Publications by authors named "Jay D Raman"

309 Publications

Perioperative Aspirin Use is Associated with Bleeding Complications During Robotic Partial Nephrectomy.

J Urol 2021 Sep 23:101097JU0000000000002240. Epub 2021 Sep 23.

Beth Israel Deaconess Medical Center, Boston, Massachusetts.

Introduction And Objective: Daily aspirin use following cardiovascular intervention is commonplace and creates concern regarding bleeding risk in patients undergoing surgery. Despite its cardio-protective role, aspirin is often discontinued 5-7 days prior to major surgery due to bleeding concerns. Single institution studies have investigated perioperative outcomes of aspirin use in robotic partial nephrectomy (RPN). We sought to evaluate the outcomes of perioperative aspirin (pASA) use during RPN in a multicenter setting.

Methods: We performed a retrospective evaluation of patients undergoing RPN at 5 high volume RPN institutions. We compared perioperative outcomes of patients taking pASA (81 mg) to those not on aspirin. We analyzed the association between pASA use and perioperative transfusion.

Results: Of 1565 patients undergoing RPN, 228 (14.5%) patients continued pASA and were older (62.8 vs. 56.8 years, p <0.001) with higher Charlson scores (mean 3 vs. 2, p <0.001). pASA was associated with increased perioperative blood transfusions (11% vs. 4%, p <0.001) and major complications (10% vs. 3%, p <0.001). On multivariable analysis, pASA was associated with increased transfusion risk (OR 1.94, 1.10-3.45, 95% CI).

Conclusions: In experienced hands, perioperative aspirin 81 mg use during RPN is reasonable and safe, however, there is a higher risk of blood transfusions and major complications. Future studies are needed to clarify the role of antiplatelet therapy in RPN patients requiring pASA for primary or secondary prevention of cardiovascular events.
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http://dx.doi.org/10.1097/JU.0000000000002240DOI Listing
September 2021

Primary Chemoablation of Low-Grade Intermediate-Risk Non-Muscle-Invasive Bladder Cancer Using UGN-102, A Mitomycin-Containing Reverse Thermal Gel (Optima II): A Phase 2b, Open-Label, Single-Arm Trial.

J Urol 2021 Aug 26:101097JU0000000000002186. Epub 2021 Aug 26.

NYU Langone Urology Associates, New York, New York.

Purpose: Low-grade intermediate-risk non-muscle-invasive bladder cancer (LG IR NMIBC) is a recurrent disease, thus requiring repeated transurethral resection of bladder tumors (TURBT) under general anesthesia. We evaluated the efficacy and safety of UGN-102, a mitomycin-containing reverse thermal gel, as a primary chemoablative therapeutic alternative to TURBT for patients with LG IR NMIBC.

Materials And Methods: This prospective, Phase 2b, open-label, single-arm trial recruited patients with biopsy-proven LG IR NMIBC to receive 6 once-weekly instillations of UGN-102. The primary endpoint was complete response (CR) rate, defined as the proportion of patients with negative endoscopic examination, negative cytology, and negative for-cause biopsy 3 months after treatment initiation. Patients with CR were followed quarterly up to 12 months to assess durability of treatment effect. Safety and adverse events were monitored throughout the trial.

Results: Sixty-three patients (38 males, 25 females, 33-96 years) enrolled and received ≥1 instillation of UGN-102. Forty-one (65%) achieved CR at 3 months, of whom 39 (95%), 30 (73%), and 25 (61%) remained disease-free at 6, 9, and 12 months after treatment initiation, respectively; 13 patients had documented recurrences. The probability of durable response 9 months after CR (12 months after treatment initiation) was estimated to be 73% by Kaplan-Meier analysis. Common adverse events (incidence ≥10%) included dysuria, urinary frequency, hematuria, micturition urgency, urinary tract infection, and fatigue.

Conclusions: Nonsurgical primary chemoablation of LG IR NMIBC using UGN-102 resulted in significant treatment response with sustained durability. UGN-102 may provide an alternative to repetitive surgery for patients with LG IR NMIBC.
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http://dx.doi.org/10.1097/JU.0000000000002186DOI Listing
August 2021

The Diagnostic Performance of Cxbladder Resolve, Alone and in Combination with Other Cxbladder Tests, in the Identification and Priority Evaluation of Patients at Risk for Urothelial Carcinoma.

J Urol 2021 Aug 5:101097JU0000000000002135. Epub 2021 Aug 5.

Kaiser Permanente, Pasadena, California.

Purpose: Cxbladder (Cxb) tests combine genomic biomarkers in urine with phenotypic and clinical data to classify hematuria patients into those at low/high probability of urothelial carcinoma (UC). Cxbladder Resolve (CxbR) is designed for use after Cxb Triage (CxbT) and Detect (CxbD), where CxbT-positive tests reflex to CxbD and CxbD-positive to CxbR to identify patients at high probability of high-impact tumors (HIT; high grade Ta, Tis or T1-T3). This study validated the diagnostic performance of CxbR in identifying HIT, and validated the algorithm of Cxb tests to segregate high-impact from low-impact tumors.

Materials And Methods: CxbR was developed in 863 hematuria patients in 3 studies in United States, Australia and New Zealand. CxbR, separately and combined with other Cxb tests, was validated in a prospective, observational U.S. study in 548 hematuria patients. All UC diagnoses were confirmed by histopathology.

Results: In the development data set, CxbR sensitivity was 92.4% (95% CI 83.3-96.7) and specificity 93.8% (95% CI 86.8-97.2) for identifying HIT within the high priority category. During external validation, sequential Cxb tests correctly ruled out 87.6% of patients from further workup (negative predictive value 99.4%); 100% of HIT were correctly identified (specificity 96.3%), and 3 low-grade tumors were missed. In both studies, all patients with HIT were correctly assigned to prioritized evaluation.

Conclusions: CxbR has high sensitivity and specificity, correctly identifying all HIT. Sequential Cxb tests accurately segregate patients with a low vs high probability of HIT, focusing resources on those patients, with a diagnostic yield 4.8-fold higher than American Urological Association guideline stratification.
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http://dx.doi.org/10.1097/JU.0000000000002135DOI Listing
August 2021

Bladder Chemoprophylaxis Following Ureterorenoscopy in Patients with Upper Tract Urothelial Carcinoma.

Eur Urol Focus 2021 Jul 30. Epub 2021 Jul 30.

Universidad Nacional de Rosario, Santa Fe, Argentina.

