Lawrence C. Jenkins

ICUD-EAU international consultation on bladder cancer 2012: Screening, diagnosis, and molecular markers

CONTEXT AND OBJECTIVE To present a summary of the 2nd International Consultation on Bladder Cancer recommendations on the screening, diagnosis, and markers of bladder cancer using an evidence-based strategy. EVIDENCE ACQUISITION A detailed Medline analysis was performed for original articles addressing bladder cancer with regard to screening, diagnosis, markers, and pathology. Proceedings from the last 5 yr of major conferences were also searched. EVIDENCE SYNTHESIS The major findings are presented in an evidence-based fashion. Large retrospective and prospective data were analyzed. CONCLUSIONS Cystoscopy alone is the most cost-effective method to detect recurrence of bladder cancer. White-light cystoscopy is the gold standard for evaluation of the lower urinary tract; however, technology like fluorescence-aided cystoscopy and narrow-band imaging can aid in improving evaluations. Urine cytology is useful for the diagnosis of high-grade tumor recurrence. Molecular medicine holds the promise that clinical outcomes will be improved by directing therapy toward the mechanisms and targets associated with the growth of an individual patients tumor. The challenge remains to optimize measurement of these targets, evaluate the impact of such targets for therapeutic drug development, and translate molecular markers into the improved clinical management of bladder cancer patients. Physicians and researchers eventually will have a robust set of molecular markers to guide prevention, diagnosis, and treatment decisions for bladder cancer.

ICUD-EAU international consultation on bladder cancer 2012: Pathology

CONTEXT To present a summary of the 2nd International Consultation on Bladder Cancer recommendations on the pathology of bladder cancer using an evidence-based strategy. OBJECTIVE To standardize descriptions of the diagnosis and reporting of urothelial carcinoma of the bladder and help optimize uniformity between individual pathology practices and institutions. EVIDENCE ACQUISITION A detailed Medline analysis was performed for original articles addressing bladder cancer with regard to pathology. Proceedings from the last 5 yr of major conferences were also searched. EVIDENCE SYNTHESIS The major findings are presented in an evidence-based fashion. Large retrospective and prospective data were analyzed. CONCLUSIONS Providing the best management for patients with bladder neoplasia relies on close cooperation and teamwork among urologists, oncologists, radiologists, and pathologists.

Ablative therapies for small renal tumours

Improvements in imaging technology have resulted in an increase in detection of small renal masses (SRMs). Minimally invasive ablation modalities, including cryoablation, radiofrequencey ablation, microwave ablation and irreversible electroporation, are currently being used to treat SRMs in select groups of patients. Cryoablation and radiofrequency ablation have been extensively studied. Presently, cryoablation is gaining popularity because the resulting ice ball can be visualized easily using ultrasonography. Tumour size and location are strong predictors of outcome of radiofrequency ablation. One of the main benefits of microwave ablation is that microwaves can propagate through all types of tissue, including desiccated and charred tissue, as well as water vapour, which might be formed during the ablation. Irreversible electroporation has been shown in animal studies to affect only the cell membrane of undesirable target tissues and to spare adjacent structures; however, clinical studies that depict the efficacy and safety of this treatment modality in humans are still sparse. As more experience is gained in the future, ablation modalities might be utilized in all patients with tumours <4 cm in diameter, rather than just as an alternative treatment for high-risk surgical patients.

ICUD-EAU International Consultation on Bladder Cancer 2012: Urothelial Carcinoma of the Prostate

CONTEXT The Second International Consultation on Bladder Cancer recommendations on urothelial carcinoma (UC) of the prostate were presented at the 2011 European Association of Urology Congress in Vienna, Austria, on March 18, 2011. OBJECTIVE Our aim is to summarize the Second International Consultation on Bladder Cancer recommendations on UC of the prostate to help clinicians assess the current evidence-based management. EVIDENCE ACQUISITION The committee performed a thorough review of new data and updated previous recommendations. Levels of evidence and grades of recommendation were assigned based on a systematic review of the literature that included a search of online databases and review articles. EVIDENCE SYNTHESIS Once a non-muscle-invasive high-grade tumor or carcinoma in situ (CIS) of the bladder has been diagnosed, careful follow-up of the prostatic urethra is necessary. Noninvasive UC including CIS of the prostate should be treated with intravesical bacillus Calmette-Guérin (BCG) following endoscopic resection. A transurethral resection of the prostate may improve contact of BCG with the prostatic urethra, and it appears that response rates to BCG are increased (level of evidence: 3). Transurethral biopsy of the prostatic urethra is effective in identifying prostatic involvement but may not accurately reveal the extent of involvement, particularly with stromal invasion. Stromal invasion by UC of the prostate carries a poor prognosis. Radical cystoprostatectomy is the treatment of choice for locoregional control in patients with prostatic stromal invasion. CONCLUSIONS These recommendations contain updated information on the diagnosis and treatment of UC of the prostate. However, prospective trials are needed to further elucidate the best management of these patients.

