Gopalakrishna, Ajay

Abstract Background The objective of this study was to evaluate the prognostic value of early PSA decline following initiation of second-generation hormone therapy (2nd HT), namely abiraterone acetate or enzalutamide, in patients with taxane-refractory metastatic castrate-resistant prostate cancer (mCRPC) and evaluate utility of this metric in informing intensified surveillance/imaging protocols. Methods We retrospectively identified 75 mCRPC patients treated with 2nd HT following docetaxel failure (defined as PSA rise and radiographic progression). Patients were categorized patients into two cohorts based on the first PSA within 3 months after initiation of therapy: PSA reduction ≥ 50% (Group A) and PSA reduction < 50% (Group B). The primary endpoint was cancer-specific mortality (CSM). The secondary endpoint was radiographic disease progression (rDP) on 2nd HT. In univariate and multivariate analyses, we investigated factors associated with rPD and CSM. Results We included 75 patients (52 in Group A, 23 in Group B) in the analytic cohort. Baseline clinico-demographic characteristics, including median age, primary Gleason score risk group, median pre-treatment PSA, disease burden, site of metastases, and pre-treatment ECOG score were not statistically different between the two groups. Median follow up time was 30 months and the median time to radiographic disease progression was 28.1 and 12.5 months (p = 0.002) in cohorts A and B, respectively. On univariate and multivariate analyses, both PSA reduction ≥ 50% and volume of metastatic disease were significantly associated with a decreased risk of radiographic disease progression (HR 0.41, 95% CI 0.21–0.80, p = 0.0113) as well as a decreased risk of cancer-specific mortality (HR 0.29, 95% CI 0.09–0.87, p = 0.0325). Conclusion PSA reduction ≥ 50% within 3 months of starting 2nd HT was associated with significantly improved radiographic disease progression-free survival and 3-year cancer-specific mortality. This suggests using PSA 50%-decline metric in surveillance patients with on 2nd HT and identifies patients who require further evaluation with imaging.

ABSTRACT Introduction Patient satisfaction after inflatable penile prosthesis (IPP) placement has been linked to preexisting curvature. Intraoperative findings such as curvature on artificial erection (AE) or asymmetric corporal measurements (ACM) are incompletely characterized in terms of impact on IPP outcome. Objective We sought to evaluate the clinical utility of AE and the significance of ACM during IPP surgery. Methods A single institution retrospective review of patients undergoing primary IPP placement between 7/2019-9/2020 was performed. Patient characteristics and intraoperative measurements were compared. Threshold for statistical significance was p≤0.05. Results A total of 130 patients underwent primary placement of penile prosthesis. Median age was 67 years (IQR 13). Comorbidities included prostatectomy in 33.8%, and known Peyronie's disease in 21.5%. Of the 27.7% (n=36) of patients who underwent intraoperative AE, 63.9% (n=23) had visible curvature. Of the patients with visible curvature, 70% (n=16) had a preoperative diagnosis of Peyronie's disease and 56.3% (n=9) underwent straightening procedures compared to 28.6% (n=2) of the 30% (n=7) with no known curvature. Incision and grafting was most frequently performed (6/11)- with a minority undergoing plication (2/11). Of the 72.3% (n=94) who did not undergo AE, only 2.1% (n=2) required additional measures for curvature correction. Median corporal measurement was 21 (IQR 2) bilaterally and median cylinder size 20 cm (IQR 4) bilaterally with 1cm rear tip extenders. Of the 18.5% (24/130) of patients with ACM, asymmetry was as follows: 20.8% (5/24) had less than 1 cm, 70.8% (17/24) had 1 to &lt;2 cm, and 8.3% (2/24) had 2 cm or greater. Of these patients 87.5% (21/24) underwent placement of an asymmetric device, only 5% (1/21) of which had residual curvature less than 30 degrees. Despite ACMs, 12.5% (3/24) of patients had a symmetric device placed, one of which had residual curvature. Only 2 patients underwent straightening procedures including plication and incision/grafting. Conclusions Intraoperative AE is effective at revealing occult penile curvature at time of IPP placement, however most men with newly detected curvature do not require additional straightening measures. We also found that 1 in 5 patients undergoing IPP had ACM but this did not correspond to residual curvature following IPP or requirement for adjunct straightening. These findings may provide reassurance to urologists who do not routinely perform AE or those who encounter ACM during corporal dilation Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific, Coloplast

