: Patients who underwent RPN and OPN for clinical stage T1 and T2, N0, M0 renal masses from 2010 to 2013 were identified in the National Cancer Data Base (NCDB). Univariate and multivariable logistic regression analyses were performed to evaluate differences in receiving RPN across various patient groups. RESULTS: A total of 23,681 patients fulfilled inclusion criteria. Utilization of RPN for management of cT1/cT2 renal masses significantly increased from 2010 to 2013 compared to OPN (Figure.1). Black (aOR1⁄40.91, 95%CI: 0.84-0.99) and Hispanic (aOR1⁄40.85, 95% CI: 0.76-0.94) patients were less likely to undergo RPN in favor of OPN. RPN was less likely to be performed in rural counties (aOR1⁄4 0.81, 95% CI: 0.66-0.98) and in patients with no insurance (aOR1⁄40.52, 95% CI: 0.45-0.61) or patients covered by Medicaid (aOR1⁄40.81, CI: 0.73-0.89). No significant difference was seen with respect to utilization of RPN between academic and non-academic facilities. Patients with higher clinical stage and co-morbidities were also less likely to undergo RPN (aOR1⁄40.23, 95% CI: 0.150.36 and 0.79, 95% CI: 0.71-0.87 respectively). CONCLUSIONS: Utilization of RPN continues to increase over time; however, there is significant disparity in utilization of RPN based on socio-economic status and race. Black or Hispanic patients and patients in rural communities and with limited insurance were more likely to be treated with OPN instead of RPN.

A nationwide analysis of re-operation after kidney transplant

INTRODUCTION We aimed to report the rate and short-term outcomes of patients undergoing re-operation following kidney transplant in the U.S. METHODS The Nationwide Inpatient Sample (NIS) database was used to examine the clinical data of patients undergoing kidney transplant and re-operation during same the hospitalization from 2002-2012. Multivariate regression analysis was performed to compare outcomes of patients with and without re-operation. RESULTS We sampled a total of 35 058 patients who underwent kidney transplant. Of these, 770 (2.2%) had re-operation during the same hospitalization. Re-operation was associated with a significant increase in mortality (30.4% vs. 3%; adjusted odds ratio [AOR] 4.62; p<0.01), mean total hospital charges (