Publications by authors named "Zeyad Schwen"

43 Publications

Initial Experience with Single-port Robotic-assisted Kidney Transplantation and Autotransplantation.

Eur Urol 2021 Mar 30. Epub 2021 Mar 30.

Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.

Background: Compared with the standard open approach, multiport robotic-assisted kidney transplantation (RAKT) has emerged as a less morbid alternative. The use of a single-port robotic approach for kidney transplantation (KT) is presented in this study as having the potential for further reducing the morbidity of KT.

Objective: To present the technique and evaluate perioperative and short-term (≤1 yr) postoperative outcomes of single-port RAKT.

Design, Setting, And Participants: Prospective evaluation of peri- and postoperative outcomes in patients who underwent allograft KT (n = 6) or kidney autotransplantation (n = 3). The IDEAL model (www.ideal-collaboration.net/framework) for safe surgical innovation was used.

Surgical Procedure: Kidney allografts from living or deceased donors were transplanted into six patients with end-stage renal disease. Single-port robotic surgery was performed through a 5-cm midline periumbilical abdominal incision with transperitoneal or extraperitoneal approaches. With similar incision and technique, the right or left kidney was removed and autotransplantation was performed in three patients.

Measurements: Intra- and postoperative variables, and outcomes were assessed with a descriptive analysis.

Results And Limitations: Single-port RAKT procedures were completed successfully, with total operative and vascular anastomosis times ranging from 300 to 450 mins and from 52 to 92 mins, respectively. All six patients had excellent graft function with serum creatinine levels at the last follow-up (2 wk to 1 yr), ranging from 1.2 to 1.5 mg/dl. Renal autotransplantation was also completed successfully with a single-port robotic approach in three patients. The total operative and vascular anastomosis times ranged from 510 to 600 mins and from 65 to 83 mins, respectively. In all three cases, serum creatinine levels remained normal after the surgery and during follow-up, and all remained symptom-free at the time of this writing (4-8 mo after their surgeries).

Conclusions: In this initial experience, single-port RAKT is feasible with potential benefits such as offering true single-site minimally invasive surgery, extraperitoneal approach, less morbidity, and comparable short-term graft functional outcomes.

Patient Summary: We presented the initial experience with the application of single-port robotic surgery for kidney transplantation and autotransplantation. This technique was found to be safe and effective, with promising postoperative outcomes and potentially with less morbidity.
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http://dx.doi.org/10.1016/j.eururo.2021.03.002DOI Listing
March 2021

Oncologic outcomes among Black and White men with grade group 4 or 5 (Gleason score 8-10) prostate cancer treated primarily by radical prostatectomy.

Cancer 2021 Mar 15. Epub 2021 Mar 15.

Department of Urology, University of Washington, Seattle, Washington.

Background: The aim of this study was to describe pathologic and short-term oncologic outcomes among Black and White men with grade group 4 or 5 prostate cancer managed primarily by radical prostatectomy.

Methods: This was a multi-institutional, observational study (2005-2015) evaluating radical prostatectomy outcomes by self-identified race. Descriptive analysis was performed via nonparametric statistical testing to compare baseline clinicopathologic data. Univariable and multivariable time-to-event analyses were performed to assess biochemical recurrence (BCR), metastasis, cancer-specific mortality (CSM), and overall survival between Black and White men.

Results: In total, 1662 men were identified with grade group 4 or 5 prostate cancer initially managed by radical prostatectomy. Black men represented 11.3% of the cohort (n = 188). Black men were younger, demonstrated a longer time from diagnosis to surgery, and were at a lower clinical stage (all P < .05). Black men had lower rates of pT3/4 disease (49.5% vs 63.5%; P < .05) but higher rates of positive surgical margins (31.6% vs 26.5%; P = .14) on pathologic evaluation. There was no difference in BCR, CSM, or overall survival over a median follow-up of 40.7 months. Black men had a lower 5-year cumulative incidence of metastasis-free survival (93.6%; 95% confidence interval [CI], 86.5%-97.0%) in comparison with White men (85.8%; 95% CI, 83.1%-88.0%), which did not persist in an age-adjusted analysis.

Conclusions: Black and White men with high-grade prostate cancer at diagnosis demonstrated similar oncologic outcomes when they were managed by primary radical prostatectomy. Our findings suggest that racial disparities in prostate cancer mortality are not related to differences in the efficacy of extirpative therapy.
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http://dx.doi.org/10.1002/cncr.33419DOI Listing
March 2021

Testicular ultrasound underestimates the size of small testicular masses: a radiologic-pathologic correlation study.

World J Urol 2021 Mar 12. Epub 2021 Mar 12.

Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Park 213, Baltimore, MD, 21287, USA.

Purpose: Increasing use and resolution of testicular ultrasound imaging has resulted in a greater diagnosis of non-palpable small testicular masses and subsequent over-treatment with orchiectomy. Our aim was to determine the diagnostic accuracy of testicular ultrasound to accurately determine the pathologic size of small testicular masses (SMTMs) and to evaluate the association of various measurements with benign pathology.

Methods: Retrospectively, an institutional testicular cancer database was reviewed to evaluate the patients who underwent an orchiectomy for a testicular mass seen on ultrasound from 2003 to 2017. Three-dimensional measurements were compared from the ultrasound and pathology specimens, including other measures such as tumor volume and percentage of testicular volume. Finally, the predictive accuracy of maximum diameter and tumor volume to predict benign pathology was evaluated using receiver-operating curve analysis.

Results: We identified 208 patients and showed that ultrasound significantly underestimated sub-centimeter testicular masses (mean difference 0.56 cm, 95%CI 0.89-0.14, p = 0.004) and testicular masses between 1 and < 2 cm (mean difference 0.50 cm, 95%CI 0.97-0.15, p = 0.009). Tumor volume measured on ultrasound was consistently similar to pathologic tumor volume across all sizes and was significantly correlated (Spearman's Rho = 0.81). Mass volume had a greater predictive accuracy for benign pathology than maximum diameter using a 1 cm cut-off (AUC 0.65 vs 0.60).

Conclusion: Using the maximal diameter, testicular ultrasound significantly miscalculated the pathologic dimensions of masses less than 2 cm compared to orchiectomy specimens. Volumetric measurements may better represent actual tumor sizes for SMTMs and may be a more useful measure for identifying those a higher risk for benign pathology, however, further studies are required.
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http://dx.doi.org/10.1007/s00345-021-03655-zDOI Listing
March 2021

Effect of Erythropoietin on Erectile Function after Radical Prostatectomy: The ERECT Randomized Clinical Trial.

J Urol 2021 Feb 3:101097JU0000000000001586. Epub 2021 Feb 3.

The Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland.

Purpose: Erectile dysfunction significantly impacts quality of life for men undergoing radical prostatectomy for prostate cancer. Erythropoietin is a promising neurotrophic factor for neurogenic erectile dysfunction based on preclinical and retrospective data.

Materials And Methods: ERECT (NCT00737893) is a phase 2, double-blinded, randomized, placebo-controlled trial (July 2017-December 2019) evaluating the impact of perioperative erythropoietin on recovery of erectile function and other patient-reported, health-related quality of life outcomes after bilateral nerve-sparing radical prostatectomy (3, 6, 9, and 12 months). Erythropoietin (20,000 units) or saline placebo was injected subcutaneously the day before, day of, and day after surgery for 3 total doses.