Objective To report perioperative, renal functional and oncologic outcomes for patients undergoing partial or radical nephrectomy for cT2 renal masses. Methods Retrospective review of patients who underwent partial ( n = 72) or radical nephrectomy ( n = 379) for cT2 renal masses from 2000 to 2016. After propensity adjustment using inverse probability weighting, the following were compared by surgery (partial or radical nephrectomy): complications, renal function measured by estimated glomerular filtration rate as continuous and as <60 mL/min/1.73 m 2 at 1 and 3 years postoperatively and overall, metastases‐free survival and cancer‐specific survival in patients with renal cell carcinoma. Results After propensity adjustment, clinical and radiographic features were well‐balanced between groups. Overall and severe complications were more common for partial compared with radical nephrectomy, although not statistically significant (19 vs 13%, P = 0.14 and 4 vs 2%, P = 0.3, respectively). Estimated glomerular filtration rate change at 1 and 3 years was more pronounced in radical compared with partial nephrectomy (median −16 vs −5 and −14 vs −2, respectively, P < 0.001). A greater proportion of radical nephrectomy patients had an estimated glomerular filtration rate <60 at 1 and 3 years (55 vs 17% and 48 vs 17%, respectively, P < 0.01). In renal cell carcinoma patients, overall, metastases‐free and cancer‐specific survival were not significantly different between groups (median survivor follow up 7.1 years, interquartile range 3.6–11.4). Conclusions Partial nephrectomy appears to be a relatively safe and a potentially effective treatment for cT2 renal masses, conferring better renal functional preservation compared with radical nephrectomy. These data support continued use of partial nephrectomy for renal masses >7 cm in appropriately selected patients.

Abstract Background Climacturia is an under-reported complication of definitive therapy for prostate cancer (PCa) - that is, radical prostatectomy (RP) and/or radiation therapy (RT). Aim We sought to identify the prevalence and predictors of climacturia and associated patient/partner bother in patients with and without prior PCa treatment. Methods We analyzed a database of patients who presented to our Men's Health clinic and filled out a questionnaire related to sexual function and pertinent medical histories. The prevalence of climacturia and associated patient/partner bother in patients with/without prior RP/RT was calculated. Univariable and multivariable logistic regressions were performed to identify predictors associated with climacturia and patient/partner bother. Outcomes The primary outcomes were the prevalence and predictors of climacturia and associated patient/partner bother in patients with/without history of definitive PCa treatment. Results Among 1,117 patients able to achieve orgasm, 192 patients (17%) had prior history of definitive therapy for PCa (RP alone = 139 [72%]; RT alone = 22 [11%]; RP + RT = 31 [16%]). Climacturia was reported by 39%, 14%, 52%, and 2.4% of patients with history of RP alone, RT alone, RP + RT, and neither RP nor RT, respectively (P &lt; .05 between all groups). 33 to 45 percent of patients with climacturia noted significant patient/partner bother. Factors significantly associated with climacturia were prior RP, prior RT, history of other prostate surgery, and erectile dysfunction, although erectile dysfunction was not significant on multivariable analysis. Significant reduction in climacturia prevalence was noted for patients who were ≥1 year out from RP, compared with patients who were &lt;1 year out. Among patients with prior RP/RT, stress urinary incontinence was associated with increased risk of climacturia, whereas diabetes was associated with decreased risk. No factors were associated with patient/partner bother. Among patients with prior RP, nerve-sparing technique did not predict presence of climacturia but was associated with reduced patient/partner bother. Clinical translation Given significant prevalence of climacturia and associated patient/partner bother, patients should be counseled on the risk of climacturia before undergoing RP/RT. Strengths and limitations Strengths include the large study population and the focus on both RP and RT. Limitations include the facts that this is a single-institution study that primarily relies on patients’ subjective reporting and that the study population may not represent the general population. Conclusions Climacturia affects a significant proportion of patients with history of RP/RT for PCa, and many patients and their partners find this bothersome.