Henning, Grant

Objectives To evaluate whether extracellular volume (ECV) fraction derived from contrast‐enhanced computed tomography (CT) is associated with recurrence risk in patients with treatment‐naïve high‐risk non‐muscle‐invasive bladder cancer (HR‐NMIBC) receiving intravesical gemcitabine/docetaxel (Gem/Doce) therapy. Patients and Methods This retrospective cohort study, conducted at a tertiary referral centre, included 103 patients with HR‐NMIBC treated with intravesical Gem/Doce between 2012 and 2024. All patients underwent pre‐resection contrast‐enhanced CT with an equilibrium phase (~3 min post‐injection). Tumour ECV fraction (%) was calculated using the formula: ECV = (ΔHUtumour/ΔHUaorta) × (1 − haematocrit) × 100, where Δ Hounsfield units (HU) represents the change in attenuation between non‐contrast and equilibrium phases. Regions of interest were manually placed in the tumour and abdominal aorta, and haematocrit values obtained within ±10 days were used. Associations between clinical variables, ECV, and recurrence were evaluated using Cox proportional hazards models, with discrimination assessed by Uno's C‐statistic. Results The median (interquartile range) follow‐up was 17 (10–25) months. High‐grade recurrence‐free survival (HG‐RFS) was 76% at 12 months and 69% at 24 months. CT‐derived ECV was the only variable significantly associated with HG‐RFS (hazard ratio 1.05, 95% confidence interval 1.03–1.08), demonstrating strong discrimination (C‐statistic, 0.81; P < 0.01). A 15% threshold offered the best sensitivity–specificity trade‐off (~70% each) for predicting HG‐RFS at 12 and 24 months. Patients with ECV ≤15% had markedly better HG‐RFS than those with ECV >15% at 24 months (88% vs 41%). Conclusions The CT‐derived ECV is a practical, first‐of‐its‐kind imaging biomarker associated with recurrence risk and useful for risk stratification in patients with HR‐NMIBC treated with intravesical Gem/Doce, a regimen increasingly used in the setting of global Bacillus Calmette‐Guérin shortages and intolerance. ECV can be rapidly quantified from routine contrast‐enhanced CT using standard picture archiving and communication system (PACS) tools, without additional imaging or proprietary software, making it a feasible metric for integration into risk‐adapted management pending large‐scale validation with extended follow‐up.

Purpose: Surgical video review can be used in urologic training, yet significant barriers to the implementation of video review programs exist, and formal assessment of usage and utility for trainees is limited. Here, we evaluate a novel video review platform to describe patterns of use and determine perceived utility. Materials and Methods: We analyzed learning points entered by trainees during video review of radical prostatectomy cases using our surgical intelligence–enabled Film Room platform between September 2023 and July 2024. Learning point content was categorized according to surgical coaching domains as technical, cognitive, nontechnical, or descriptive. Entries were compared by surgical step and level of training. Anonymous surveys were distributed to trainees to determine perceived utility and reveal patterns of video review. Results: Thirteen trainees entered 480 unique learning points across all radical prostatectomy steps and spanning surgical coaching domains during the study period. Learning points varied by training level, with junior trainees entering points more often than senior trainees for Retzius-space dissection ( N = 73 vs 17, p < 0.01) and seminal vesicle and posterior dissection ( N = 58 vs 27, p < 0.01). Trainees used video review in preparation for both upcoming cases and performance analysis. Ninety-four percent of survey respondents reported they either agreed or strongly agreed that video review helped them develop surgical skills. Conclusions: We found usage across training levels and high perceived utility of our Film Room platform for video review of robotic prostatectomy. Implementation of video review platforms holds promise to augment existing urologic training and should be explored further.

ABSTRACT Purpose The natural history of biochemical recurrence (BCR) after radical prostatectomy (RP) remains understudied, with limited long‐term data from large cohorts inclusive of both salvage radiotherapy (SRT)‐treated and untreated patients. Herein, we sought to evaluate the outcomes of patients with BCR and the impact of SRT on disease progression. Materials and Methods Patients undergoing RP who developed BCR (PSA ≥ 0.20 ng/mL) were included. Patients with BCR treated with SRT were compared to untreated patients using risk‐set matching with time‐dependent propensity scores. The primary outcome was metastases, analyzed using Kaplan–Meier and Cox models. The number needed to treat (NNT) with SRT to prevent progression was derived at 5 and 15 years. Results Among 6881 patients with BCR, 2109 received SRT. At a median follow‐up of 10.2 years, 1147 patients developed metastases. The median PSA at the time of SRT was 0.50 ng/mL. After 1:1 propensity score matching (2109 patients per cohort), SRT significantly reduced the risk of metastases at 5 (12.7% vs. 19.3%, p < 0.0001) and 15 years (28.6% vs. 31.5%, p < 0.001). On multivariable analysis, SRT independently reduced metastasis risk (HR 0.75, 95% CI 0.63–0.90, p = 0.002), translating to NNT of 23 and 15 at 5 and 15 years, respectively. Interaction analyses between SRT and nodal status ( p = 0.04) showed greater metastasis risk reduction in pN+ (HR 0.41, 95% CI 0.22–0.77, p = 0.005) compared to pN− disease (HR 0.81, 95% CI 0.67–0.97, p = 0.02). Conclusions Most patients with BCR post‐RP do not progress to metastasis. For those who do progress, SRT inarguably improves the oncologic outcomes in the BCR setting. However, careful patient selection and shared decision making should be encouraged in order to limit overtreatment and side effects.