Results: Of 63 patients assessed for eligibility, 56 patients were randomized. Arms (29 erythropoietin, 27 placebo) were well balanced (89.3% robotic, median age 55.5 years). International Index of Erectile Function-Erectile Function Domain (IIEF-EF) scores increased from median 12.5 at 3 months to 24.5 at 12 months. Median 2-week serum hemoglobin was higher for the erythropoietin arm compared to placebo (14.7 vs 13.6, p=0.02). There was no statistically significant difference in IIEF-EF scores at 6 months comparing erythropoietin to placebo (p=0.50) or at other time points (mixed model regression coefficient: -1.7, 95% CI -6.1-2.7, p=0.45). Excellent nerve-sparing rating (10/10) was associated with improved IIEF-EF recovery (+5.2, p=0.022). Other patient-reported, health-related quality of life domains as well as oncologic outcome and complications were similar between arms during followup.

Conclusions: In the context of brief perioperative dosing, erythropoietin did not improve recovery of erectile function for men undergoing radical prostatectomy for prostate cancer compared to placebo. Further research to identify effective adjuncts to improve health-related quality of life for these men is needed.
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http://dx.doi.org/10.1097/JU.0000000000001586DOI Listing
February 2021

Surgical ergonomics for urologists: a practical guide.

Nat Rev Urol 2021 Mar 11;18(3):160-169. Epub 2021 Jan 11.

The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Poor ergonomics in the operating room can have detrimental effects on a surgeon's physical, psychological and economic well-being. This problem is of particular importance to urologists who are trained in nearly all operative approaches (open, laparoscopic, robotic-assisted, microscopic and endoscopic surgery), each with their own ergonomic considerations. The vast majority of urologists have experienced work-related musculoskeletal pain or injury at some point in their career, which can result in leaves of absence, medical and/or surgical treatment, burnout, changes of specialty and even early retirement. Surgical ergonomics in urology has been understudied and underemphasized. In this Review, we characterize the burden of musculoskeletal injury in urologists and focus on various ergonomic considerations relevant to the urology surgeon. Although the strength of evidence remains limited in this space, we highlight several practical recommendations stratified by operative approach that can be incorporated into practice without interrupting workflow whilst minimizing injury to the surgeon. These recommendations might also serve as the foundation for ergonomics training curricula in residency and continuing medical education programmes. With improved awareness of ergonomic principles and the sequelae of injury related to urological surgery, urologists can be more mindful of their operating room environment and identify ways of reducing their own symptoms and risk of injury.
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http://dx.doi.org/10.1038/s41585-020-00414-4DOI Listing
March 2021

Robot-assisted Radical Prostatectomy Using Single-port Perineal Approach: Technique and Single-surgeon Matched-paired Comparative Outcomes.

Eur Urol 2021 Mar 21;79(3):384-392. Epub 2020 Dec 21.

Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA. Electronic address:

Background: Radical perineal prostatectomy (RPP) has been revived with the advent of single-port (SP) robotic surgery. However, its interest and precise role need to be evaluated and better defined.

Objective: To describe in detail the technique of SP-RPP and compare initial perioperative outcomes with those of multiport robot-assisted transperitoneal radical prostatectomy (MP-RARP).

Design, Setting, And Participants: From October 2018 to June 2020, perioperative data of 26 consecutive patients who underwent SP-RPP for localized prostate cancer (PCa) in a single institution were prospectively entered into an institutional review board-approved database. Data of 86 consecutive patients treated from September 2017 to September 2018 with MP-RARP by the same surgeon, before the beginning of the SP experience, were used as comparators.

Surgical Procedure: SP-RPP was performed using the SP robotic platform (Intuitive Surgical, Sunnyvale, CA, USA) according to the technique described in the supplementary video.

Measurements: Demographics, and intra- and postoperative data were analyzed in a matched-paired design with a 1:1 ratio on the following factors: age at surgery, prostate-specific antigen level, preoperative Gleason score, and history of abdominal surgery.

Results And Limitations: After matching, baseline characteristics were comparable except for the rate of prior laparotomy, which was higher in the SP-RPP group (52% vs 8%, p < 0.001). In the SP-RPP group, 84% of the patients had a high risk and an unfavorable intermediate risk of positive surgical margins (PSMs) versus 57% in the MP-RARP group (p = 0.03). While the rate of nonlimited PSMs (ie, >3 mm) was higher in the SP-RPP group (38.5% vs 7.7%, p < 0.01), the number of patients with biochemical recurrence at 1 yr was comparable between SP-RPP and MP-RARP (1 vs 3, p = 0.3).

Conclusions: SP-RPP is a complex procedure for patients with a complex surgical history and high-risk localized PCa with limited alternative therapeutic options.

Patient Summary: Our study suggests that patients with high-risk localized prostate cancer and limited treatment options due to a complex abdominal surgical history (ie, frozen pelvis) may be suitable candidates for single-port radical perineal prostatectomy.
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http://dx.doi.org/10.1016/j.eururo.2020.12.013DOI Listing
March 2021

Contemporary Assessment of the Most Cited Clinical, Basic Science, and Guidelines Papers in Urology: A Reference for Urology Journal Club.

Urology 2021 Mar 21;149:58-69. Epub 2020 Nov 21.

The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD.

Objective: To perform bibliometric analysis of the top cited articles in urology as a guide for journal club article selection.

Methods: Bibliometric citation analysis was performed using Scopus. Tables illustrating the top cited clinical, basic science, and guidelines/position statements papers were constructed. Linear regression was used to determine association between h-index and number of citations.

Results: A total of 3,188,861 publications from 1788 to 2020 were analyzed. The top 100 cited clinical papers from 1788 to 2020, top 100 cited contemporary clinical papers from 2000 to 2020, top 25 cited basic science papers, and the top 25 cited guidelines/position statement papers were reported. Median number of citations in the top 100 cited clinical papers was 1463 (interquartile range 1186-1821). Memorial Sloan Kettering Cancer Center (12), Johns Hopkins University (6), and Harvard University (6) contributed the most top cited clinical papers in urology. Urologic oncology was the most represented subspecialty in both clinical (75%) and basic science (96%) papers. First author and last author h-index were found to correlate with the number paper citations in the top 100 cited clinical papers from 1788 to 2020 (first author β:5.3, P= .003, last author β:4.5, P= .03). Only 7% of the most cited clinical papers in urology were from female first authors, which was not statistically significantly different from those reported in prior publications published in 2009 and 2013.

Conclusion: Contemporary citation analysis of indexed manuscripts in urology may serve as a valuable educational tool for urologists and trainees.
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http://dx.doi.org/10.1016/j.urology.2020.11.019DOI Listing
March 2021

Pure Single-site Robot-assisted Radical Prostatectomy Using Single-port Versus Multiport Robotic Radical Prostatectomy: A Single-institution Comparative Study.

Eur Urol Focus 2020 Nov 4. Epub 2020 Nov 4.

Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA. Electronic address:

Background: Pure single-site robot-assisted extraperitoneal prostatectomy (EPP) using a single-port (SP) robotic platform has been shown to be feasible and safe in previous descriptive studies.

