Sammy E. Elsamra

Accuracy of Multiparametric Magnetic Resonance Imaging for Extracapsular Extension of Prostate Cancer in Community Practice.

INTRODUCTIONnThe presence of extracapsular extension (ECE) in prostate cancer (PCa) can influence a surgeons decision to perform a nerve-sparing approach during radical prostatectomy (RP). Preoperatively, multiparametric MRI (mp-MRI) is often used to stage PCa. More recently, the use of mp-MRI has gained wide acceptance in fusion biopsy of the prostate. In this framework, the reported accuracy of mp-MRI has been highly variable, with data often originating from large referral centers with experienced radiologists. We sought to determine the sensitivity and specificity of mp-MRI for detecting ECE in the community.nnnMATERIALS AND METHODSnWe reviewed a prospectively maintained database of men with PCa who had undergone RP. We recorded the prevalence of ECE at RP and determined the sensitivity, specificity, positive predictive value, and negative predictive value of MRI for detecting ECE. We assessed these values according to the DAmico risk groups and compared the predictive value of MRI to that of the Partin tables.nnnRESULTSnThe prevalence of ECE was 11.5%, 28.1%, and 47.1% in the low-, intermediate, and high-risk groups, respectively, with an overall prevalence of 24.1%. The overall sensitivity, specificity, positive predictive value, and negative predictive value of MRI was 12.5%, 93.1%, 36.4%, and 77.0%, respectively.nnnCONCLUSIONnThe reduction in the sensitivity of preoperative mp-MRI to determine ECE in the community setting is significant. Even with stratification using the DAmico criteria and Partin tables, the performance of mp-MRI was not significantly improved. Because most cases of PCa are diagnosed and treated in the community, it is questionable whether mp-MRI is a suitable staging modality in the community.

Pharmacokinetic drug evaluation of atezolizumab for the treatment of locally advanced or metastatic urothelial carcinoma.

ABSTRACT Introduction: Muscle invasive bladder cancer (MIBC) is difficult to manage for patients who progress during or after initial chemotherapy regimens. Current regimens offer low response rates with high toxicities. The advent of immune checkpoint inhibitors may represent a new opportunity for effective management of these patients. Areas covered: Atezolizumab is an engineered humanized monoclonal immunoglobulin G1 antibody that binds selectively to PD-L1 and prevents its interaction with PD-1 and B7-1. It is administered intravenously and is given every 3 weeks as long as there is no evidence of tumor progression. Phase I trials confirmed antitumor activity of atezolizumab in patients with advanced or metastatic urothelial carcinoma. Phase II trials showed an improved response rate and a longer durable response than current conventional therapy. Phase III trials are currently underway with an estimated accrual end date of 2017. Expert opinion: MIBC is a high-risk disease, and after progression on current chemotherapy regimens, second-line treatments leave much to be desired. Emerging evidence of efficacy and safety and a recent accelerated approval by the FDA presents atezolizumab as a promising treatment option. Current clinical challenges include the details of disease progression and determining where immune checkpoint inhibition will reside in the treatment algorithm.

Comparison of Urinary Tract Infection Rates Associated with Transurethral Catheterization, Suprapubic Tube and Clean Intermittent Catheterization in the Postoperative Setting: A Network Meta-Analysis