Kidney-sparing procedures for upper tract urothelial carcinoma (UTUC) have evolved from imperative to elective indications for management of low-risk disease. Ureterorenoscopy is the most common procedure for the diagnosis, treatment, and surveillance of UTUC. A notable consideration following ureterorenoscopy is the higher risk of downstream bladder seeding. Here we review the importance of and scientific evidence for chemoprophylaxis after ureterorenoscopy. PATIENT SUMMARY: For patients with low-risk cancer of the upper urinary tract, a procedure called ureterorenoscopy (URS) involving insertion of a thin telescope through the ureter and into the kidney is increasingly used for biopsy. URS increases the risk of cancer seeding in the bladder. We review evidence on the benefit of prophylactic bladder chemotherapy after URS.
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http://dx.doi.org/10.1016/j.euf.2021.07.007DOI Listing
July 2021

Predictive model for systemic recurrence following cisplatin-based neoadjuvant chemotherapy and radical nephroureterectomy for high risk upper tract urothelial carcinoma.

Urol Oncol 2021 Jul 28. Epub 2021 Jul 28.

Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX; Institute for Urology and Reproductive Health, Sechenov University, Moscow.

Introduction: Neoadjuvant chemotherapy (NAC) is increasingly used prior to radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). Systemic recurrence (SR) carries a dismal prognosis. We sought to determine risk factors associated with SR in this setting.

Methods: We evaluated a multi-center database of patients with UTUC who received cisplatin-based NAC before RNU. Final pathology at RNU was dichotomized into ypT<2 vs ypT≥2. Univariable and multivariable analyses were performed to identify risk factors associated with SR. Three groups were defined based on the number of significant risk factors (groups 1, 2, 3 for 0-1, 2, 3 risk factors, respectively) and evaluated for recurrence-free survival (RFS) using the Kaplan-Meier method.

Results: 106 patients were identified between 2004 and 2018. Median age was 67.0 years [IQR = 61-73.3]; 57 (54%) and 49 (46 %) patients received MVAC and GC, respectively. Final pathological stage was ypT<2 in 57 (54%); 23% (24/106) had SR. On univariable analysis, pathological variables on final specimen including ypT≥2, lymphovascular invasion (ypLVI), and nodal involvement were associated with SR. On multivariable analysis, ypLVI OR = 4.1 (95% CI 1.2-13.6; P = 0.024) and pathological nodal involvement OR = 4.5 (95% CI 1.3-15.7; P = 0.017) were predictive of recurrence. Stratifying by the number of risk factors, the 2-year RFS was 95%, 55%, and 18% for groups 1, 2, and 3 respectively (log-rank <0.001).

Conclusion: This model evaluates the risk of SR following NAC and RNU to guide counseling and decision-making after surgery. Adverse pathological variable including ypLVI and nodal involvement, in combination with ypT-stage, are strongly associated with SR.
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http://dx.doi.org/10.1016/j.urolonc.2021.05.037DOI Listing
July 2021

Warm ischemia time length during on-clamp partial nephrectomy: dose it really matter?

Minerva Urol Nephrol 2021 Jul 26. Epub 2021 Jul 26.

Department of Urology, La Paz University Hospital, Madrid, Spain.

Background: The impact of warm ischemia time (WIT) on renal functional recovery remains controversial. We examined the length of WIT >30 min. on the long-term renal function following on-clamp partial nephrectomy (PN).

Methods: Data from 23 centers for patients undergoing on-clamp PN between 2000 and 2018 were analyzed. We included patients with two kidneys, single tumor, cT1, minimum 1-year followup, and preoperative eGFR ≥60 ml/min/1.73m2. Patients were divided into two groups according to WIT length: group Ⅰ "WIT ≤30 min." and group Ⅱ "WIT >30 min.". A propensity-score matched analysis (1:1 match) was performed to eliminate potential confounding factors between groups. We compared eGFR values, eGFR (%) preservation, eGFR decline, events of chronic kidney disease (CKD) upgrading, and CKD-free progression rates between both groups. Cox regression analysis evaluated WIT impact on upgrading of CKD stages.

Results: The primary cohort consisted of 3526 patients: group Ⅰ (n=2868) and group Ⅱ (n=658). After matching the final cohort consisted of 344 patients in each group. At last followup, there were no significant differences in median eGFR values at 1, 3, 5, and 10 years (P>0.05) between the matched groups. In addition, the median eGFR (%) preservation and absolute eGFR change were similar (89% in group Ⅰ vs. 87% in group Ⅱ, p=0.638) and (-10 in group Ⅰ vs. -11 in group Ⅱ, p=0.577), respectively. The 5 years new-onset CKD-free progression rates were comparable in the non-matched groups (79% in group Ⅰ vs. 81% in group Ⅱ, log-rank, p=0.763) and the matched groups (78.8% in group Ⅰ vs. 76.3% in group Ⅱ, log-rank, p=0.905). Univariable Cox regression analysis showed that WIT >30 min. was not a predictor of overall CKD upgrading (HR:0.953, 95%CI 0.829-1.094, p=0.764) nor upgrading into CKD stage ≥Ⅲ (HR:0.972, 95%CI 0.805-1.173, p=0.764). Retrospective design is a limitation of our study.

Conclusions: Our analysis based on a large multicenter international cohort study suggests that WIT length during PN has no effect on the long-term renal function outcomes in patients having two kidneys and preoperative eGFR ≥60 ml/min/1.73m2.
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http://dx.doi.org/10.23736/S2724-6051.21.04466-9DOI Listing
July 2021

Assessment of Prostate Cancer Treatment Among Black and White Patients During the COVID-19 Pandemic.

JAMA Oncol 2021 Jul 22. Epub 2021 Jul 22.

Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania.

Importance: Early in the COVID-19 pandemic, racial/ethnic minority communities disproportionately experienced poor outcomes; however, the association of the pandemic with prostate cancer (PCa) care is unknown.

Objective: To assess the association between race and PCa care delivery for Black and White patients during the first wave of the COVID-19 pandemic.

Design, Setting, And Participants: This multicenter, regional, collaborative, retrospective cohort study compared prostatectomy rates between Black and White patients with untreated nonmetastatic PCa during the COVID-19 pandemic (269 patients from March 16 to May 15, 2020) and prior (378 patients from March 11 to May 10, 2019).

Main Outcomes And Measures: Prostatectomy rates.

