Kristen R. Scarpato

The Impact of Health Literacy on Surgical Outcomes Following Radical Cystectomy

Health literacy is the ability to obtain, comprehend, and act on medical information and is an independent predictor of health outcomes in patients with chronic health conditions. However, little has been reported regarding the potential association of health literacy and surgical outcomes. We hypothesized that patient complications after radical cystectomy would be associated with health literacy. In a sample of 368 patients, we found that higher health literacy scores (as determined by the Brief Health Literacy Screen) were associated with decreased odds of developing minor complications (odds ratio = 0.90, 95% confidence interval [0.83, 0.97]). Health literacy should be considered when caring for patients undergoing radical cystectomy and should serve as a potential indicator of the need for additional resources to improve postoperative outcomes.

Magnetic resonance-ultrasound fusion prostate biopsy in the diagnosis of prostate cancer

The advent of multiparametric magnetic resonance imaging (MRI) has ushered in a new era for urologists who perform prostate needle biopsies. The fusion of MRI with transrectal ultrasound (US) allows the direct targeting of suspicious lesions, which has been shown to improve the performance of conventional random biopsy techniques by increasing detection of clinically relevant disease while also decreasing detection of low-risk cancer. However, as with any new technology, many questions regarding effectiveness, reproducibility, and generalizability still remain. In this review, we (1) provide a summary of the various sequences that comprise a MRI of the prostate; (2) evaluate the 3 different ways of incorporating MRI into targeted biopsies of the prostate including in-bore MRI-guided biopsy, cognitive fusion, and device-mediated fusion; (3) review the sensitivity of MR-US fusion in the detection of clinically significant and clinically insignificant disease; and (4) review the barriers to the widespread implementation of MR-US fusion into everyday practice. Whereas other articles in this issue of Urologic Oncology Seminars will discuss other aspects of MRI in the management of prostate cancer, the purpose of this article is to provide an overview of MR-US fusion biopsies in the diagnosis of prostate cancer.

Use of mpMRI in active surveillance for localized prostate cancer

INTRODUCTION In an effort to limit prostate cancer (PCa) overdiagnosis and overtreatment, which have occurred in response to widespread prostate specific antigen testing, numerous strategies aimed at improved risk stratification of patients with PCa have evolved. Multiparametric magnetic resonance imaging (MRI) is being used in concert with prostate specific antigen testing and prostate biopsies to improve sensitivity and specificity of these tests. There are limited data on how multiparametric MRI can be incorporated into active surveillance (AS) protocols. EVIDENCE ACQUISITION A PubMed literature search of available English language publications on PCa, AS, and MRI was conducted. Appropriate articles were selected and included for review. Bibliographies were also used to expand our search. EVIDENCE SYNTHESIS Data from 41 studies were reviewed. AS inclusion criteria and protocols varied among studies, as did indications for use of MRI. Technological improvements are briefly highlighted. Studies are broadly categorized and discussed according to the role of MRI in patient selection, disease staging, and monitoring in AS protocols. CONCLUSIONS Although improvements in MRI technology have been useful for biopsy guidance and in the diagnosis and staging of PCa, this literature search demonstrates that more prospective research is needed, specifically regarding how this promising technology can be incorporated into AS protocols.

Oncologic Outcomes after Anterior Exenteration for Muscle Invasive Bladder Cancer in Women

PURPOSE We investigated oncologic and urinary outcomes after anterior exenteration for urothelial cell carcinoma in females, identifying tumor characteristics associated with female pelvic organ involvement. We hypothesized that a lack of trigonal or bladder floor tumor, intraoperative palpable posterior mass and clinical lymphadenopathy is associated with a lack of female pelvic organ involvement. MATERIALS AND METHODS We retrospectively reviewed the charts of female patients who underwent radical cystectomy at our institution from 1999 to 2014. Patient and operative characteristics were extracted from the electronic medical record, and performance of hysterectomy was tested for association with disease recurrence. Categorical and continuous variables were analyzed with the chi-square and Student t-test, and Kaplan-Meier analysis was performed to determine recurrence-free survival according to hysterectomy performance. Women who had neobladder creation were additionally evaluated for an association between hysterectomy status, and nighttime wetting and catheter use. RESULTS Of 322 eligible patients 160 with urothelial cancer did not have a hysterectomy before cystectomy. Mean followup was 2.2 years (SD 2.8). There were 22 patients (13.8%) who had recurrence during followup. No patient or surgical factor other than use of adjuvant chemotherapy or radiation (p <0.01) was associated with recurrence. Of 139 women 32 (23.0%) who underwent exenteration had female pelvic organ involvement. At least 1 of the 3 characteristics of interest were present in 28 of 99 (28.3%) women with any genitourinary organ involvement compared to only 4 of 40 (10.0%) of those who did not (p=0.01). Nighttime continence ranged between 21.9% and 48% but there was no significant association with continence and hysterectomy status. CONCLUSIONS Lack of trigonal/bladder floor tumor, palpable posterior mass and clinical lymphadenopathy is associated with the absence of pelvic organ involvement. Individualized risk assessment using these factors along with patient preferences should be used to guide surgical planning.