Objective: To compare the perioperative outcomes of patients undergoing SP-EPP versus conventional multiport (MP) transperitoneal robot-assisted radical prostatectomy (RARP).

Design, Setting, And Participants: From January 2019 to January 2020, data of 100 consecutive patients who underwent SP-EPP performed by the same surgeon and 110 consecutive patients who underwent MP-RARP by three surgeons from the same institution were prospectively collected.

Intervention: All SP-EPPs were performed in a pure single-site fashion without Trendelenburg.

Outcome Measurements And Statistical Analysis: Demographic characteristics as well as intra- and postoperative data of patients in both groups were analyzed. Quantitative data were described in terms of median and quartiles.

Results And Limitations: After SP-EPP, the rate of patients discharged the same day was nine times higher than that after MP-RARP (p < 0.001), and the median length of postoperative hospital stay was significantly shorter: 4.3 h (interquartile range [IQR] 3.3-17.4) versus 26.1 h (IQR 21.5-44.8). The rate of opioid use in the hospital and after discharge in the SP group was at least half that in the MP group (respectively, 32% vs 64%, p < 0.001, and 35% vs 87%, p < 0.001). The overall positive surgical margin rate as well as continence rate at 12 mo (85% vs 88%, p = 0.97) and the prostate-specific antigen relapse-free survival (p = 0.09) were statistically comparable between the SP and MP groups.

Conclusions: Pure single-site SP-EPP was associated with a shorter length of stay as well as a decreased need for postoperative pain medication and narcotic administration in comparison with conventional transperitoneal multiport prostatectomy, with comparable postoperative complications and readmission rate.

Patient Summary: Surgical treatment of localized prostate cancer using a single-port robotic platform allows for a shorter hospital stay, less pain, and less opioid use than conventional robotic surgery without more morbidity. TAKE  HOME MESSAGE: Pure single-site single-port extraperitoneal prostatectomy was associated with a shorter length of stay as well as a decreased need for postoperative pain medication and narcotic administration in comparison with conventional transperitoneal multiport prostatectomy, with comparable postoperative complication and readmission rate.
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http://dx.doi.org/10.1016/j.euf.2020.10.006DOI Listing
November 2020

High-dimensional Cytometry (ExCYT) and Mass Spectrometry of Myeloid Infiltrate in Clinically Localized Clear Cell Renal Cell Carcinoma Identifies Novel Potential Myeloid Targets for Immunotherapy.

Mol Cell Proteomics 2020 11 31;19(11):1850-1859. Epub 2020 Jul 31.

Bloomberg-Kimmel Institute for Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Oncology, Johns Hopkins School of Medicine and The Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland, USA. Electronic address:

Renal Cell Carcinoma (RCC) is one of the most commonly diagnosed cancers worldwide with research efforts dramatically improving understanding of the biology of the disease. To investigate the role of the immune system in treatment-naïve clear cell Renal Cell Carcinoma (ccRCC), we interrogated the immune infiltrate in patient-matched ccRCC tumor samples, benign normal adjacent tissue (NAT) and peripheral blood mononuclear cells (PBMCs isolated from whole blood, focusing our attention on the myeloid cell infiltrate. Using flow cytometric, MS, and ExCYT analysis, we discovered unique myeloid populations in PBMCs across patient samples. Furthermore, normal adjacent tissues and ccRCC tissues contained numerous myeloid populations with a unique signature for both tissues. Enrichment of the immune cell (CD45) fraction and subsequent gene expression analysis revealed a number of myeloid-related genes that were differentially expressed. These data provide evidence, for the first time, of an immunosuppressive and pro-tumorigenic role of myeloid cells in early, clinically localized ccRCC. The identification of a number of immune proteins for therapeutic targeting provides a rationale for investigation into the potential efficacy of earlier intervention with single-agent or combination immunotherapy for ccRCC.
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http://dx.doi.org/10.1074/mcp.RA120.002049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7664124PMC
November 2020

A Comparative Analysis of Surgical Scar Cosmesis Based on Operative Approach for Radical Prostatectomy.

J Endourol 2021 Feb 15;35(2):138-143. Epub 2020 Sep 15.

The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Recent developments in minimally invasive approaches to radical prostatectomy (RP) for localized prostate cancer have improved oncological outcomes, but may also affect surgical scar cosmesis, an important component of survivorship and patient quality of life. Our aim was to evaluate surgical scar appearance based on operative approach to RP using a validated tool for evaluating psychosocial impact of scar appearance. Men between the ages of 45 and 80 were surveyed on an online crowdsourcing platform. Well-healed surgical scars after open, multiport (MP) robotic (transperitoneal and extraperitoneal), and single-port (SP) robotic RP were digitally rendered on stock photos to control for patient appearance. Respondents evaluated images using the SCAR-Q© psychosocial impact domain. Additionally, different RP scars were ranked by appearance and assigned 10-point appearance scores. Two hundred thirty-four surveys were included for analysis (completion rate 84.2%). The median age was 54 (IQR: 49-61) and 35% (85/234) had previous abdominal surgery, of which 45% (38/85) was robotic or laparoscopic. SP scars had better psychosocial impact scores (median 100 out of 100 69 and 58) than MP and open, respectively (both  < 0.001). SP scars were consistently ranked higher by appearance (median rank 1, IQR: 1-1) than MP (2, IQR: 2-3) and open (3, IQR: 3-4) ( < 0.001). SP without assistant port had the highest appearance score (median 9, IQR: 7-9) among all scars ( < 0.001). SP scars scored highest on psychosocial impact and were consistently ranked highest in appearance. These findings may be informative for optimizing both cosmetic appearance and quality of life for patients undergoing RP.
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http://dx.doi.org/10.1089/end.2020.0649DOI Listing
February 2021

Primary robotic retroperitoneal lymph node dissection following orchiectomy for testicular germ cell tumors: a single-surgeon experience.

J Robot Surg 2021 Apr 22;15(2):309-313. Epub 2020 Jun 22.

The James Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

The objectives were to evaluate the safety and oncologic efficacy of primary robotic retroperitoneal lymph node (R-RPLND) dissection for testicular germ cell tumors. A retrospective analysis was performed on all primary R-RPLND cases performed by a single surgeon, who performs both open and R-RPLND at a high-volume academic institution, between August 2013 and August 2019. Data on patient demographics, operative techniques, perioperative outcomes, and tumor characteristics were obtained. 28 men were identified who underwent primary R-RPLND. The majority of patients (N = 21, 75%) had clinical stage I disease, and a bilateral template was more commonly performed than either single side alone (N = 13, 46%). Of note, two cases involving clinical stage II disease were converted electively from robotic to open procedures at the discretion of the surgeon. R-RPLND patients experienced no intraoperative complications. The median follow-up time was 8 months (interquartile range 4-29 months). One (4%) patient developed a disease recurrence at 10 months after R-RPLND. Conclusion: primary R-RPLND is a safe and efficacious procedure for carefully selected men with stage I and II non-seminomatous germ cell tumors of the testis. Long-term data are needed to evaluate the comparative oncologic efficacy with open surgery and the notably high rate of chylous ascites.
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http://dx.doi.org/10.1007/s11701-020-01107-1DOI Listing
April 2021

Effect of Pharmacologic Prophylaxis on Venous Thromboembolism After Radical Prostatectomy: The PREVENTER Randomized Clinical Trial.