Results: Of the 647 men with nonmetastatic PCa, 172 (26.6%) were non-Hispanic Black men, and 475 (73.4%) were non-Hispanic White men. Black men were significantly less likely to undergo prostatectomy during the pandemic compared with White patients (1 of 76 [1.3%] vs 50 of 193 [25.9%]; P < .001), despite similar COVID-19 risk factors, biopsy Gleason grade groups, and comparable prostatectomy rates prior to the pandemic (17 of 96 [17.7%] vs 54 of 282 [19.1%]; P = .75). Black men had higher median prostate-specific antigen levels prior to biopsy (8.8 ng/mL [interquartile range, 5.3-15.2 ng/mL] vs 7.2 ng/mL [interquartile range, 5.1-11.1 ng/mL]; P = .04). A linear combination of regression coefficients with an interaction term for year demonstrated an odds ratio for likelihood of surgery of 0.06 (95% CI, 0.01-0.35; P = .002) for Black patients and 1.41 (95% CI, 0.81-2.44; P = .23) for White patients during the pandemic compared with prior to the pandemic. Changes in surgical volume varied by site (from a 33% increase to complete shutdown), with sites that experienced the largest reduction in cancer surgery caring for a greater proportion of Black patients.

Conclusions And Relevance: In this large multi-institutional regional collaborative cohort study, the odds of PCa surgery were lower among Black patients compared with White patients during the initial wave of the COVID-19 pandemic. Although localized PCa does not require immediate treatment, the lessons from this study suggest systemic inequities within health care and are likely applicable across medical specialties. Public health efforts are needed to fully recognize the unintended consequence of diversion of cancer resources to the COVID-19 pandemic to develop balanced mitigation strategies as viral rates continue to fluctuate.
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http://dx.doi.org/10.1001/jamaoncol.2021.2755DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8299356PMC
July 2021

Potential Winners and Losers: Understanding How the Oncology Care Model May Differentially Affect Hospitals.

JCO Oncol Pract 2021 Aug 9;17(8):e1150-e1161. Epub 2021 Jul 9.

Division of Urology, Penn State College of Medicine, Hershey, PA.

Purpose: With the introduction of the Oncology Care Model and plans for the transition to Oncology Care First, alternative payment models (APMs) are an increasingly important piece of the oncology care landscape. Evidence is mixed on the Oncology Care Model's impact on utilization and costs, but as policymakers consider expansion of similar models, it is critical to understand the characteristics of hospitals that may be differentially affected.

Methods: We used 2007-2016 SEER-Medicare data to identify patients with breast and prostate cancer receiving chemotherapy, endocrine therapy (breast), or androgen deprivation therapy (prostate). For each hospital, we calculated 6-month expected mortality, emergency department (ED) visits, inpatient admissions, and costs, all commonly collected APM outcomes. After calculating observed-to-expected rates for each outcome by hospital, we estimated the association between observed-to-expected rates and characteristics of each hospital to understand hospital characteristics that might be associated with higher- or lower-than-expected rates of each outcome.

Results: Hospitals with > 15% rural patients had significantly higher-than-expected mortality (0.31 points higher, < .001) and ED visit rates (0.10 points higher, = .029) as well as significantly lower costs (0.06 points lower, = .004). Hospitals unaffiliated with a medical school also experienced significantly higher-than-expected mortality and ED visits. Hospitals eligible for disproportionate share hospital payment experienced significantly higher ED visits but lower costs. For-profit hospitals experienced higher-than-expected mortality.

Conclusion: Rural hospitals and those unaffiliated with a medical school may require special consideration as APMs expand in oncology care. Designated cancer centers and larger hospitals may be advantaged.
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http://dx.doi.org/10.1200/OP.21.00050DOI Listing
August 2021

Impact of the evolving United States Preventative Services Task Force policy statements on incidence and distribution of prostate cancer over 15 years in a statewide cancer registry.

Prostate Int 2021 Mar 5;9(1):12-17. Epub 2020 Jul 5.

Division of Urology, Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA.

Background: The United States Preventative Services Task Force (USPSTF) guideline on Prostate Specific Antigen (PSA)-based prostate cancer screening evolved both in 2008 (Grade I for men < 75 years and Grade D for men > 75 years) and in 2012 (Grade D for all ages).

Materials And Methods: A statewide cancer registry operated by the Pennsylvania Department of Health was accessed to analyze over a 15-year period prostate cancer rates across different categories including age, stage, and geographic distribution.

Results: Local prostate cancer rates decreased significantly when comparing before and after USPSTF's guideline changes: 2002-2008 vs. 2009-2012 vs. 2013-2016 (p < 0.005). Conversely, the distant cancer rates increased significantly in Caucasian men (but not in African American men) (p = 0.0078). In age group analysis, distant cancer rates increased significantly in all age ranges, most notably in younger men (50-59 years). No observed difference in the trend of distant cancer rates when considering rural versus urban counties.

Conclusions: Incident prostate cancer cases diagnosed in Pennsylvania have decreased over the past 15 years with a recent rise in distant carcinomas potentially attributable to the USPSTF recommendations against PSA-based screening. Although the USPSTF revised their PSA-based prostate cancer screening guideline in 2018 (Grade C for men 55-69 years and Grade D for men > 70 years), the implications of the aforementioned observations on mortality outcomes merit further follow-up.
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http://dx.doi.org/10.1016/j.prnil.2020.06.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8053697PMC
March 2021

Laboratory Reporting Parameters of Microhematuria: Implications for Interpreting the 2020 AUA Guideline.

Urology 2021 Aug 23;154:24-27. Epub 2021 Apr 23.

Department of Surgery, Division of Urology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA.

Objective: To explore how laboratories in the United States (U.S.) report red blood cell per high powered field (RBC/HPF) counts on urinalysis and to evaluate whether this methodology permits effective risk stratification in accordance with the 2020 AUA/SUFU microhematuria guidelines.

Materials And Methods: Reporting methods for RBC/HPF counts (ranges, or actual counts) were collected by querying urologists in U.S. academic medical institutions or commercial laboratories. We explore whether (1) the reporting schemes were concordant with the risk strata in the new microhematuria guideline (3-10 [low risk], 11-25 [intermediate risk], and more than 25 [high risk]), and (2) evaluate the potential for risk group misclassification based on reporting methodology.

Results: Data were available for 141 laboratories. Seventy-two (51%) use RBC/HPF ranges, while the remainder use actual counts (or counts to a threshold). Sixty (42%) report range cutoffs which are not concordant with the microhematuria guidelines risk groups. Furthermore, fifty-six (40%) do not include the cutoff of 25 RBC/HPF which could potentially misclassify intermediate and high risk groups. Finally, sixteen (11%) do not include the cut-off of 3 RBC/HPF that defines the presence of microhematuria.