Management of noninvasive bladder cancers.

Purpose of review To summarize clinical management of nonmuscle-invasive bladder cancer (NMIBC) and discuss recent advances in the field. Recent findings NMIBC remains a common and expensive clinical entity. Prevention, early detection, and risk-adapted treatment are the mainstays of clinical management, all of which may improve as a result of recent research. Photodynamic diagnosis has demonstrated improved detection of nascent disease, and specific clinical scenarios have been identified in which photodynamic diagnosis may improve clinical outcomes. New intravesical chemotherapeutic and immunotherapeutic agents challenge our current paradigm for intermediate/high-risk NMIBC and may delay need for cystectomy after bacillus Calmette–Guerin failure. Progress in risk stratification increasingly permits individualized management regimens for NMIBC. Summary NMIBC includes many heterogeneous disease states with a variety of clinical behaviors that may evolve over time. Improved detection and risk stratification promise assignment of the optimal treatment option for an individual patient at a given time.

The Impact of Health Literacy and Clinicodemographic Factors on Use of Discharge Services after Radical Cystectomy

Purpose: There are few data on the relationship between health literacy and discharge disposition. We hypothesized that patient discharge needs after radical cystectomy are affected by health literacy. Materials and Methods: We identified 504 patients who underwent radical cystectomy and completed the validated BHLS (Brief Health Literacy Screen) after November 2010. Bivariate and logistic regression analyses were performed to determine whether health literacy is associated with the use of discharge resources after radical cystectomy. Results: Of patients treated with radical cystectomy 50.6% required discharge services and had lower health literacy (BHLS 11.9 vs 12.5, p = 0.016) than patients discharged home without services. On multivariable analysis older age (OR 1.1, 95% CI 1.0–1.1, p = 0.002), female gender (OR 2.3, 95% CI 1.2–4.4, p = 0.019), body mass index (OR 1.1, 95% CI 1.0–1.1, p = 0.034), Charlson comorbidity index score (OR 1.1, 95% CI 1.0–1.2, p = 0.037) and length of stay (OR 1.1, 95% CI 1.0–1.2, p = 0.019) were significantly associated with the use of discharge resources. Patients with continent vs incontinent urinary diversion were less likely to require discharge services (OR 0.4, 95% CI 0.2–0.8, p = 0.013). Conclusions: Older age, female gender, body mass index, comorbidities, length of stay and incontinent diversion are associated with increased use of discharge resources after radical cystectomy. Low health literacy may affect patient discharge disposition but it was not significant on multivariable analysis. Factors that influence the complex self‐care required of patients after cystectomy should be considered during discharge planning.

Natural biology and management of nonmuscle invasive bladder cancer.

Purpose of review This article reviews the natural biology of noninvasive bladder cancer and its management strategies while summarizing the most recent advances in the field. Recent findings Nonmuscle invasive bladder cancer (NMIBC) has a tendency to recur and progress. Risk stratification has helped triage patients but improved tools, including biomarkers, are still needed. Enhanced endoscopy with photodynamic imaging, narrow band imaging, optical coherence tomography and confocal laser endomicroscopy show promise for diagnosis, risk stratification and disease monitoring. Attempts at better treatment, especially in refractory high-risk cases, include the addition of intravesical hyperthermia, combination and sequential therapy with existing agents and the use of novel agents such as mycobacterial cell wall extract. New data are emerging regarding the potential role of active surveillance in low-risk patients. Summary NMIBC represents a variety of disease states and continues to pose management challenges. As our understanding of tumor biology improves and technology advances, achieving better outcomes through individualized care may be possible.