Active surveillance for low-risk bladder cancer

BACKGROUND Most newly diagnosed bladder cancers present as non-muscle invasive bladder cancer (NMIBC). NMIBC is a heterogeneous disease with varying treatment options, follow-up schedules, and oncologic outcomes. We sought to review the role of active surveillance for low risk bladder cancer in the literature. METHODS A PubMed search was performed using the following keywords: active surveillance, low risk, bladder, transurethral resection of bladder tumor, cost, and quality of life. Relevant articles were reviewed and utilized. RESULTS Low-risk bladder cancer--defined as pTa low-grade papillary tumors--is the type of NMIBC with the most favorable oncologic outcome and which almost never progresses to muscle invasive disease or metastasizes. Bladder cancer has the highest per patient treatment costs of all cancers. One of the reasons is the high rate of recurrence. Patients with low-grade bladder tumors often experience a recurrence after primary transurethral resection. Many patients undergo multiple resections in the hospital. CONCLUSIONS Appropriately selected patients with recurrent low-risk bladder cancer could be managed with either office fulguration or cystoscopic surveillance. Active surveillance for patients with low-risk bladder cancer avoids or delays the surgical and anesthetic risks of a TURBT, thus optimizing quality of life without compromising the patients risk of cancer progression.

MP56-19 COMPARING PLAQUE MORPHOLOGY BETWEEN MEN DEVELOPING PEYRONIE'S DISEASE (PD) AFTER RADICAL PROSTATECTOMY (RP) TO THAT OF DE NOVO PEYRONIE'S DISEASE PATIENTS

METHODS: Penile tissues from 12 Scx-GFP mice with ages 4 week, 5 week, 6 week, and 1.2 years, were dissected and processed following routine histology protocols. 6mm thick sections were stained with H&E, Massons’ trichrome (TRI), Verhoeff’s elastin (ELA), and DAPI. All sections were imaged using bright field or fluorescence microscopy techniques. Cell orientations along collagen fibers with age were analyzed using Image J Fiji. RESULTS: Figure: With age, CCG illustrated well-oriented struts at an angle of 32 to the baculum. Additionally, scleraxis and elastin expressions, and smooth muscle content increased within the struts, specifically in the 6 week-old mice. The expression of scleraxis indicated that the CCG contains mechanoactive collagenous and elastin-ridden struts that support biomechanical function of the baculum. Within the CCG of the mouse, there was more sinusoidal space in the younger age groups (4-6 weeks), and this space decreased with age, and elastin expression increased significantly (see 1 year). Compared to the CCG (A,C,E,G), the CCP (B,D,F,H) illustrated significantly lower expressions of scleraxis, elastin, and smooth muscle. CONCLUSIONS: The collagen-producing fibroblasts within the CCG and CCP express scleraxis, indicative of local mechanoactive areas. Based upon orientation of cells expressing scleraxis, the biomechanical function of the CCP is to push the glans of the penis like a piston, while the CCG stiffens the penis during erection and pulls the glans of the penis back into the prepuce post-erection. The CCG is similar to the HCC with regard to compositional ratio of collagen to muscle, elastin localization, and biomechanical function and as such is a good model to study human penile physiology.

MP84-19 BOTHER ASSOCIATED WITH CLIMACTURIA AFTER RADICAL PROSTATECTOMY: PREVALENCE, DEGREE AND PREDICTORS

INTRODUCTION AND OBJECTIVES: While erectile dysfunction (ED) and incontinence are well-understood complications of radical prostatectomy (RP), climacturia remains under-appreciated despite its prevalence in this population. Clinical experience suggests that many men and partners are bothered by this RP sequela. Our objective was to characterize and define predictors of climacturia-associated bother in men and their partners after RP. METHODS: The study was a retrospective review of all men presenting to a single center for management of sexual dysfunction following RP. Patients were queried on various domains of sexual dysfunction including ED, orgasmic and ejaculatory dysfunction, sexual incontinence, and penile deformity. Patients were specifically asked to quantify the amount and frequency of climacturia as well to report their level of bother and to quantify the degree of partner bother. Predictors of bother in patients with climacturia were determined using multivariable analysis (MVA). RESULTS: 252 patients post-RP were included. Mean patient and partner ages were 60 8 years and 55 9 years, respectively. 81% of patients were white and 82% of patients were in stable relationships with a mean duration of 24 14 years. 59% of patients reported at least one occurrence of climacturia. Significantly more men reported bother related to climacturia than partner bother related to OAI (39% vs 13%, respectively; RR1⁄42.95, 95% CI: 2.29-3.80, p<0.01). Patient and reported partner bother were related (r1⁄40.31, p<0.001). Both patient and partner bother were negatively related to length of relationship (r1⁄4-0.14, p1⁄40.05; r1⁄4-0.18, p1⁄40.02). In MVA predicting patient bother, only perceived partner bother remained significant (OR1⁄44.49, 95% CI: 1.6412.27, p<0.01). In MVA predicting reported partner bother, both patient bother (OR1⁄44.49, 95% CI: 1.64-12.27, p<0.01) and duration of relationship (OR1⁄40.96, 95% CI: 0.92-1.00, p1⁄40.05) were significant predictors. CONCLUSIONS: Climacturia is highly prevalent (59% of men) and bothersome in men and their partners following RP. While patient and partner bother from climacturia are related and more commonly seen in shorter relationships, patients are more bothered by climacturia than are their partners. Physicians treating patients with RP should both counsel patients about climacturia pre-operatively and specifically inquire about climacturia post-operatively.