Conclusion: A significant number of laboratories report RBC/HPF counts in ranges that differ from thresholds in the 2020 AUA/SUFU guideline. The implication is potential misclassification of microhematuria both at minimum threshold diagnosis (3 RBC/HPF), and additionally between intermediate and high risk groups. Standardization of reporting schemes to actual RBC/HPF counts may allow improved adherence to guidelines while providing data for future guideline development.
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http://dx.doi.org/10.1016/j.urology.2021.04.014DOI Listing
August 2021

Association between urinary arsenic, blood cadmium, blood lead, and blood mercury levels and serum prostate-specific antigen in a population-based cohort of men in the United States.

PLoS One 2021 23;16(4):e0250744. Epub 2021 Apr 23.

Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, United States of America.

Exposures to heavy metals have been linked to prostate cancer risk. The relationship of these exposures with serum prostate-specific antigen (PSA), a marker used for prostate cancer screening, is unknown. We examined whether total urinary arsenic, urinary dimethylarsonic acid, blood cadmium, blood lead, and total blood mercury levels are associated with elevated PSA among presumably healthy U.S. men. Prostate cancer-free men, aged ≥40 years, were identified from the 2003-2010 National Health and Nutrition Examination Survey. Logistic regression analyses with survey sample weights were used to examine the association between heavy metal levels and elevated PSA for the total population and stratified by black and white race, after adjusting for confounders. There were 5,477 men included. Approximately 7% had elevated PSA. Men with an elevated PSA had statistically significantly higher levels of blood cadmium and blood lead compared to men with a normal PSA (p-values ≤ 0.02), with black men having higher levels. After adjusting for age, race/ethnicity, body mass index, smoking, and education, there was no association found between any of the heavy metal levels and elevated PSA for the total population. In addition, there was no association found when stratified by black and white race. Further investigation is warranted in a larger cohort of men who persistently are exposed to these heavy metals.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0250744PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8064543PMC
April 2021

Preventing Prostate Biopsy Complications: to Augment or to Swab?

Urology 2021 Sep 18;155:12-19. Epub 2021 Apr 18.

Department of Urology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA. Electronic address:

Objective: To use data from a large, prospectively- acquired regional collaborative database to compare the risk of infectious complications associated with three American Urologic Association- recommended antibiotic prophylaxis pathways, including culture-directed or augmented antibiotics, following prostate biopsy.

Methods: Data on prostate biopsies and outcomes were collected from the Pennsylvania Urologic Regional Collaborative, a regional quality collaborative working to improve the diagnosis and treatment of prostate cancer. Patients were categorized as receiving one of three prophylaxis pathways: culture-directed, augmented, or provider-discretion. Infectious complications included fever, urinary tract infections or sepsis within one month of biopsy. Odds ratios of infectious complication by pathway were determined, and univariate and multivariate analyses of patient and biopsy characteristics were performed.

Results: 11,940 biopsies were included, 120 of which resulted in infectious outcomes. Of the total biopsies, 3246 used "culture-directed", 1446 used "augmented" and 7207 used "provider-discretion" prophylaxis. Compared to provider-discretion, the culture-directed pathway had 84% less chance of any infectious outcome (OR= 0.159, 95% CI = [0.074, 0.344], P < 0.001). There was no difference in infectious complications between augmented and provider-discretion pathways.

Conclusions: The culture-directed pathway for transrectal prostate biopsy resulted in significantly fewer infectious complications compared to other prophylaxis strategies. Tailoring antibiotics addresses antibiotic-resistant bacteria and reduces future risk of resistance. These findings make a strong case for incorporating culture-directed antibiotic prophylaxis into clinical practice guidelines to reduce infection following prostate biopsies.
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http://dx.doi.org/10.1016/j.urology.2021.02.043DOI Listing
September 2021

Pathological characteristics of the large renal mass: potential implication for clinical role of renal biopsy.

Can J Urol 2021 04;28(2):10620-10624

Fox Chase Cancer Center, Temple University, Philadelphia, Pennsylvania, USA.

Introduction: To assess whether patients with a large renal mass, treated by radical nephrectomy (RN), could have benefited from preoperative renal mass biopsy (RMB). The decision to perform partial nephrectomy (PN) for an organ-confined > 4 cm renal mass can be complex. Albeit often feasible, oncologic safety of PN in this cohort is debated. Yet, a significant portion of large renal masses that undergo RN prove benign or indolent, indicating a potential role for RMB to guide nephron preservation.

Materials And Methods: We queried prospectively maintained databases from three institutions to identify patients who underwent RN for localized > 4 cm renal mass. We excluded patients with nodal or distant metastases. Multivariable analysis assessed how clinicopathologic variables, mass anatomic complexity, and patient comorbidities related to the likelihood of harboring an indolent neoplasm.

Results: A total of 702 patients underwent RN for localized > 4 cm renal mass (median tumor size 7.0 cm (IQR 5.5-9.2); 12.8% (n = 90) of patients were diagnosed with oncocytoma/oncocytic neoplasm (n = 27, 3.8%) or chromophobe RCC (n = 63, 9.0%). When stratified by tumor size, indolent tumors comprised 10.1% of 4-7 cm masses, 15.6% of ≥ 7-10 cm masses, and 17.3% of ≥ 10 cm tumors. Upon multivariate analysis, younger age was associated with indolent tumors (p = 0.04, OR 0.97, 95% CI 0.94-0.99).

Conclusions: Approximately 1 in 8 patients with a renal mass > 4 cm harbored benign or low risk indolent potential lesions and were associated with younger age. As such, patients with large renal masses for whom risk trade-offs between PN and RN are unclear, present a unique opportunity for greater utilization of RMB.
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April 2021

An integrated multi-omics analysis identifies prognostic molecular subtypes of non-muscle-invasive bladder cancer.

Nat Commun 2021 04 16;12(1):2301. Epub 2021 Apr 16.

Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK.

The molecular landscape in non-muscle-invasive bladder cancer (NMIBC) is characterized by large biological heterogeneity with variable clinical outcomes. Here, we perform an integrative multi-omics analysis of patients diagnosed with NMIBC (n = 834). Transcriptomic analysis identifies four classes (1, 2a, 2b and 3) reflecting tumor biology and disease aggressiveness. Both transcriptome-based subtyping and the level of chromosomal instability provide independent prognostic value beyond established prognostic clinicopathological parameters. High chromosomal instability, p53-pathway disruption and APOBEC-related mutations are significantly associated with transcriptomic class 2a and poor outcome. RNA-derived immune cell infiltration is associated with chromosomally unstable tumors and enriched in class 2b. Spatial proteomics analysis confirms the higher infiltration of class 2b tumors and demonstrates an association between higher immune cell infiltration and lower recurrence rates. Finally, the independent prognostic value of the transcriptomic classes is documented in 1228 validation samples using a single sample classification tool. The classifier provides a framework for biomarker discovery and for optimizing treatment and surveillance in next-generation clinical trials.
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http://dx.doi.org/10.1038/s41467-021-22465-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8052448PMC
April 2021

Subtype-associated epigenomic landscape and 3D genome structure in bladder cancer.