Eur Urol 2020 09 19;78(3):360-368. Epub 2020 May 19.

The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Background: Direct high-quality evidence is lacking evaluating perioperative pharmacologic prophylaxis (PP) after radical prostatectomy (RP) to prevent venous thromboembolism (VTE) leading to significant practice variation.

Objective: To study the impact of in-hospital PP on symptomatic VTE incidence and adverse events after RP at 30 d, with the secondary objective of evaluating overall VTE in a screening subcohort.

Design, Setting, And Participants: A prospective, phase 4, single-center, randomized trial of men with prostate cancer undergoing open or robotic-assisted laparoscopic RP was conducted (July 2017-November 2018).

Intervention: PP (subcutaneous heparin) plus routine care versus routine care alone. The screening subcohort was offered lower extremity duplex ultrasound at 30 d.

Outcomes Measurements And Statistical Analysis: The primary efficacy outcome was symptomatic VTE incidence (pulmonary embolism [PE] or deep venous thrombosis [DVT]). Primary safety outcomes included the incidence of symptomatic lymphocele, hematoma, or bleeding after surgery. Secondary outcomes were overall VTE, estimated blood loss, total surgical drain output, complications, and surveillance imaging bias. Fisher's exact test and modified Poisson regression were performed.

Results And Limitations: A total of 501 patients (75% robotic) were randomized and >99% (500/501) completed follow-up. At second interim analysis (N = 445), the symptomatic VTE rate was 2.3% (four PE + DVT and one DVT) for routine care versus 0.9% (one PE + DVT and one DVT) for PP (relative risk 0.40 [95% confidence interval 0.08-2.03], p = 0.3) meeting a futility threshold for early stopping. In the screening subcohort, the overall VTE rate was 3.3% versus 2.4% (p = 0.7). Results were similar at the final analysis (symptomatic VTE: 2.0% vs 0.8%, p = 0.3; overall VTE: 2.9% vs 2.8%, p = 1). No differences were observed in safety or secondary outcomes. All VTE events (seven symptomatic and three asymptomatic) occurred in patients undergoing pelvic lymph node dissection.

Conclusions: This study was not able to demonstrate a statistically significant reduction in symptomatic VTE associated with PP. There was no increase in the development of symptomatic lymphoceles, bleeding, or other adverse events. Given that the event rate was lower than powered for, further research is needed among high-risk patients (Caprini score ≥8) or patients receiving pelvic lymph node dissection.

Patient Summary: In this report, we randomized patients undergoing radical prostatectomy to perioperative pharmacologic prophylaxis or routine care alone. We found that pharmacologic prophylaxis did not reduce postoperative symptomatic venous thromboembolism significantly for men at routine risk. Importantly, pharmacologic prophylaxis did not increase adverse events, such as formation of lymphoceles or bleeding, and can safely be implemented when indicated for patients with risk factors undergoing radical prostatectomy.
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http://dx.doi.org/10.1016/j.eururo.2020.05.001DOI Listing
September 2020

Prostate Health Index and multiparametric magnetic resonance imaging to predict prostate cancer grade reclassification in active surveillance.

BJU Int 2020 09 2;126(3):373-378. Epub 2020 Jun 2.

Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Objective: To identify the value of combining the Prostate Health Index (PHI) and multiparametric magnetic resonance imaging (mpMRI), tools which have previously been shown to be independently predictive of prostate cancer (PCa) grade reclassification (GR; Gleason score >6), for the purpose of predicting GR at the next surveillance biopsy to reduce unnecessary prostate biopsies for men in PCa active surveillance (AS).

Patients And Methods: Between 2014 and 2019, we retrospectively identified 253 consecutive men in the Johns Hopkins AS programme who had mpMRI and PHI followed by a systematic ± targeted biopsy. PHI and PHI density (PHID) were evaluated across Prostate Imaging-Reporting and Data System version 2.0 (PI-RADSv2) scores and compared to those with and without GR. Next, the negative predictive value (NPV) and area under the receiver operating curve (AUC) were calculated to compare the diagnostic value of PI-RADSv2 score combined with PHI, PHID, or prostate-specific antigen density (PSAD) for GR using their respective first quartile as a cut-off.

Results: Of the 253 men, 38 men (15%) had GR. Men with GR had higher PHI values (40.7 vs 32.0, P = 0.001), PHID (0.83 vs 0.57, P = 0.007), and PSAD (0.12 vs 0.10, P = 0.037). A PI-RADSv2 ≤3 alone had a NPV of 91.6% for GR (AUC 0.67). Using a PHI cut-off of 25.6 in addition to PI-RADSv2 ≤3, the NPV and AUC were both increased to 98% and 0.70, respectively. Using a PSAD cut-off of 0.07 ng/mL/mL with PI-RADSv2 had an AUC of 0.69 and NPV of 95.4%. PHI and PI-RADSv2 together could have avoided 20% of biopsies at the cost of missing 2.6% of GRs.

Conclusions: The combination of PHI and mpMRI can aid in the prediction of GR in men on AS and may be useful for decreasing the burden of surveillance prostate biopsies.
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http://dx.doi.org/10.1111/bju.15101DOI Listing
September 2020

The incidence, predictors, and survival of disappearing small renal masses on active surveillance.

Urol Oncol 2020 02 6;38(2):42.e1-42.e6. Epub 2019 Nov 6.

James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, MD.

Objective: To evaluate the incidence, predictors, and survival for those small renal masses (SRM, solid mass ≤4 cm suspicious for a clinical T1a renal cell carcinoma) that disappear on imaging while undergoing active surveillance (AS).

Subjects/patients And Methods: The Delayed Intervention and Surveillance for SRM registry prospectively enrolled 739 patients with SRMs. Patients having at least 1 image showing no lesion were considered to have a "disappearing" SRM. Logistic regression assessed predictors of having a disappearing SRM and Kaplan-Meier estimates illustrated relative survival.

Results: Of 374 patients enrolled in AS, 22 (5.9%) experienced a disappearing SRM. Mean time to tumor disappearance was 2.0 years (SD = 1.9) and 50.0% reappeared on subsequent CT imaging. SRM disappearance, most commonly encountered on ultrasound imaging surveillance, was independently associated with tumors <1 cm on multivariable analysis (OR = 10.6 (95% CI: 1.1-100.3), P = 0.04). Furthermore, patients with disappearing SRMs were healthier than other patients on AS with no compromise in overall survival during follow-up (5-year survival = 100% vs. 73.2%, P = 0.06).

Conclusions: Approximately 5% of SRM on AS will disappear during follow-up on surveillance imaging. Most of these represent artifacts of heterogeneous imaging modalities, including ultrasound, and the SRM will reappear on subsequent imaging. Given the indolent nature of these lesions, disappearance events do not require reflex repeat imaging and patients should continue AS with their original surveillance schedule intact. A smaller percentage of patients undergoing AS for a SRM may have a mass the permanently disappears.
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http://dx.doi.org/10.1016/j.urolonc.2019.10.005DOI Listing
February 2020

Transperineal prostate biopsy with cognitive magnetic resonance imaging/biplanar ultrasound fusion: description of technique and early results.