Chapter 13 – Prostate-Specific Antigen Screening Guidelines

The introduction of prostate-specific antigen (PSA) testing in 1986 dramatically increased the incidence of prostate cancer such that it is now the most commonly diagnosed cancer in the industrialized world. While PSA testing can detect prostate cancers at an early localized stage, screening for prostate cancer has generated considerable controversy because of the uncertainty surrounding its ability to lower prostate cancer mortality. PSA testing leads to overdiagnosis and overtreatment of this disease, resulting in significant detrimental physical, psychological, and financial consequences. In 2013 the United States Preventive Services Task Force (USPSTF) recommended against PSA testing because the harms of testing appear to outweigh the benefits. The American Urological Association developed new guidelines for the early detection of prostate cancer to balance reduction in prostate cancer mortality against the harms associated with screening. This chapter reviews evidence concerning the benefits and harms of PSA testing for prostate cancer.

The Neurovascular Bundle: Wide Excision

In select cases of high-volume prostate cancer, a wide excision of the neurovascular bundle is the best option. The decision can be made in part, based upon digital rectal examination, extent of disease on prostate biopsy, and possible staging MRI examination. This technique may avoid a positive surgical margin, but at the expense of reduced recovery of erectile function. In this chapter, we will consider the selection criteria for non-nerve sparing technique, relevant anatomy, and outcomes.

MP44-01 A COMPARISON OF PRACTICE PATTERNS IN THE MANAGEMENT OF VESICOURETERAL REFLUX BETWEEN PEDIATRIC UROLOGISTS AND PEDIATRIC NEPHROLOGISTS

INTRODUCTION AND OBJECTIVES: Vesicoureteral reflux (VUR) is often diagnosed and managed by both Pediatric Urologists (PU) and Pediatric Nephrologists (PN), yet little data exists comparing practice patterns between these two subspecialties. We sought to describe practice variation between PU and PN as it pertains to VUR. METHODS: An e-mail invitation was sent to 675 SPU and 753 ASPN members. Survey Monkey was used to obtain demographic and practice pattern data for commonly encountered clinical scenarios relating to VUR and urinary tract infection (UTI). Data from non-PU/PN responders and from those answering fewer than 37 of the 39 questions (95%) was excluded from analysis. Statistical analysis was performed using SPSS 17.0. Categorical variables were compared using Chisquare test or Fisher’s Exact Test. Pair-wise comparisons were made using the Bonferroni adjustment. RESULTS: 255 (18%) physicians responded; of these, 4 (2%) were non-PU/PN and 48 (19%) answered 95% of survey questions, resulting in a final cohort of 203 respondents (133 PU, 70 PN). Age and practice setting were similar; more non-US PU than PN responded to the survey (20% vs. 7%, P<0.05). 98% of PU and 83% of PN responded that they would evaluate a child with a single febrile UTI with imaging (p<0.001). 91% of PU and 99% of PN would evaluate a child with a multiple afebrile UTIs with imaging (p<0.001). Independent of the type of UTI, PU favor using KUB and DMSA more frequently than PN, whereas PN prefer renal sonogram or VCUG. 78% and 74% of PU were somewhat/very likely to consider deflux or reimplant for breakthrough infection, versus 60% and 28% of PN (p<0.05). 91% of PU vs. 76% of PN believe that treating bowel and bladder dysfunction (BBD) alone may lead to resolution of VUR (p<0.01). BBD screening by PU (58%) involved history and other modalities; PN rely most often on history alone (60%). 58% of urologists are somewhat/very likely to screen siblings with sonogram versus 40% of nephrologists (p<0.01). PU and PN were equally concerned with the emergence of resistant bacterial organisms when making decisions regarding prophylactic antibiotics (PN 72% vs. PU 69%). CONCLUSIONS: Minimal consensus exists between PU and PN in the diagnosis and management of VUR. PU use more diverse imaging in diagnosis and are more likely to pursue surgical intervention for breakthrough UTIs than PN. More aggressive evaluation for BBD by PU than PN may be related to belief in the impact BBD on VUR resolution. Further investigation is necessary to determine if practice variation is related to training, society guidelines, or other factors.