Genome Biol 2021 04 15;22(1):105. Epub 2021 Apr 15.

Department of Biochemistry and Molecular Genetics, Feinberg School of Medicine Northwestern University, Chicago, IL, USA.

Muscle-invasive bladder cancers are characterized by their distinct expression of luminal and basal genes, which could be used to predict key clinical features such as disease progression and overall survival. Transcriptionally, FOXA1, GATA3, and PPARG are shown to be essential for luminal subtype-specific gene regulation and subtype switching, while TP63, STAT3, and TFAP2 family members are critical for regulation of basal subtype-specific genes. Despite these advances, the underlying epigenetic mechanisms and 3D chromatin architecture responsible for subtype-specific regulation in bladder cancer remain unknown. RESULT: We determine the genome-wide transcriptome, enhancer landscape, and transcription factor binding profiles of FOXA1 and GATA3 in luminal and basal subtypes of bladder cancer. Furthermore, we report the first-ever mapping of genome-wide chromatin interactions by Hi-C in both bladder cancer cell lines and primary patient tumors. We show that subtype-specific transcription is accompanied by specific open chromatin and epigenomic marks, at least partially driven by distinct transcription factor binding at distal enhancers of luminal and basal bladder cancers. Finally, we identify a novel clinically relevant transcription factor, Neuronal PAS Domain Protein 2 (NPAS2), in luminal bladder cancers that regulates other subtype-specific genes and influences cancer cell proliferation and migration. CONCLUSION: In summary, our work identifies unique epigenomic signatures and 3D genome structures in luminal and basal urinary bladder cancers and suggests a novel link between the circadian transcription factor NPAS2 and a clinical bladder cancer subtype.
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http://dx.doi.org/10.1186/s13059-021-02325-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8048365PMC
April 2021

The Consequences of Inadvertent Radical Nephrectomy in the Treatment of Upper Tract Urothelial Carcinoma.

Urology 2021 Aug 22;154:127-135. Epub 2021 Mar 22.

Department of Urology, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY.

Objective: To determine factors associated with performing inadvertent radical nephrectomy (RN) for upper tract urothelial carcinoma (UTUC), and to assess the impact of radical nephrectomy on overall survival (OS) compared to radical nephroureterectomy (NU).

Methods: Using the National Cancer Database (NCDB), patients with UTUC of the renal pelvis who were diagnosed with renal cortical tumors and underwent RN (n = 820) with subsequent surgical pathology demonstrating urothelial carcinoma were identified. These patients were compared to those diagnosed with renal pelvis tumors who appropriately underwent NU (n = 16,464) between 2005 and 2015. Multivariable logistic regression was used to determine patient, facility and tumor-related factors associated with undergoing RN. The impact of surgery (RN vs NU) on OS was determined by Cox-regression after propensity score matching.

Results: A total of 4.7% patients with UTUC underwent inadvertent RN. Black race (adjusted odds ratio [aOR] 1.62, 95%CI 1.23-2.13), larger tumors, advanced tumor stage, and high-grade tumors (P < 0.0001) were associated with RN. However, surgery at a facility performing a higher volume of NU/year was associated with lower odds of having RN performed (aOR 0.85, 95%CI 0.75-0.97). After propensity score matching, the 5-year OS was 39.9% for those undergoing RN vs 49.9% for those undergoing NU (hazard ratio 1.45, 95%CI 1.30-1.62).

Conclusion: Inadvertent RN is not uncommon, occurring in almost 5% of patients with UTUC in the NCDB. Patients who underwent RN had significantly worse OS as compared to those treated with NU. These data highlight that accurate diagnosis of UTUC is paramount and clinicians should not hesitate to perform further workup when imaging findings are equivocal.
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http://dx.doi.org/10.1016/j.urology.2021.03.003DOI Listing
August 2021

Is pelvic MRI imaging sufficient cross-sectional imaging for staging intermediate and high-risk prostate cancer?

Urol Oncol 2021 07 17;39(7):433.e9-433.e15. Epub 2021 Feb 17.

Division of Urology, Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA. Electronic address:

Objectives: The American Urological Association's (AUA) and National Comprehensive Cancer Network's (NCCN) provide highly recognized guidelines for staging prostate cancer (CaP). However, both are vague as to specific type of cross-sectional imaging (CT vs. MRI) and extent (abdominal vs. pelvis), thereby raising concern for overlapping imaging. We investigated if current AUA and NCCN CaP staging guidelines can become more specific yet maintain sufficient staging.

Methods: We identified 493 patients diagnosed with CaP between 2011 and 2017 and focused analysis on those with AUA and NCCN Intermediate risk (IR) and High risk (HR) groups. Type of staging imaging was recorded and frequency of overlapping (CT + MRI) and abdominal imaging determined. Significance of radiologist findings, for both overlapping and abdominal imaging, were classified as nonurologic, nonsignificant urologic, and CaP significant.

Results: Among IR and HR AUA and NCCN risk groups, 82 (35.7%) and 95 (37.3%) patients, respectively, experienced overlapping imaging, of which only 7 patients in AUA and 9 patients in NCCN risk groups had an abnormal CT with normal MRI. However, only 3 of these CTs had CaP significant findings, of which 2 identified bone metastases, which were subsequently detected on bone scan. In regard to the extent of imaging, a total of 157 (68.2%) AUA and 178 (69.8%) NCCN IR and HR patients received abdominal scans, of which only 46 (20.0%) and 49 (19.2%) were abnormal among AUA and NCCN risk groups, respectively. Among these abnormal abdominal scans, only 10 showed CaP significant findings, of which half were suspected bone metastases, and confirmed on recommended bone scan.

Conclusions: Due to nonspecific staging guidelines in IR and HR CaP regarding type and extent of cross-sectional imaging, patients are frequently receiving imaging of overlapping locations. Based on low occurrences of unique CaP significant findings on CT and abdominal imaging, our exploratory analysis suggests that narrowing cross-sectional imaging recommendations to pelvic MRI may reduce imaging overlap while maintaining sufficient staging.
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http://dx.doi.org/10.1016/j.urolonc.2021.01.029DOI Listing
July 2021

Widely Variable Parental Leave Practices for Urology Residency Programs in the United States.