World J Urol 2020 Aug 2;38(8):1943-1949. Epub 2019 Nov 2.

The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Park 213, Baltimore, MD, 21287, USA.

Objective: To describe our technique and early results performing transperineal prostate biopsy using cognitive magnetic resonance imaging (MRI)/biplanar ultrasound fusion. Key components of this technique include use of the PrecisionPoint Transperineal Access System (Perineologic, Cumberland, MD) and simultaneous transrectal ultrasound guidance in the axial and sagittal planes.

Patients And Methods: In total, 95 patients (38 studied retrospectively and 57 studied prospectively) underwent a transperineal MRI-targeted prostate biopsy using the technique detailed in this manuscript. All biopsies were performed by a single urologist (MAG). Data were collected with respect to cancer detection rates, tolerability, and complications. The subset of patients who were studied prospectively was assessed for complications by telephone interviews performed at 4-6 days and 25-31 days following the prostate biopsy.

Results: Between February 2018 and June 2019, 95 men underwent a transperineal prostate biopsy using MRI/biplanar ultrasound fusion guidance. Patients had a total of 124 PI-RADS 3-5 lesions that were targeted for biopsy. In total, 108 (87.1%) lesions were found to harbor prostate cancer of any grade. Grade group ≥ 2 prostate cancer was found in 81 (65.3%) of targeted lesions. The detection rates for grade group ≥ 1 and grade group ≥ 2 prostate cancer rose with increasing PI-RADS score. In 65 (68.4%) cases, the patient's highest grade prostate cancer was found within an MRI target. Additionally, 12 of 55 (21.8%) patients who were found to have no or grade group 1 prostate cancer on systematic biopsy were upgraded to grade group ≥ 2 prostate cancer with MRI targeting. Only 1 (1.1%) patient received periprocedural antibiotics and no patient experienced an infectious complication. Self-limited hematuria and hematospermia were commonly reported following the procedure (75.4% and 40.4%, respectively) and only 1 (1.1%) patient developed urinary retention.

Conclusions: We demonstrate the safety and feasibility of performing transperineal prostate biopsy using cognitive MRI/biplanar ultrasound fusion guidance. The described technique affords the safety benefits of the transperineal approach as well as obviates the need for a formal fusion platform. Additionally, this method can conveniently be performed under local anesthesia with acceptable tolerability.
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http://dx.doi.org/10.1007/s00345-019-02992-4DOI Listing
August 2020

Outcomes of very high-risk prostate cancer after radical prostatectomy: Validation study from 3 centers.

Cancer 2019 02 13;125(3):391-397. Epub 2018 Nov 13.

Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, Texas.

Background: Among men with localized high-risk prostate cancer (PCa), patients who meet very high-risk (VHR) criteria have been shown to experience worse outcomes after radical prostatectomy (RP) in a previous study. Variations of VHR criteria have been suggested to be prognostic in other single-center cohorts, but multicenter outcomes validating VHR criteria have not been described. This study was designed to validate VHR criteria for identifying which PCa patients are at greatest risk for cancer progression.

Methods: Patients with high-risk PCa undergoing RP (2005-2015) at 3 tertiary centers were pooled. The outcomes of men with VHR PCa were compared with the outcomes of those who did not meet VHR criteria. The high-risk criteria were a clinical stage of T3 to T4, a prostate-specific antigen level > 20 ng/mL, or a biopsy Gleason grade sum of 8 to 10. The VHR criteria were multiple high-risk features, >4 biopsy cores with a Gleason grade sum of 8 to 10, or primary Gleason grade pattern 5. Biochemical recurrence, metastasis (METS), and cancer-specific mortality (CSM) were assessed with competing risks regressions. Overall mortality was assessed with Cox survival models.

Results: Among 1981 patients with high-risk PCa, men with VHR PCa (n = 602) had adverse pathologic outcomes: 37% versus 25% for positive margins and 37% versus 15% for positive lymph nodes (P <  .001 for both comparisons). Patients with VHR PCa also had higher adjusted hazard ratios for METS (2.78; 95% confidence interval [CI], 2.08-3.72), CSM (6.77; 95% CI, 2.91-15.7), and overall mortality (2.44; 95% CI, 1.56-3.80; P <  .001 for all comparisons).

Conclusions: In a validation study of patients who underwent treatment for high-risk PCa, VHR criteria were strongly associated with adverse pathologic and oncologic outcomes.
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http://dx.doi.org/10.1002/cncr.31833DOI Listing
February 2019

A Prospective Cohort Study of Postdischarge Opioid Practices After Radical Prostatectomy: The ORIOLES Initiative.

Eur Urol 2019 02 21;75(2):215-218. Epub 2018 Oct 21.

The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Opioid pain medications are overprescribed, but few data are available to help in appropriate tailoring of postdischarge opioid prescriptions after surgery. Prior studies are retrospective and based on incomplete responses (<50%) to questionnaires, with small sample sizes for any particular surgery. The ORIOLES initiative was a prospective cohort study (2017-2018) designed to measure postdischarge opioid prescribing and use and clinical predictors of use for consecutive patients after radical prostatectomy. The objectives were to establish a postdischarge opioid reference value to meet the needs of >80% of patients and compare open and robotic surgery. A total of 205 adult patients were enrolled, with 100% completing follow-up. In units of oral morphine equivalents (OMEQ), a median of 225mg was prescribed and 22.5mg used. There was no difference by surgical approach or among patients with a history of pain-related diagnoses. Overall, 77% of postdischarge opioid medication was unused, with 84% of patients requiring ≤112.5mg OMEQ. Only 9% of patients appropriately disposed of leftover medication. Approximately 5% reported continued incisional pain due to surgery at 30d, but none required continued opioid medication use. Prescribing more opioids was independently associated with greater opioid use in adjusted models. PATIENT SUMMARY: In this report, we looked at opioid medication use following discharge after radical prostatectomy. We found that 77% of opioid pain medication prescribed was unused, with 84% of patients using less than half of their prescription. Prescribing more opioids was associated with greater use; only 9% of patients appropriately disposed of leftover medication.
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http://dx.doi.org/10.1016/j.eururo.2018.10.013DOI Listing
February 2019

Best of the 2018 AUA Annual Meeting.

Rev Urol 2018 ;20(2):98-100

Institute and Department of Urology, Johns Hopkins University School of Medicine Baltimore, MD.

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http://dx.doi.org/10.3909/riu0806DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6168331PMC
January 2018

Clinical and Radiographic Predictors of Great Vessel Resection or Reconstruction During Retroperitoneal Lymph Node Dissection for Testicular Cancer.

Urology 2019 01 1;123:186-190. Epub 2018 Sep 1.

University of Chicago, Department of Surgery, Section of Urology, Chicago, IL.

Objective: To evaluate whether specific clinical or radiographic factors predict inferior vena cava (IVC) or abdominal aortic (AA) resection or reconstruction (RoR) at the time of postchemotherapy retroperitoneal lymph node dissection (RPLND) for germ cell tumors of the testicle.