MP84-02 UTILITY OF 2D PHOTOGRAPHY IN THE ASSESSMENT OF PENILE CURVATURE IN MEN WITH PEYRONIE's DISEASE (PD): THE GOSOFT STUDY

INTRODUCTION AND OBJECTIVES: Penile duplex Doppler ultrasound (PDDU) with intracavernosal injection (ICI) with erectogenic agents is commonly used to evaluate vascular parameters in men with erectile dysfunction (ED). Recent studies have suggested significant variability in outcomes based on ICI dosing protocols, suggesting a need for standardization of injection protocols. Given a lack of literature on this topic, we sought to identify predictors for increased need of ICI dosing to achieve adequate rigidity at the time of PDDU. METHODS: A retrospective chart review was performed of all patients undergoing PDDU for evaluation of ED from January 2014 to November 2015. At the time of PDDU, men received a combination of papaverine(30 mg/mL), phentolamine(1 mg/mL), and alprostadil(10 mcg/mL) in 0.1 mL increments until an erection sufficient for penetration was achieved or 1.0 cc was administered. Clinicopathologic and demographic variables were reviewed, and univariate and multivariate analyses were used to identify characteristics associated with increased erectogenic requirements. RESULTS: A total of 262 men (mean age 53;) underwent PDDU during the study period. Mean IIEF-6 score was 12.4 (SD 10.2), and a mean 2.1 injections (SD 1.1) with 0.34 cc (SD 0.34) were administered. On multivariate analysis, lower IIEF-ED domain score (p<0.01), coronary disease (p1⁄40.03), and diabetes (p1⁄40.01) were associated with increased requirement for erectogenic medications. CONCLUSIONS: Patients with lower IIEF scores, coronary disease, and diabetes mellitus may require higher volumes of erectogenic medications at the time of PDDU. This information may help to create standardized and efficient protocols for repeated dosing regimen.

PD31-05 THE DEPRESSION AND RELATIONSHIP IMPACT IN PEYRONIE'S DISEASE STUDY (DRIPD): BASELINE POPULATION CHARACTERISTICS AND PREDICTORS

(PEG/PIG) at the time of IPP was rare (45/1124, 4.0%), indicating that 96% of adjunctive maneuvers used to achieve straightening were either penile modeling or tunical plications. In men with PD without ED, 7% (35/501) underwent IPP placement with the remainder of procedures split almost evenly between tunical plication (235/501, 46.9%) and PEG/PIG (231/501, 46.1%). Only 2.8% (13/466) of men with PD treated with non-implant surgery went on to have an IPP. CONCLUSIONS: This is the first published description of PD surgical practice patterns derived from a large, population-based dataset. 70% of men that underwent surgery for PD in New York had concomitant ED and received an IPP. In the vast majority of these cases, complex reconstructive procedures using grafting was not required. Patients with PD without ED were usually treated with nonimplant procedures, and these men only rarely went on to receive an IPP.

MP76-12 REGULAR LOW DOSE SILDENAFIL REDUCES VENOUS LEAK RATES AFTER RADICAL PROSTATECTOMY

days preceding visits. Quality of life (QoL) was assessed by the SF36 questionnaire at Weeks 1 and 52 (end of study). RESULTS: Hypogonadal subjects with SD were significantly older (p1⁄40.001), and had lower serum estradiol levels (p1⁄40.043); baseline T levels were not significantly different. Sexual desire and activity, which were similar in both groups at baseline, improved to a similar extent in each group. In men with and without SD, LPCN 1021 significantly improved penile rigidity (p<0.001 and p1⁄40.028, respectively) and ability to maintain an erection (p<0.001 and p1⁄40.007, respectively). Non-significant differences were observed for the same with T gel 1.62%. In addition, LPCN 1021 significantly improved depressed mood (p1⁄40.002), mental health (p1⁄40.023) and mental component summary (p1⁄40.008) in hypogonadal subjects with SD. CONCLUSIONS: Conclusions: Twice daily administration of oral LPCN 1021 over 52 weeks improved several parameters of sexual function in hypogonadal men with SD prior to treatment. 1Cunningham GR, et al. J Clin Endocrinol Metab. 2015 Mar;100(3):1146-55.