Urology 2021 Jul 13;153:81-86. Epub 2021 Feb 13.

Department of Surgery, Division of Urology, The Pennsylvania State University, College of Medicine, Hershey, PA.

Objective: To query a cohort of program directors to better understand the contemporary landscape of parental leave for urology trainees. The American Board of Urology mandates that a resident must work 46 weeks annually in order to not extend residency. We hypothesize that formal parental leave policies may vary by institution and may not be easily accessible.

Methods And Materials: A 22 question survey designed to assess parental leave policies was distributed to 144 American College of Graduate Medical Education accredited Urology residency program directors in the United States via e-mail. Results were collected anonymously.

Results: A total of 65 program directors completed the survey for a response rate of 43%. The median age of program directors was 49 and 78% were male. Only 12% reported no formal maternity leave policy, while 21% reported no formal paternity leave policy. Maternity leave duration varied greatly with 6 (49%) and 12 weeks (27%) as the most common duration, while paternity leave was most commonly reported as 2 (39%), 6 (18%) and 12 weeks (19%) in length. Most parental leave policies were available via an institutional website (81%), with only 39% available on a public website. While most leave policies covered compensation, few addressed call expectations or procedural safety precautions.

Conclusion: Parental leave policies across Urology training programs in the United States are variable, and may not cover critical components of pregnancy or leave. An opportunity exists to create a comprehensive, standardized parental leave policy.
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http://dx.doi.org/10.1016/j.urology.2020.12.049DOI Listing
July 2021

Microhematuria: AUA/SUFU Guideline. Letter. 2020; 778.

J Urol 2021 05 12;205(5):1533-1534. Epub 2021 Feb 12.

Department of Urology, Penn State Health, Hershey, Pennsylvania.

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http://dx.doi.org/10.1097/JU.0000000000001648DOI Listing
May 2021

Adherent perinephric fat affects perioperative outcomes after partial nephrectomy: a systematic review and meta-analysis.

Int J Clin Oncol 2021 Apr 27;26(4):636-646. Epub 2021 Jan 27.

Department of Urology, Rennes University Hospital, Rennes, France.

To investigate the association of adherent perinephric fat (APF) with perioperative outcomes, we conducted a systematic review and meta-analysis of the literature to clarify the impact of APF in patients undergoing partial nephrectomy. A systematic literature search using the Medline, Scopus, and Cochrane databases was performed in April 2019 and updated in November 2019 to identify studies investigating the effect of APF on perioperative outcomes in patients treated with partial nephrectomy with the aim of evaluating its impact on intraoperative, postoperative and oncological outcomes. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of the included studies. A total of 1534 patients in nine nonrandomized, observational studies met our inclusion criteria. Patients with APF were significantly older (p = 0.0001), had a higher BMI (p = 0.0001) and were predominately male (p = 0.003). APF was associated with a higher operative time (p = 0.001) and higher blood loss (p = 0.002). No significant impact of APF was found in terms of postoperative complications, positive margins or length of stay. APF was also found to be associated with malignant renal histology of RCC on final pathology (p = 0.005). APF was associated with some adverse perioperative outcomes, especially a prolonged operating time and higher blood loss. In addition, APF was also associated with underlying renal malignancy, but the precise causal mechanism requires further exploration.
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http://dx.doi.org/10.1007/s10147-021-01871-6DOI Listing
April 2021

The Significance of Preoperative Serum Sodium and Hemoglobin in Outcomes of Upper Tract Urothelial Carcinoma: Multi-Center Analysis Between China and the United States.

Cancer Manag Res 2020 8;12:9825-9836. Epub 2020 Oct 8.

Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Beijing, People's Republic of China.

Purpose: To analyze the effect of preoperative serum sodium and hemoglobin on oncologic outcomes in upper tract urothelial carcinoma (UTUC) based on a multi-center cohort from China and the United States (U.S.).

Methods: We retrospectively reviewed the records of 775 patients with UTUC treated surgically at tertiary care medical facilities in China or the US from 1998 to 2015. We analyzed associations of preoperative serum sodium and hemoglobin with clinicopathological characteristics, overall survival (OS), cancer-specific survival (CSS) and intravesical recurrence free survival (IVRFS).

Results: The US patients had comparatively lower serum sodium and similar hemoglobin at baseline. Preoperative low serum sodium value was associated with tumor multifocality, lymph node metastasis (LNM) and lymphovascular invasion (LVI); preoperative anemia was associated with advanced age, tumor multifocality, high tumor grade and LVI. Preoperative low serum sodium was an independent predictor of worse OS in the entire cohort; preoperative anemia was an independent predictor of worse OS and CSS in the US cohort alone, Chinese cohort alone and the combined cohort. We developed a predictive nomogram for OS which exhibited better prognostic value when it included the values of sodium and anemia, and successfully validated it in different cohorts.

Conclusion: Preoperative low serum sodium and anemia could be informative in predicting worse pathologic and survival outcomes in different UTUC patient ethnic groups.
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http://dx.doi.org/10.2147/CMAR.S267969DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7549885PMC
October 2020

Endoscopic Closure of a Large Rectovesical Fistula Following Robotic Prostatectomy.

J Endourol Case Rep 2020 17;6(3):139-142. Epub 2020 Sep 17.

Division of Urology, Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA.

Rectovesical fistulae (RVF) are uncommon complications of pelvic surgeries and are a potential cause of significant morbidity. RVF are not typically closed endoscopically but rather require reoperative surgery of the lower pelvis with closure of tract, interposition of fat or omentum, and possible permanent bowel diversion. We present a unique case of a rectovesical fistula developing after robotic prostatectomy that was managed by multimodal multistage endoscopic therapy as an alternative to conventional operative repair. A healthy 78-year-old Caucasian man underwent a robot-assisted laparoscopic radical prostatectomy with bilateral pelvic lymph node dissection for high-risk adenocarcinoma of the prostate. The patient's postoperative course was complicated by an unrecognized rectal injury culminating in emergent exploration, abdominal washout, creation of a diverting loop transverse colostomy, and resultant development of a large rectovesical fistula. Given the patient's hostile abdomen and desire for conservative management the fistula was managed through a combined cystoscopic and endoscopic procedure that utilized suturing and clipping to close the fistula. This novel technique was followed by a series of three subsequent endoscopic procedures that enabled us to gradually downsize the fistula over time and ultimately achieve complete closure. The patient's colostomy was eventually reversed with return of bowel continuity. Although uncommon, RVF are significant complications of pelvic surgery. The presence of abdominal/pelvic adhesions from previous surgeries or patient comorbidities can make open surgical repair extremely challenging or impracticable. Therefore, it is important to recognize and consider the use of endoscopic techniques as potential options for closure of rectovesical fistula in certain situations.
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http://dx.doi.org/10.1089/cren.2019.0132DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7580594PMC
September 2020

Histologic Heterogeneity of Extirpated Renal Cell Carcinoma Specimens: Implications for Renal Mass Biopsy.