Materials And Methods: Two hundred seventy-seven patients undergoing postchemotherapy RPLND at two institutions between 2005 and 2015 were identified. Preoperative imaging was reviewed with radiologists blinded to operative details. Univariable and multivariable logistic regressions were performed, and a model was created to predict the need for great vessel RoR using radiographic and clinical factors.

Results: Of 97 patients with preoperative imaging and clinical data available, 16 (17%) underwent RoR at RPLND. On univariable analysis dominant mass size, degree of circumferential vessel involvement, and vessel deformity were associated with RoR (all P <.05). No patients with clinical stage IIA or IIB disease at diagnosis required RoR. In the multivariable model, mass involvement of the IVC >135° (odds ratio 65.5, 7.8-548, P <.01) and involvement of the AA >330° (odds ratio 29.0, 3.44-245, P <.01) were predictive for RoR. These thresholds yielded a PPV of 48% and 50% and a NPV of 92% and 97% for IVC and AA RoR, respectively.

Conclusion: Degree of circumferential involvement of the great vessels is an independent predictor for resection or reconstruction of the IVC or AA at postchemotherapy RPLND. Patients at high risk of great vessel reconstruction should be informed accordingly and have the proper teams available for complex vascular reconstruction.
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http://dx.doi.org/10.1016/j.urology.2018.08.028DOI Listing
January 2019

A Review of Outcomes and Technique for the Robotic-Assisted Laparoscopic Retroperitoneal Lymph Node Dissection for Testicular Cancer.

Adv Urol 2018 3;2018:2146080. Epub 2018 May 3.

Department of Urology, James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Objectives: The robotic-assisted laparoscopic retroperitoneal lymph node dissection (R-RPLND) represents a new frontier in the surgical management of testicular cancer in the realm of minimally invasive urologic oncology. We aimed to review the early outcomes as compared to the laparoscopic and open approaches as well as describe the operative technique for the R-RPLND.

Materials And Methods: We reviewed all the literature related to the R-RPLND based on an electronic PubMed search up until July 2017.

Results And Discussion: Encouraged by favorable early oncologic and safety outcomes for treatment of clinical stage (CS) I nonseminomatous germ cell tumor (NSGCT), the R-RPLND affords the same recovery advantages as the laparoscopic retroperitoneal lymph node dissection (L-RPLND) while offering greater dexterity, superior visualization, and a theoretically shorter learning curve for the surgeon. While R-RPLND has a promising future in the management of patients with primary and postchemotherapy NSGCT, larger and more vigorous prospective studies are needed before supplanting the open RPLND as the gold standard approach for primary low-stage NSGCT or becoming an equivalent surgical modality in the postchemotherapy setting.
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http://dx.doi.org/10.1155/2018/2146080DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5960558PMC
May 2018

Adjuvant radiation with androgen-deprivation therapy for men with lymph node metastases after radical prostatectomy: identifying men who benefit.

BJU Int 2019 02 1;123(2):252-260. Epub 2018 May 1.

Department of Urology, James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, USA.

Objectives: To perform a comparative analysis of three current management strategies for patients with lymph node metastases (LNM; pN1) following radical prostatectomy (RP): observation, androgen-deprivation therapy (ADT), and external beam radiation therapy (EBRT) + ADT.

Patients And Methods: Patients with LNM after RP were identified using the National Cancer Database (2004-2013). Exclusion criteria included any use of radiation therapy or ADT before RP, clinical M1 disease, or incomplete follow-up data. Patients were categorised according to postoperative management strategy. The primary outcome was overall survival (OS). Kaplan-Meier curves and adjusted multivariable Cox proportional hazards models were employed. Sub-analyses further evaluated patient risk stratification and time to receipt of adjuvant therapy.

Results: A total of 8 074 patients met the inclusion criteria. Postoperatively, 4 489 (55.6%) received observation, 2 065 (25.6%) ADT, and 1 520 (18.8%) ADT + EBRT. The mean (median; interquartile range) follow-up was 52.3 (48.0; 28.5-73.5) months. Patients receiving ADT or ADT + EBRT had higher pathological Gleason scores, T-stage, positive surgical margin rates, and nodal burden. Adjusted multivariable Cox models showed improved OS for ADT + EBRT vs observation (hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.64-0.94; P = 0.008) and vs ADT (HR 0.76, 95% CI: 0.63-0.93; P = 0.007). There was no difference in OS for ADT vs observation (HR 1.01, 95% CI: 0.87-1.18; P = 0.88). Findings were similar when restricting adjuvant cohorts for timing of adjuvant therapy. There was no difference in OS between groups for up to 2 549 (31.6%) patients lacking any of the following adverse features: ≥pT3b disease, Gleason score ≥9, three or more positive nodes, or positive surgical margin.

Conclusions: For patients with LNM after RP, the use of adjuvant ADT + EBRT improved OS in the majority of patients, especially those with adverse pathological features. Conversely, adjuvant therapy did not confer significant OS benefit in up to 30% of patients without high-risk features, who may be managed with observation and forego the morbidity associated with immediate ADT or radiation.
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http://dx.doi.org/10.1111/bju.14241DOI Listing
February 2019

Initial Experience Performing In-office Ultrasound-guided Transperineal Prostate Biopsy Under Local Anesthesia Using the PrecisionPoint Transperineal Access System.

Urology 2018 May 1;115:8-13. Epub 2018 Feb 1.

The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD. Electronic address:

Objective: To describe our procedural technique and initial outcomes performing in-office transperineal prostate biopsies using the PrecisionPoint Transperineal Access System (Perineologic, Cumberland, MD).

Patients And Methods: Following institutional review board approval, we retrospectively reviewed the records of men who underwent an in-office transperineal prostate biopsy using the PrecisionPoint device. Records were reviewed for baseline characteristics, biopsy results, and postbiopsy complications.

Results: Between January 4, 2017 and August 23, 2017, 43 men underwent an in-office transperineal prostate biopsy using the PrecisionPoint Transperineal Access System. Patients had a median serum prostate specific antigen level of 6.1 ng/mL (range 0.8-32.9). Of the 43 biopsies, 12 (27.9%) were performed for active surveillance of low-risk prostate cancer and 31 (72.1%) were performed for cancer screening. Overall, 21 (48.8%) men were found to have prostate cancer. Among those on active surveillance, cancer was detected in 8 of 12 (66.7%) patients, with 2 of 12 (16.7%) found to have Gleason ≥3 + 4 = 7 prostate cancer. Additionally, cancer was detected in 13 of 31 (41.9%) patients undergoing a biopsy for prostate cancer screening, with 5 (16.1%) found to have Gleason ≥3 + 4 = 7 disease. In total, 3 (7.0%) patients experienced a postbiopsy complication: 2 (4.7%) with urinary retention and 1 (2.3%) with gross hematuria requiring catheterization. No patient experienced an infectious complication despite omission of periprocedural antibiotics in all cases.

Conclusion: The PrecisionPoint device allowed for the successful performance of in-office transperineal prostate biopsies under local anesthesia without the need for periprocedural antibiotics. We observed an acceptable cancer detection rate with no infectious complications.
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http://dx.doi.org/10.1016/j.urology.2018.01.021DOI Listing
May 2018

Comparison of Pathological Stage in Patients Treated with and without Neoadjuvant Chemotherapy for High Risk Upper Tract Urothelial Carcinoma.

