Varsha Sinha

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.

Liposuction and lipofilling for treatment of symptomatic silicone toxicosis of the gluteal region.

BACKGROUND Silicone injection can cause numerous posttreatment complications-including debilitating pain, cellulitis, abscesses, overlying skin compromise, and siliconomas distorting overlying tissues-that can be difficult to manage. OBJECTIVES The authors evaluate liposuction as a treatment for patients experiencing complications from silicone injections to the gluteal region, to both preserve aesthetic appearance and minimize further risk of complication from these procedures. METHODS Eight patients (7 women and 1 man) who presented consecutively to us between 2010 and 2013 with complications from silicone injections to their gluteal region were enrolled in this study. Each patient was evaluated by computed tomography scan and a 0 to 6 visual analog scale for pain. Emergency room (ER) visits, previous hospital admissions, and cellulitis requiring antibiotics in the 12 months prior to treatment were recorded. Patients were treated with ultrasonic and standard liposuction followed by lipotransfer into the gluteal musculature. A Student t test was used for statistical comparison of pre- and postoperative values. RESULTS Average patient age was 36 years (range, 25-43 years). All patients initially presented with intense pain as assessed by a visual analog scale; by the 12th week postoperatively, the entire cohort experienced remission in pain. At 1 year postoperatively, no patients had infections (vs 75% preoperatively; P = .028), visited the ER (vs 50% preoperatively; P = .058), or were hospitalized (vs an average of 1.5 hospitalizations per patient preoperatively; P = .066). CONCLUSIONS Liposuction with immediate intramuscular fat transfer for buttock augmentation appears to be a safe surgical option that preserves aesthetic appearance for patients with gluteal silicone toxicosis.

Reproductive health of men with spinal cord injury

Most men with spinal cord injury (SCI) are infertile due to a combination of erectile dysfunction, ejaculatory dysfunction, and abnormal semen quality. This article addresses issues that should be considered when managing the reproductive health of men with SCI. The authors present recommendations based on their decades of experience in managing the reproductive health of more than 1,000 men with SCI. Men with SCI face obstacles when pursuing sexual activity and/or biologic fatherhood. Hypogonadism and premature symptoms of aging may interfere with sexual function. Erectile dysfunction is prevalent in the SCI population, and treatments for erectile dysfunction in the general population are also effective in the SCI population. Most men with SCI cannot ejaculate with sexual intercourse. The procedures of penile vibratory stimulation (PVS) and/or electroejaculation (EEJ) are effective in obtaining an ejaculate from 97% of men with SCI. The ejaculate often contains sufficient total motile sperm to consider the assisted conception procedures of intrauterine insemination or even intravaginal insemination at home. If PVS and/or EEJ fail, sperm may be retrieved surgically from the testis or epididymis. Surgical sperm retrieval typically yields enough motile sperm only for in vitro fertilization with intracytoplasmic sperm injection. The majority of new cases of SCI occur in young men at the peak of their reproductive health. With proper medical management, these men can expect to experience active sexual lives and biologic fatherhood, if these are their goals. Numerous tools are available to physicians for helping these patients reach their goals.

Post-vasectomy pain syndrome: diagnosis, management and treatment options

Vasectomy is the most effective form of sterilization for men. With approximately 500,000 vasectomies performed each year in the United States, 1–2% of these patients will experience chronic testicular pain for greater than three months after the procedure. Post-vasectomy pain syndrome (PVPS) is diagnosis of exclusion, and may be caused by direct damage to spermatic cord structures, compression of nerves in the spermatic cord via inflammation, back pressure from epididymal congestion, and perineural fibrosis. Treatment should begin with the most noninvasive options and progress towards surgical management if symptoms persist. Noninvasive therapies include acupuncture, pelvic floor therapy and pharmacologic options. Ultimately, management of PVPS requires a multimodal approach. Thorough understanding of the potential etiologies of PVPS along with the therapeutic options currently available is important to improve quality of life.

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.

MP80-14 LYMPH NODE YIELD AS A PREDICTOR OF OVERALL SURVIVAL FOLLOWING REGIONAL LYMPHADENECTOMY FOR PENILE CANCER

INTRODUCTION AND OBJECTIVES: There is limited data to define an appropriate threshold for lymph node yield (LNY) following regional lymphadenectomy (rND) for penile squamous cell carcinoma (pSCC) and, whether that specific threshold impacts overall survival (OS). We sought to determine whether a specific LNY affects OS following rND for pSCC and, to define the minimum beneficial number of lymph nodes (LN) to retrieve. METHODS: Using the National Cancer Database (NCDB), we identified men diagnosed with pSCC, who underwent rND, from 2004 to 2013. We excluded men diagnosed on autopsy or at the time of death, with preoperative chemotherapy or radiotherapy, M+ disease, and with < 3 months of follow up. We assessed the statistical distribution of LNY following rND. A multivariable logistic regression model was developed to assess predictors of OS including: age, comorbidity, race, stage, grade, nodal status, and LNY. Kaplan-Meier (KM) survival analysis was performed to compare OS by varying thresholds of LNY. RESULTS: 938 men with pSCC underwent rND. Of these 452 met inclusion criteria. Median follow up was 29.9 months. The median number of regional LN retrieved was 16. Based on the statistical distribution of LNY and, sensitivity analysis, a threshold of 15 LNs appeared to be clinically and statistically relevant. There was no significant difference in race, stage, grade for men with LNY 15 vs >15. However, men with LNY 15 were older than those with LNY >15 (64 vs 58 years, p<0.01). On multivariable analysis, significant independent predictors of worse OS were: age (HR: 1.02; CI [1-1.03], p<0.05), N+ disease (HR: 3.06; CI [2.12-4.42], p<0.001), and LNY 15 (HR: 1.62; CI [1.17-2.24], p<0.01). Men with a LNY 15 demonstrated a significantly decreased 5-year OS compared to those with LNY > 15 (50% VS 73%, p<0.05). On subgroup analysis of men with T2, N0, LNY >15 trended toward better 5-year OS vs LNY 15 (90% VS 71%, p1⁄40.06) (Figure) CONCLUSIONS: LNY following rND for pSCC appears to have an impact on OS independent of age, stage, nodal status and grade. A minimum LNY >15 following rND may have a beneficial impact on OS and may serve as the quantitative threshold for defining an adequate rND.