J Kidney Cancer VHL 2020 25;7(3):20-25. Epub 2020 Aug 25.

Division of Urology, Department of Surgery, Penn State College of Medicine, Hershey, PA, USA.

Pathologic characteristics of extirpated renal cell carcinoma (RCC) specimens <7 cm were reviewed to get better information on technical nuances of renal mass biopsy (RMB). Specimens were stratified according to tumor stage, nuclear grade, size, histology, presence of lymphovascular invasion (LVI), necrosis, and sarcomatoid features. When considering pT1 (0-7 cm) tumors, pT1b (4-7 cm) RCC masses were more likely to have necrosis (43% vs 16%, P < 0.001), LVI (6% vs 2%, P = 0.024), high-grade nuclear elements (29% vs 17%, P < 0.001), and sarcomatoid features (2% vs 0%, P = 0.006) compared with pT1a (0-4 cm) tumors. Additionally, pT3a tumors were more highly associated with necrosis (P = 0.005), LVI, sarcomatoid features, and high-grade disease (P for all < 0.001) when compared to pT1 masses. For masses <4 cm, pT3a cancers were more likely to demonstrate necrosis (38% vs 16%, P < 0.001), LVI (22% vs 2%, P < 0.001), high-grade nuclear elements (45% vs 17%, P < 0.001), and sarcomatoid features (12% vs 0%, P < 0.001) compared to pT1a tumors. Similarly, for masses 4-7 cm, pathologic T3a tumors were significantly more likely to have sarcomatoid features (12% vs 2%, P = 0.006) and LVI (22% vs 6%, P = 0.003) compared to pT1b tumors. In summary, pT3a tumors and those RCC masses >4 cm exhibit considerable histologic heterogeneity and may harbor elements that are not easily appreciated with limited renal sampling. Therefore, if RMB is considered for renal masses greater than 4 cm or those that abut sinus fat, a multi-quadrant biopsy approach is necessary to ensure adequate sampling and characterization of the mass.
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http://dx.doi.org/10.15586/jkcvhl.2020.134DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7478168PMC
August 2020

Incidence and preoperative predictors for major complications following radical nephroureterectomy.

Transl Androl Urol 2020 Aug;9(4):1786-1793

Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA.

Background: Radical nephroureterectomy (RNU) is the referent standard for managing bulky, invasive, or high grade upper-tract urothelial carcinoma (UTUC). The UTUC patient population, however, generally harbor medical comorbidities thereby placing them at risk of surgical complications. This study reviews a large international cohort of RNU patients to define the risk of major complications and preoperative factors associated with their occurrence.

Methods: Patients undergoing RNU at 14 academic medical centers between 2002 and 2015 were retrospectively reviewed. Preoperative clinical, demographic, operative, and comorbidity indices were recorded. The modified Clavien-Dindo index was used to grade complications occurring within 30 days of surgery. The association between preoperative variables and major complications occurring after RNU was determined by multivariable logistic regression.

Results: One thousand two hundred and sixty-six patients (707 men; 559 women) with a median age of 70 years and BMI of 27 kg/m were included. Over three-quarters of the cohort was white, 50.1% had baseline chronic kidney disease (CKD) ≥ stage III, 22.4% had a Charlson comorbidity index (CCI) score >5, and 17.1% had an Eastern Cooperative Oncology Group (ECOG) performance status ≥2. Overall, 413 (32.6%) experienced a complication including 103 (8.1%) with a major event. Specific distribution of major complications included 49 Clavien III, 44 Clavien IV, and 10 Clavien V. On univariate analysis, patient age (P=0.006), hypertension (P=0.002), diabetes mellitus (P=0.023), CKD stage (P<0.001), American Society of Anesthesiologists (ASA) score (P=0.022), ECOG (P<0.001), and CCI (P<0.001) all were associated with major complications. On multivariate analysis, ECOG ≥2 (OR 2.38, 95% CI, 1.46-3.90), P=0.001), CCI >5 (OR 3.45, 95% CI, 1.41-8.33, P=0.007), and CKD stage ≥3 (OR 3.64, P=0.008) were independently associated with major complications.

Conclusions: Major complications following RNU occurred in almost 10% of patients. Impaired preoperative performance status and baseline CKD are preoperative variables associated with these major post-surgical adverse event. These easily measurable indices warrant consideration and discussion prior to proceeding with RNU.
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http://dx.doi.org/10.21037/tau.2020.01.22DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7475660PMC
August 2020

Comparison of the Comprehensive Complication Index and Clavien-Dindo systems in predicting perioperative outcomes following radical nephroureterectomy.

Transl Androl Urol 2020 Aug;9(4):1780-1785

Division of Urology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA.

Background: Complications can occur following radical nephroureterectomy (RNU) in 20-40% of patients. The Comprehensive Complication Index (CCI) is an alternative grading system to the Clavien-Dindo (CD) grading system that aggregates all complications experienced by a patient on a continuous (as opposed to categorical) scale. We investigate whether the cumulative nature of CCI renders it superior to CD in predicting perioperative course after RNU.

Methods: The records of 596 patents who underwent RNU at 7 academic medical centers from 2005 to 2015 were reviewed. Complications occurring within 30 days of RNU were annotated using both the CD and CCI classification systems. Logistic regression was used to determine associations between CD and CCI with perioperative covariates as well as measures of convalescence [hospital length of stay (LOS) and readmission].

Results: A total of 377 men and 219 women with a median age of 71, BMI of 27, and Charlson comorbidity score of 4 were included. Over half underwent a minimally invasive RNU. Median LOS following RNU was 6.0 days (range, 1-37 days) and readmission within 30-days occurred in 45 (8%) patients. Overall, 136 patients (23%) experienced a post-operative complication with 91 having a single complication and 45 with multiple (range, 2-6); 44 (7%) patients had Clavien III or greater complications, and the median CCI for those patients experiencing a complication was 20.9 (range, 8.7-100). Both the upper quartile of CCI (≥75th %) and major CD complications were associated with higher baseline Charlson score, ECOG ≥2, and CKD stage ≥ III (all P<0.05). However, only the upper quartile of CCI was associated with LOS (8.9 5.4 days, P<0.01) and hospital readmission (OR 3.2, 95% CI: 1.9-5.6, P=0.02) after RNU.