382 Background: The natural history of biochemical recurrence (BCR) after radical prostatectomy (RP) is heterogeneous, with most patients not progressing to metastasis. Determining the impact and optimal timing of salvage radiation therapy (SRT) remains challenging, particularly in the absence of prospective randomized trials with a surveillance control arm. Our objective isto quantify the oncologic benefit of SRT among men with BCR after RP. Methods: Patients who underwent RP at Mayo Clinic between 1990 and 2017 and developed BCR (PSA≥0.20ng/mL) were included. Patients treated with SRT were compared to those managed with surveillance using risk-set matching with time-dependent propensity scores, accounting for covariates at BCR and post-BCR. The primary outcome was metastases, analyzed via Kaplan-Meier and Cox proportional hazard models. The number needed to treat (NNT) with SRT to prevent progression was calculated using regression outputs at 5 and 15 years post-BCR. Interaction analyses identified factors modifying SRT’s effect on metastasis. Results: Of 6,881 patients with BCR, 2,109 received SRT. At a median follow-up of 10.2 years, 1,147 patients with BCR developed metastases. After 1:1 matching, SRT was associated with lower metastasis risk than surveillance at 5 years (12.7% vs 19.3%, p<0.0001) and 15 years (28.6% vs. 31.5%, p<0.001). SRT was independently associated with decreased metastasis risk (HR 0.75, 95%CI 0.63–0.90, p=0.002) on multivariable analysis, translating to NNT of 23 and 15 at 5 and 15 years, respectively (Table). Additionally, we noted a significant interaction between PSA at SRT and the association of SRT with metastasis (p-interaction=0.02), such that the reduction in metastatic progression with SRT vs. surveillance was restricted to the cohort of patients who received SRT for PSA>0.40ng/mL (HR 0.66, 95%CI 0.54–0.80, p<0.001). Conclusions: Most patients with BCR post-RP do not develop metastases. Indeed, the NNT with SRT to reduce metastasis versus surveillance indicates a generally indolent disease course. Further, the lack of a significant association of SRT with reduction of metastases in patients with a PSA≤0.40ng/mL underscores the importance of careful patient selection when considering early SRT. Our data establish the rationale for a randomized trial comparing early SRT versus surveillance for appropriately selected patients with BCR after RP. Hazard ratios of SRT after matching by propensity scores, and number needed to treat for systemic progression, prostate cancer specific mortality and overall mortality. DiseaseOutcome Hazard Ratio(95% CI) P value Number Needed to Treat* (95% CI) 5 years 15 years Systemic progression 0.75(0.63 – 0.90) 0.002 23(17 – 41) 15(11 – 27) Prostate cancer mortality 0.81 (0.64 – 1.03) 0.086 103(62 – 494) 26(15 – 124) Overall mortality 0.79 (0.70 – 0.89) 0.0001 38(29 – 62) 12(9 – 20) *Number needed to treat (NNT) calculated using regression based absolute differences in event free survival between salvage radiation therapy (SRT) and observation.

Introduction: Biomarkers are often used in conjunction with MRI to improve the specificity of prostate cancer screening. Our objective was to evaluate the real-world utility of the 4Kscore test in the setting of MRI. We explored the association of the 4Kscore test with the decision to pursue prostate biopsy and its contribution to the accurate detection of clinically significant prostate cancer. Methods: We retrospectively analyzed patients undergoing the 4Kscore test and MRI for consideration of prostate biopsy. Multivariable logistic regression was used to model the association of 4Kscore with the decision to pursue biopsy. Receiver-operating characteristic curves were used to calculate the AUC of 4Kscore alone, PSA with MRI, and 4Kscore with MRI for detection of Gleason Grade Group ≥ 2 (GG ≥ 2) prostate cancer. Results: Of 442 patients, 311 (70%) proceeded to biopsy. 4Kscore was associated with the decision to pursue biopsy for continuous (odds ratio [OR] 1.05 per 1-point increase in 4Kscore, 95% confidence interval [CI] 1.02-1.07; P < .001) and categorical (high-risk 4Kscore: OR 16.1, 6.62-39.3, P < .001; intermediate-risk 4Kscore: OR 6.89, 95% CI 3.15-15.1; P < .01) models. For the detection of GG ≥ 2 prostate cancer, the AUC of 4Kscore with MRI (AUC = 0.866) was superior to 4Kscore alone (AUC = 0.800, P < .001) and PSA with MRI (AUC = 0.792, P < .001). Conclusions: In patients with MRI, the 4Kscore is associated with the decision to pursue prostate biopsy and augments the accurate prediction of GG ≥ 2 prostate cancer. Our findings suggest 4Kscore provides independent information as an adjunct to MRI for real-world clinical decision making.