Purpose: We performed a network meta‐analysis of available randomized, controlled trials to elucidate the risks of urinary tract infection associated with transurethral catheterization, suprapubic tubes and intermittent catheterization in the postoperative setting. Materials and Methods: PubMed®, EMBASE® and Google Scholar™ searches were performed for eligible randomized, controlled trials from January 1980 to July 2015 that included patients who underwent transurethral catheterization, suprapubic tube placement or intermittent catheterization at the time of surgery and catheterization lasting up to postoperative day 30. The primary outcome of comparison was the urinary tract infection rate via a network meta‐analysis with random effects model using the netmeta package in R 3.2 (www.r‐project.org/). Results: Included in analysis were 14 randomized, controlled trials in a total of 1,391 patients. Intermittent catheterization and suprapubic tubes showed no evidence of decreased urinary tract infection rates compared to transurethral catheterization. Suprapubic tubes and intermittent catheterization had comparable urinary tract infection rates (OR 0.903, 95% CI 0.479–2.555). On subgroup analysis of 10 randomized, controlled trials with available mean catheterization duration data in a total of 928 patients intermittent catheterization and suprapubic tube were associated with significantly decreased risk of urinary tract infection compared to transurethral catheterization when catheterization duration was greater than 5 days (OR 0.173, 95% CI 0.073–0.412 and OR 0.142, 95% CI 0.073–0.276, respectively). Conclusions: Transurethral catheterization is not associated with an increased urinary tract infection risk compared to suprapubic tubes and intermittent catheterization if catheterization duration is 5 days or less. However, a suprapubic tube or intermittent catheterization is associated with a lower rate of urinary tract infection if longer term catheterization is expected in the postoperative period.

Can Activities of Daily Living Predict Complications following Percutaneous Nephrolithotomy

PURPOSEnActivities of daily living provide information about the functional status of an individual and can predict postoperative complications after general and oncological surgery. However, they have rarely been applied to urology. We evaluated whether deficits in activities of daily living could predict complications after percutaneous nephrolithotomy and how this compares with the Charlson comorbidity index and the ASA(®) (American Society of Anesthesiologists(®)) classification.nnnMATERIALS AND METHODSnWe retrospectively reviewed the records of all patients who underwent percutaneous nephrolithotomy between March 2013 and March 2014. Those with complete assessment of activities of daily living were included in analysis. Perioperative outcomes, complications and hospital length of stay were examined according to the degree of deficits in daily living activities.nnnRESULTSnOverall 176 patients underwent a total of 192 percutaneous nephrolithotomies. Deficits in activities of daily living were seen in 16% of patients, including minor in 9% and major in 7%. Complications developed more frequently in those with vs without deficits in daily living activities (53% vs 31%, p = 0.029) and length of stay was longer (2.0 vs 4.5 days, p = 0.005). On multivariate logistic regression activities of daily living were an independent predictor of complications (OR 1.11, p = 0.01) but ASA classification and Charlson comorbidity index were not.nnnCONCLUSIONSnActivities of daily living are easily evaluated prior to surgery. They independently predict complications following percutaneous nephrolithotomy better than the Charlson comorbidity index or the ASA classification. Preoperative assessment of daily living activities can help risk stratify patients and may inform treatment decisions.

Comparison of the Metabolic Profile of Mixed Calcium Oxalate/Uric Acid Stone Formers to That of Pure Calcium Oxalate and Pure Uric Acid Stone Formers

OBJECTIVEnTo compare the metabolic profile of patients who form mixed calcium oxalate (CaOx)/uric acid (UA) stones to those of pure CaOx and pure UA stone formers.nnnMETHODSnWe performed a retrospective review of 232 patients, with both stone composition analysis and 24-hour urine collection, seen between March 2002 and April 2012. Analysis of 24-hour urine constituents across the 3 stone groups (pure UA, pure CaOx, and mixed CaOx/UA) was performed using univariate analysis of variance and multivariate linear regression models adjusting for clinical and demographic factors and 24-hour urine collection elements.nnnRESULTSnA total of 27 patients (11.6%) had mixed CaOx/UA, 122 (52.6%) had pure CaOx, and 83 (35.8%) had pure UA calculi. Univariate analysis demonstrated significant differences between mixed CaOx/UA patients and pure CaOx patients for urine pH (mixed, 5.63 ± 0.49 vs pure, CaOx 5.93 ± 0.51; Pxa0= .009) and supersaturation (SS) UA (mixed, 1.84 ± 1.09 vs pure, CaOx 1.26 ± 0.93; Pxa0= .01), and a significant difference between mixed CaOx/UA patients and pure UA patients for SS CaOx (mixed, 7.18 ± 4.23 vs pure, UA 4.90 ± 2.96; Pxa0= .005). Multivariate analysis demonstrated that mixed CaOx/UA patients had no significant difference in SS CaOx as compared with pure CaOx patients (difference,xa0-0.27; Pxa0= .66), whereas at the same time had no significant difference in SS UA as compared with pure UA patients (-0.07; Pxa0=xa0.69).nnnCONCLUSIONnThe metabolic profile of patients who form mixed CaOx/UA stones demonstrates abnormalities that promote both CaOx and UA stone formation. Dietary and medical management for this group of patients should address treatment of both defects.