Conclusions: The CD and CCI classification systems both are associated with similar baseline and perioperative characteristics for RNU patients. However, the cumulative nature of the CCI allows for superior prediction of postoperative course after RNU including LOS and readmission.
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http://dx.doi.org/10.21037/tau.2020.01.16DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7475662PMC
August 2020

An editorial comment for the special series "Upper-Tract Urothelial Carcinoma: Current State and Future Directions".

Transl Androl Urol 2020 Aug;9(4):1778-1779

Professor and Chief of Urology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA 17033, USA.

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http://dx.doi.org/10.21037/tau-2019-utuc-15DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7475657PMC
August 2020

Design, Development, and Multi-Characterization of an Integrated Clinical Transrectal Ultrasound and Photoacoustic Device for Human Prostate Imaging.

Diagnostics (Basel) 2020 Aug 7;10(8). Epub 2020 Aug 7.

Department of Biomedical Engineering, Pennsylvania State University, University Park, State College, PA 16802, USA.

The standard diagnostic procedure for prostate cancer (PCa) is transrectal ultrasound (TRUS)-guided needle biopsy. However, due to the low sensitivity of TRUS to cancerous tissue in the prostate, small yet clinically significant tumors can be missed. Magnetic resonance imaging (MRI) with TRUS fusion biopsy has recently been introduced as a way to improve the identification of clinically significant PCa in men. However, the spatial errors in coregistering the preprocedural MRI with the real-time TRUS causes false negatives. A real-time and intraprocedural imaging modality that can sensitively detect PCa tumors and, more importantly, differentiate aggressive from nonaggressive tumors could largely improve the guidance of biopsy sampling to improve diagnostic accuracy and patient risk stratification. In this work, we seek to fill this long-standing gap in clinical diagnosis of PCa via the development of a dual-modality imaging device that integrates the emerging photoacoustic imaging (PAI) technique with the established TRUS for improved guidance of PCa needle biopsy. Unlike previously published studies on the integration of TRUS with PAI capabilities, this work introduces a novel approach for integrating a focused light delivery mechanism with a clinical-grade commercial TRUS probe, while assuring much-needed ease of operation in the transrectal space. We further present the clinical potential of our device by (i) performing rigorous characterization studies, (ii) examining the acoustic and optical safety parameters for human prostate imaging, and (iii) demonstrating the structural and functional imaging capabilities using deep-tissue-mimicking phantoms. Our TRUSPA experimental studies demonstrated a field-of-view in the range of 130 to 150 degrees and spatial resolutions in the range of 300 μm to 400 μm at a soft tissue imaging depth of 5 cm.
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http://dx.doi.org/10.3390/diagnostics10080566DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7460329PMC
August 2020

Patterns of Initial Metastatic Recurrence After Surgery for High-Risk Nonmetastatic Renal Cell Carcinoma.

Urology 2020 Dec 8;146:152-157. Epub 2020 Aug 8.

Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, WI. Electronic address:

Objective: To evaluate postoperative recurrence patterns for high-risk nonmetastatic renal cell carcinoma (RCC) and to identify prognostic factors associated with site-specific metastatic recurrence using a multi-institutional contemporary cohort.

Methods: Data for nonmetastatic ≥pT3a RCC patients treated with surgery at 4 independent centers was analyzed. Initial recurrence locations were identified, and imaging templates were defined by anatomic landmarks using radiologic definitions. Prognostic factors for site specific recurrence were evaluated with univariate and multivariable analyses.

Results: A total of 1057 patients were treated surgically for ≥pT3a RCC. Initial recurrence location was in a single site for 160 (59.3%) patients and at multiple locations in 110 (41.7%) patients. The most common sites of metastatic recurrence were lung (144/270, 53.3%), liver (54/270, 20.0%), and bone (48/270, 17.8%). Recurrence was identified in 52 of 270 (19.3%) patients outside the chest/abdomen template, most commonly in the pelvis (25/270, 9.3%). Bone and brain metastases were the most common organs for metastases outside chest/abdomen. Patients with tumor diameter >10 cm and grade 4 were more likely to recur in the bone (HR 3.61, P <.001) and brain (HR 16.5, P <.001).

Conclusion: Metastatic progression outside chest/abdomen imaging templates was present in 1 of 5 high risk patients at initial metastatic RCC diagnosis, most commonly in the pelvis. Patients with large (>10 cm) tumors and grade 4 histology are at highest risk for bone and brain metastases.
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http://dx.doi.org/10.1016/j.urology.2020.07.045DOI Listing
December 2020

Can preoperative imaging characteristics predict pT3 bladder cancer following cystectomy?

World J Urol 2021 Jun 28;39(6):1941-1945. Epub 2020 Jul 28.

Division of Urology, Department of Surgery, College of Medicine, The Pennsylvania State University, 500 University Drive, H055, Hershey, PA, 17033-0850, USA.

Purpose: Imaging characteristics in bladder cancer (BC), such as hydronephrosis, are predictive of ≥ pT3 disease at time of radical cystectomy (RC). The predictive capacity of other findings, such as perivesical stranding (PS), remains unclear. We investigated whether PS was associated with ≥ pT3 BC in patients who did not receive neoadjuvant chemotherapy (NAC).

Methods: We identified 433 patients with BC who underwent RC from 2003 to 2018 of which 128 did not receive NAC. Evidence of PS on pre-TURBT imaging was determined by radiologist review and a stranding grading system was created. Factors associated with PS and hydronephrosis were identified. Multivariable logistic regressions evaluated PS and hydronephrosis as predictors for ≥ pT3 BC.

Results: Of the 128 patients who did not receive NAC, 48 (38%) had pT3 and 12 (9%) had pT4 BC. 125 (98%) patients had CT and three (2%) had MRI. PS and hydronephrosis on imaging were identified in 19 (15%) and 45 (35%) patients. PS was not associated with imaging type (p = 0.38), BMI (p = 0.18), or pathologic T stage (p = 0.24). Hydronephrosis was more frequently associated with higher pathologic T stage (p = 0.034). Multivariable analysis demonstrated that PS was not predictive of ≥ pT3 BC (p = 0.457), while hydronephrosis was positively associated (p = 0.003). Stratification by grade of stranding did not improve the predictive capacity of PS (p = 0.667).

Conclusion: While hydronephrosis is an indicator of higher stage BC, PS failed to be a reliable predictor of ≥ pT3 stage. These observations should give pause in using PS on imaging to guide decisions until further investigations can be explored.
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http://dx.doi.org/10.1007/s00345-020-03375-wDOI Listing
June 2021
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