J Urol 2018 07 4;200(1):68-73. Epub 2018 Jan 4.

Department of Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland; The Greenberg Bladder Cancer Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland.

Purpose: High risk upper tract urothelial carcinoma has been associated with poor survival outcomes. Limited retrospective data support neoadjuvant chemotherapy prior to radical nephroureterectomy. To validate prior findings we evaluated differences in the pathological stage distribution in patients with high risk upper tract urothelial carcinoma based on the administration of neoadjuvant chemotherapy before radical nephroureterectomy.

Materials And Methods: We retrospectively analyzed the records of 240 patients with upper tract urothelial carcinoma at The Johns Hopkins Hospital from 2003 to 2017. Patients with biopsy proven high grade disease and a visible lesion on cross-sectional imaging were offered neoadjuvant chemotherapy prior to radical nephroureterectomy. A control group of a time matched cohort of patients with biopsy proven high grade disease underwent extirpative surgery alone. The chi-square and Fisher exact tests were used to evaluate clinical and pathological variables between the cohorts.

Results: There were 32 patients in the study group and 208 in the control group. Significantly lower pathological stage was noted in the study group than in the control group (p <0.001). Significantly fewer patients with pT2 disease or higher were treated with neoadjuvant chemotherapy (37.5% vs 59.6%, p = 0.02). There was a 46.5% reduction in the prevalence of pT3 disease or higher in study group patients without clinically node positive or low volume metastatic disease (25.9% vs 48.4%, p = 0.04). A 9.4% complete remission rate was observed in patients who underwent neoadjuvant chemotherapy.

Conclusions: Patients with high risk upper tract urothelial carcinoma treated with neoadjuvant chemotherapy were noted to have a lower pathological stage distribution than patients treated with radical nephroureterectomy alone.
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http://dx.doi.org/10.1016/j.juro.2017.12.054DOI Listing
July 2018

Retroperitoneal lymph node dissection for testicular seminomas: population-based practice and survival outcomes.

World J Urol 2018 Jan 12;36(1):73-78. Epub 2017 Oct 12.

The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, 600 N. Wolfe Street/Marburg 134, Baltimore, MD, 21287, USA.

Purpose: While retroperitoneal lymph node dissection (RPLND) is traditionally reserved for nonseminomatous germ cell tumors, recent efforts to reduce long-term toxicities of radiation and chemotherapy have turned attention to its application for testicular seminomas. Currently, RPLND is reserved for the post-chemotherapy for stage II testicular seminomas; we aimed to describe current utilization of RPNLD for testicular seminomas by stage and implications for survival.

Methods: A national sample of men diagnosed with stage IA/IB/IS/IIA/IIB/IIC testicular seminoma (1988-2013) was evaluated from SEER Program registries. Stage-specific utilization of RPLND was determined. Cox proportional hazards models, adjusted for age, race, and radiotherapy, evaluated overall (OS) and cancer-specific survival (CSS) for the RPLND cohort. Adjusted models assessed predictors of RPLND.

Results: A total of 17,681 men (mean age 38.1 years) with testicular seminoma were included with low utilization of RPLND for stage I disease (1.3% overall) and higher rates for stage II disease (10.6% overall). There were no appreciable trends over time. Patients receiving RPLND did not appear to have worse OS or CSS on adjusted stage-by-stage analysis. Higher stage disease (IIA-IIC) was associated with greater need for RPLND while radiotherapy was associated with decreased use [OR 0.40 (0.32-0.51), p < 0.001].

Conclusions: Utilization of RPLND for testicular seminomas in the post-chemotherapy setting has remained stable over a 25-year period. Patients undergoing RPLND are a higher risk cohort but stage-by-stage survival outcomes appeared comparable to men not undergoing RPLND. Upcoming trials implementing RPLND as a first-line modality for testicular seminoma or isolated retroperitoneal relapse will help better quantify relative recurrence and survival.
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http://dx.doi.org/10.1007/s00345-017-2099-0DOI Listing
January 2018

Growth Kinetics of Small Renal Masses on Active Surveillance: Variability and Results from the DISSRM Registry.

J Urol 2018 03 23;199(3):641-648. Epub 2017 Sep 23.

The James Buchanan Brady Urological Institute, The Johns Hopkins Hospital (ACU, HDP, RA, MAG, MHJ, HG, MFR, BJT, MEA, PMP), Baltimore, Maryland; Division of Urology, Beth Israel Deaconess Medical Center (PC, AAW), Boston, Massachusetts; Department of Urology, Columbia University Medical Center (JMM), New York, New York.

Purpose: Active surveillance is emerging as a safe and effective strategy for the management of small renal masses (4 cm or less). We characterized the growth rate and its pertinence to clinical outcomes in a prospective multi-institutional study of patients with small renal masses.

Materials And Methods: Since 2009, the DISSRM (Delayed Intervention and Surveillance for Small Renal Masses) prospective, multi-institutional registry of patients with small renal masses has enrolled patients who elect primary intervention or active surveillance. Patients who elect active surveillance received regularly scheduled imaging and those with 3 or more followup images were included in the current study to evaluate growth rates.

Results: We evaluated 318 patients who elected active surveillance, of whom 271 (85.2%) had 3 or more followup images available with a median imaging followup of 1.83 years. The overall mean ± SD small renal mass growth rate was 0.09 ± 1.51 cm per year (median 0.09) with no variables demonstrating statistically significant associations. The growth rate and variability decreased with longer followup (0.54 and 0.07 cm per year at less than 6 months and greater than 1 year, respectively). No patients had metastatic disease or died of kidney cancer. No statistically significant difference was noted in the growth rate in patients with biopsy demonstrated renal cell carcinoma or in those who died.

Conclusions: Small renal mass growth kinetics are highly variable early on active surveillance with growth rates and variability decreasing with time. Early in active surveillance, especially during the initial 6 to 12 months, the growth rate is variable and does not reliably predict death or adverse pathological features in the patient subset with available pathology findings. An elevated growth rate may indicate the need for further assessment with imaging or consideration of biopsy prior to progressing to treatment. Additional followup will inform the best clinical pathway for elevated growth rates.
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http://dx.doi.org/10.1016/j.juro.2017.09.087DOI Listing
March 2018

Radiotherapy for stage I and II testicular seminomas: Secondary malignancies and survival.

Urol Oncol 2017 10 13;35(10):606.e1-606.e7. Epub 2017 Jul 13.

Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD.

Introduction: Testicular seminoma affects relatively young men with excellent survival outcomes. There has been increasing concern that radiotherapy (RT) leads to secondary malignant neoplasms (SMNs) and subsequent mortality. We evaluated the effect of RT on incidence of SMNs and quantified cancer-related mortality and other causes of death for patients with stage I and II testicular seminoma.

Material And Methods: A national sample of men (1988-2013) diagnosed with stage IA/IB/IS/IIA/IIB/IIC testicular seminomas from Surveillance, Epidemiology, and End Results were evaluated. Use of RT over time and survival curves (5/10/15-year) was stratified by stage. Log-binomial regression determined relative risk of developing SMNs. Incidence rate ratios (IRR) and age-adjusted Cox proportional hazards models compared overall, cancer-specific survival (CSS), and other cancer-specific survival. Competing-risks regression generated cumulative incidence functions. Prevalence ratios explored excess deaths owing to specific causes.