Open versus robotic cystectomy: Comparison of outcomes

Open radical cystectomy (ORC) is the current gold standard treatment for muscle invasive bladder cancer. As surgeons become more proficient in minimally invasive and robotic surgical techniques, the number of patients undergoing robotic-assisted radical cystectomy (RARC) is increasing. Although minimally invasive methods are on the rise, research that critically compares open surgery with robotic methods is limited. In this review, we surveyed and appraised the current literature comparing ORC and RARC with regards to perioperative, functional, and oncologic outcomes in order to distinguish the benefits and disadvantages of each method. Here we report that RARC is associated with several perioperative advantages over ORC such as lower estimated blood loss and transfusion rate, and possibly faster gastrointestinal recovery, lower narcotic requirement, and shorter length of stay. ORC is less costly and permits less time in the operating room. Recent data suggests that there is no difference between ORC and RARC when comparing urinary continence and postoperative quality of life. Moreover, ORC and RARC are both associated with similar rates of obtaining positive surgical margins, lymph node yield, and recurrence. However, RARC patients had an increased likelihood of having distant metastases to extrapelvic lymph nodes and the peritoneum. At this point, it is unclear if ORC or RARC has superior patient outcomes, and more research is needed to ascertain management-altering conclusions.

Radiation exposure during percutaneous ablation of small renal masses: A multi-institutional multimodality analysis

OBJECTIVEnTo understand the effective radiation dose during percutaneous cryoablation (CA) and radiofrequency ablation (RFA) and characterize variables that may affect the individual dose.nnnMATERIALS AND METHODSnThe effective radiation dose was determined by conversion of the dose-length product from CT scans performed during percutaneous CA or RFA for patients with solitary renal masses (<4u2009cm) at four academic centers. Radiation dose per case was compared between patients and institutions using multivariate and univariate analysis. Lifetime attributable risk of cancer was calculated for each institution and utilized to determine the number needed to harm for a range of ages at the time of exposure.nnnRESULTSnOne hundred twenty-three patients met the inclusion criteria with a mean age of 71 years. Sixty-nine percent of patients were male, mean body-mass index (BMI) was 29.4, and mean tumor size was 2.2u2009cm. The mean effective radiation dose per ablation was 40 mSv (range 3.7-147). On multivariate analysis, only BMI and institution were associated with the radiation dose. No significant difference in radiation exposure was seen for RFA or CA procedures.nnnCONCLUSIONSnRadiation exposure during percutaneous ablation is similar to a multiphase CT scan. However, there is wide variability in individual treatment exposure, varying from 3.7 to 147 mSv, depending primarily on institution and BMI. Standardization of protocols is required to achieve as low as reasonably achievable levels of radiation.

Twitter Use among Academic Urology Programs

Introduction: Twitter is a popular social media platform that has an important role in the urological community. Benefits include dissemination of knowledge, cross‐institutional communication, amplification of conference content and greater engagement of the public, with increased departmental exposure. However, to date the use of Twitter by academic urology programs has yet to be examined. Methods: The existence and profile of institutional Twitter accounts of each United States urology residency program was recorded and reassessed in 6 months. Geographic stratification of Twitter presence was evaluated with chi‐square analysis. The relationship between Twitter variables and U.S. News and World Report ranking was evaluated using Pearsons correlation coefficient. Detailed account data were collected for the top 5 accounts by tweet volume. Conference hashtag activity for the 2013 to 2015 AUA (American Urological Association) annual meetings was compared. Results: The total number of residency programs with a Twitter account is 38 (30%). Median number of tweets, followers, following and age of account was 58, 154, 107.5 and 20 months, respectively. Geographic stratification failed to show significant difference (p=0.73). Of the 38 accounts 11 were inactive over 6 months. The 27 active accounts had an average percent increase of 161% in tweets and 148% in followers. Twitter presence showed no difference in U.S. News and World Report ranking (p=0.51). The conference hashtags #AUA13 to #AUA15 increased in activity each year. Conclusions: A minority of academic urology programs use Twitter. Account activity grew significantly with time. The role of Twitter is still being defined but is rapidly gaining traction as a new powerful communication tool among urologists and with the public.

Chairmen in Academic Urologic Practice: A Descriptive Analysis

OBJECTIVEnTo examine and characterize the demographics and scholarly characteristics of academic urology chairmen at the time of appointment.nnnMATERIALS AND METHODSnThe chairman of each United States urology residency program as of September 2016 was included in the study. Interim chairmen, as well as programs for which no clearly defined chair could be identified, were excluded. Demographic and academic data were collected via publically available curriculum vitae, departmental websites, Google search engine, and PubMed and Scopus websites.nnnRESULTSnOne hundred thirteen chairmen were included in the study. The majority were male (96%) and mean age at appointment was 46 years (standard deviationu2009=u20096.3 years). Mean number of publications and H-index at the time of appointment was 105 and 31.1, respectively. Fellowship training was completed by 75% of chairmen, of which urologic oncology (Nu2009=u200943), endourology (Nu2009=u200912), and infertility/andrology (Nu2009=u200910) were the most common. The most common additional graduate degrees prior to appointment were MBA (Nu2009=u20097) and PhD (Nu2009=u20096). The most frequently attended institutions for residency were Johns Hopkins University (13) and Northwestern University (5), whereas Memorial Sloan Kettering Cancer Center (13) and Baylor University (7) were the most frequent for fellowship. Twenty percent of chairmen attained the chairman position at their former residency program and 7% at their former fellowship program.nnnCONCLUSIONnOur study describes the demographic and academic characteristics of urology academic chairmen at the time of appointment. The majority of chairmen are male and specialize in urologic oncology. Chairmen often receive the chair appointment at their former residency program.

Androgen deprivation therapy for the treatment of prostate cancer: a focus on pharmacokinetics

ABSTRACT Introduction: Medical therapy has undergone many changes as our understanding of prostate cancer cell biology has improved. Androgen deprivation therapy (ADT) remains the mainstay of therapy for metastatic disease. Metastatic castrate-resistant prostate cancer (CRPC) is an important concern since we are unable to stop progression with currently available agents. Areas covered: Pharmacologic ADT is the most commonly used treatment for metastatic prostate cancer. Multiple agents are available for both first-line and second-line use: antiandrogens, estrogens, luteinizing hormone-releasing hormone agonists/antagonists, and CYP17 inhibitors. With adoption of these drugs, it is important to consider their pharmacokinetic and pharmacodynamic properties. Many undergo metabolism through cytochrome P450. Levels may be altered with co-administration of drugs acting as enzyme inhibitors or inducers. Understanding mechanism of action, metabolism, and excretion of these drugs allows clinicians to provide the best therapeutic care while minimizing adverse events. Expert opinion: Many men with metastatic prostate cancer will progress to castration resistance. An understanding of resistance mechanisms at the cellular level has revealed new drug targets with hopes of halting or reversing progression of metastatic disease. Second-line agents, traditionally reserved for CRPC, are being studied in metastatic castrate-sensitive prostate cancer, and may offer practice-changing evidence supporting their use.