Results: A total of 16,463 men were included with 9,126 (55.4%) undergoing RT with markedly decreased use for stage I seminoma in recent years (<20%) and ~50% for stage IIA. RT increased risk of SMNs (relative risk = 1.84 [95% CI: 1.61-2.10, P<0.01]). Survival rates were excellent (15-year CSS for stage I [≥99%], stage IIA [98.1%], stage IIB-C [96%-97%]). RT was associated with improved CSS for stage IB and IIA, but demonstrated less benefit for stage IA (IRR = 0.63 [95% CI: 0.35-1.14, P = 0.10]) with worse other cancer-specific survival (IRR = 1.80 [95% CI: 0.97-3.59, P = 0.05]). Gastrointestinal, respiratory, urinary, and hematologic malignances accounted for 84% of SMN deaths.

Conclusions: RT offers excellent CSS for men with stage I/II seminoma and an increased risk of SMN later in life. Future studies should better evaluate risk-stratification for stage IB patients.
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http://dx.doi.org/10.1016/j.urolonc.2017.06.051DOI Listing
October 2017

Lymph node density predicts recurrence and death after inguinal lymph node dissection for penile cancer.

Investig Clin Urol 2017 01 4;58(1):20-26. Epub 2017 Jan 4.

The James Buchanan Brady Urological Institute, Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Purpose: To determine the impact of lymph node density (LND) on survival after inguinal lymph node dissection (ILND) for penile cancer.

Materials And Methods: Our institutional penile cancer database was queried for patients who underwent ILND. Clinicopathologic characteristics including LND and total number of positive lymph nodes (LNs) were analyzed to determine impact on recurrence-free survival (RFS) and overall survival (OS). LND, or the percent of positive LN out of total LN, was calculated as a categorical variable at varying thresholds.

Results: Twenty-eight patients with complete follow-up were identified. Indications for ILND were stage >T2 in 20 patients (71.4%), palpable adenopathy in 7 (25%), high grade T1 in 1 (3.6%). Median node yield was 17.5 (interquartile range, 12-22), and positive LNs were found in 14 patients (50%). RFS and OS were significantly lower for patients with >15% LN density (median RFS: 62 months vs. 6.3 months, p=0.0120; median OS: 73.6 months vs. 6.3 months, p<0.001). Controlling for age, medical comorbidities, number of positive LN, T stage, pelvic LN status and indication, LN density >15% was independently associated with worse RFS (hazard ratio [HR], 3.6; p=0.04) and OS (HR, 73.6; p=0.002). The c-index for LND was higher than total positive LNs for RFS (0.64 vs. 0.54) and OS (0.79 vs. 0.61).

Conclusions: In this small, retrospective penile cancer cohort, the presence of nodal involvement >15% was associated with decreased RFS and OS, and outperformed total number of positive LN as a prognostic indicator.
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http://dx.doi.org/10.4111/icu.2017.58.1.20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5240287PMC
January 2017

Editorial Comment from Dr Schwen and Dr Pierorazio to Robot-assisted partial nephrectomy confers excellent long-term outcomes for the treatment of complex cystic renal tumors: Median follow up of 58 months.

Int J Urol 2016 12 17;23(12):983. Epub 2016 Oct 17.

The Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

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http://dx.doi.org/10.1111/iju.13244DOI Listing
December 2016

Pathological analysis of the prostatic anterior fat pad at radical prostatectomy: insights from a prospective series.

BJU Int 2017 03 30;119(3):444-448. Epub 2016 Sep 30.

Department of Urology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA.

Objective: To assess factors associated with lymphatic drainage and lymph node (LN) metastasis to the prostatic anterior fat pad (PAFP) in men with prostate cancer and the utility of routine PAFP analysis at the time of radical prostatectomy (RP).

Patients And Methods: Our institution began to prospectively collect PAFP tissue in 2010. The PAFP was removed at the time of RP and sent as a pathological specimen separate from the pelvic LNs and prostate. Consecutive RPs performed at our institution in which the PAFP was removed were reviewed to determine the rate of LNs in the PAFP, the rate of metastatic LNs in the PAFP, and the association of metastatic PAFP LN with clinical and pathological features. The impact on biochemical recurrence (BCR) was assessed with a Cox's proportional hazard model.

Results: In all, 2 413 PAFP specimens were available for analysis. LNs were found in the PAFP in 255 (10.6%) cases and metastatic LNs in the PAFPs were found in 14 (0.6%) cases. Metastatic PAFP LNs were associated with anterior tumours in 11 of the 14 cases (P = 0.01), and were present only in preoperative D'Amico intermediate- (six of 14) and high- (eight of 14) risk patients (P < 0.001). Metastatic PAFP LNs were associated with extraprostatic disease in 13 of the 14 cases, although concomitant pelvic LN involvement was present in only four of the 14 cases. With a mean follow-up of 1.5 years, three of the 14 patients with metastatic PAFP LN developed BCR. Positive LN involvement in either the pelvic LN or PAFP had worse BCR than LN-negative patients (P < 0.001); however, there was no difference in BCR between patients with positive pelvic LN and positive PAFP LN (P = 0.5).

Conclusion: Metastatic PAFP LNs are rare and always occur in the presence of other adverse pathological features. The routine pathological analysis of PAFP as a separate specimen, especially in low-risk disease, may not be warranted.
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http://dx.doi.org/10.1111/bju.13654DOI Listing
March 2017

Prostate Health Index (PHI) Predicts High-stage Pathology in African American Men.

Urology 2016 Apr 10;90:136-40. Epub 2015 Dec 10.

The James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD; The Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD.

Objective: To evaluate the association between the Prostate Health Index (PHI) and adverse pathology in a cohort of African American (AA) men undergoing radical prostatectomy.

Materials And Methods: Eighty AA men with prostate-specific antigen (PSA) of 2-10 ng/mL underwent measurement of PSA, free PSA (fPSA), and p2PSA prior to radical prostatectomy. PHI was calculated as [(p2PSA/fPSA) × (PSA)(½)]. Biomarker association with pT3 disease was assessed using logistic regression, and covariates were added to a baseline multivariable model including digital rectal examination. Biomarker ability to predict pT3 disease was measured using the area under the receiver operator characteristic curve.

Results: Sixteen men (20%) demonstrated pT3 disease on final pathology. Mean age, PSA, and %fPSA were similar in men with and without pT3 disease (all P  >  .05), whereas PHI was significantly greater in men with pT3 disease (mean 57.2 vs 46.6, P  =  .04). Addition of PHI to the baseline multivariable model improved discriminative ability by 12.9% (P  =. .04) and yielded greater diagnostic accuracy than models, including other individual biomarkers.

Conclusion: In AA men with PSA of 2-10 ng/mL, PHI was predictive of pT3 prostate cancer and may help to identify men at increased risk of adverse pathology. Additional studies are needed to substantiate these findings and identify appropriate thresholds for clinical use.
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http://dx.doi.org/10.1016/j.urology.2015.12.004DOI Listing
April 2016