A prospective evaluation of the prostate microbiome in malignant and benign tissue using transperineal biopsy.

BACKGROUND: The link between the prostate microbiome and prostate cancer remains unclear. Few studies have analyzed the microbiota of prostate tissue, and these have been limited by potential contamination by transrectal biopsy. Transperineal prostate biopsy offers an alternative and avoids fecal cross-contamination. We aim to characterize the prostate microbiome using transperineal biopsy. METHODS: Patients with clinical suspicion for prostate cancer who were to undergo transperineal prostate biopsy with magnetic resonance imaging (MRI) fusion guidance were prospectively enrolled from 2022 to 2023. Patients were excluded if they had Prostate Imaging Reporting and Data System lesions with scores ≤ 3, a history of prostate biopsy within 1 year, a history of prostate cancer, or antibiotic use within 30 days of biopsy. Tissue was collected from the MRI target lesions and nonneoplastic transitional zone. Bacteria were identified using 16S ribosomal RNA gene sequencing. RESULTS: Across the 42 patients, 76% were found to have prostate cancer. Beta diversity indices differed significantly between the perineum, voided urine, and prostate tissue. There were no beta diversity differences between cancerous or benign tissue, or between pre- and postbiopsy urines. There appear to be unique genera more abundant in cancerous versus benign tissue. There were no differences in alpha diversity indices relative to clinical findings including cancer status, grade, and risk group. CONCLUSIONS: We demonstrate a rigorous method to better characterize the prostate microbiome using transperineal biopsy and to limit contamination. These findings provide a framework for future large-scale studies of the microbiome of prostate cancer.

Robotic versus open radical cystectomy for bladder cancer: evaluation of complications, survival, and opioid prescribing patterns.

We aim to compare complications, readmission, survival, and prescribing patterns of opioids for post-operative pain management for Robotic-assisted laparoscopic radical cystectomy (RARC) as compared to open radical cystectomy (ORC). Patients that underwent RARC or ORC for bladder cancer at a tertiary care center from 2005 to 2021 were included. Recurrence-free survival (RFS) and overall survival (OS) were evaluated with Kaplan-Meier curves and multivariable Cox proportional hazards regression models. Comparisons of narcotic usage were completed with oral morphine equivalents (OMEQ). Multivariable linear regression was used to assess predictors of OMEQ utilization. A total of 128 RARC and 461 ORC patients were included. There was no difference in rates of Clavien-Dindo grade ≥ 3 complications between RARC and ORC (36.7 vs 30.1%, p = 0.16). After a mean follow up of 3.4 years, RFS (HR 0.96, 95%CI 0.58-1.56) and OS (HR 0.69, 95%CI 0.46-1.05) were comparable between RARC and ORC. There was no difference in the narcotic usage between patients in the RARC and ORC groups during the last 24 h of hospitalization (median OMEQ: 0 vs 0, p = 0.33) and upon discharge (median OMEQ: 178 vs 210, p = 0.36). Predictors of higher OMEQ discharge prescriptions included younger age [(- )3.46, 95%CI (-)5.5-(-)0.34], no epidural during hospitalization [- 95.85, 95%CI (- )144.95-(- )107.36], and early time-period of surgery [(- )151.04, 95%CI (- )194.72-(- )107.36]. RARC has comparable 90-day complication rates and early survival outcomes to ORC and remains a viable option for bladder cancer. RARC results in comparable levels of opioid utilization for pain management as ORC.

Neoadjuvant Chemotherapy Before Radical Cystectomy for Muscle-Invasive Bladder Cancer: Elective and Eligibility Factors Impacting Utilization.

INTRODUCTION: We aimed to assess utilization of neoadjuvant chemotherapy (NAC) and etiologies for lack of NAC receipt among patients with muscle-invasive bladder cancer (MIBC). METHODS: Patients diagnosed with MIBC undergoing radical cystectomy at a single institution (2005-2021) were included. Patients were categorized by receipt of NAC, and reasons for no NAC were categorized into eligibility and elective factors. Overall survival was analyzed using univariable and multivariable Cox proportional hazards regression models and modeled with Kaplan-Meier curves. RESULTS: Three hundred eighty patients with MIBC were included; 154 (40.5%) received NAC. Patients were not candidates for NAC due to renal dysfunction (16.6%), clinical contraindications (4.7%), salvage setting (2.1%), and histology (5.3%; total N = 109). Among 271 (71.3%) who were eligible, utilization increased from early (2005-2016) to recent (2016-2021) time periods (34.2% to 85.7% among NAC-eligible, P < .001; 22.8% vs 67.1% among all MIBC, P < .001). Elective factors for not receiving NAC included patient symptoms (7.8%), disease progression concern (7.0%), patient preference/refusal (20.3%) and provider discretion (8.1%) among 271 NAC-eligible patients. Notably, patient preference/refusal decreased from 33.6% to 3.4% in recent years (P < .001). On multivariable analysis, lack of NAC utilization due to renal dysfunction (HR 2.18, P = .002), clinical contraindications (HR 2.62, P = .01), and elective factors (HR 1.88, P = .01) were associated with worse overall survival. CONCLUSIONS: NAC utilization increased over time with 85.7% of eligible patients with MIBC receiving NAC in recent years. Renal dysfunction, patient preference, and clinical contraindications were primary etiologies for lack of NAC. Fewer patients refused NAC in recent years leading to a potential ceiling for NAC utilization.

Four versus 3 Cycles of Neoadjuvant Chemotherapy for Muscle-Invasive Bladder Cancer: Implications for Pathological Response and Survival.

PURPOSE: The ideal number of neoadjuvant chemotherapy (NAC) cycles for muscle-invasive bladder cancer is uncertain with 3 to 4 representing the standard of care (SOC). We compared ypT0 rates and survival between patients receiving 4 versus 3 cycles of NAC with evaluation of chemotherapy-related toxicity for correlation with tumor chemosensitivity and pathological response. MATERIALS AND METHODS: Patients receiving NAC followed by radical cystectomy for cT2-4N0M0 urothelial carcinoma from 2 institutions were included. Primary study groups included 4 cisplatin-based NAC cycles, 3 cisplatin-based NAC cycles, and nonSOC NAC (1-2 cycles or noncisplatin-based) to compare ypT0/≤ypT1 rates and survival. A cohort of patients not receiving NAC was included for pathological reference. RESULTS: Of 693 total patients, 318 (45.9%) received NAC. ypT0 and ≤ypT1 rates were 42/157 (26.8%) and 86/157 (54.8%) for 4 cycles, 38/114 (33.3%) and 71/114 (62.3%) for 3 cycles, and 6/47 (12.8%) and 13/47 (27.7%) for nonSOC (p=0.03 and p <0.01, respectively). Pathological response appeared higher among patients receiving 3 cycles due to toxicity (ypT0: 29/77 [37.7%]; ≤ypT1: 51/77 [66.2%]) but did not reach statistical significance. Toxicities leading to treatment modifications were thrombocytopenia (32.1%), neutropenia (27.2%), renal insufficiency (22.2%), and constitutional symptoms (18.5%). NonSOC patients had lower Kaplan-Meier survival (cT2-cT4N0M0: log-rank p=0.07; cT2N0M0: log-rank p=0.02). There were no statistically significant differences in survival between 4 and 3 cycles (HR 1.00 [95% CI 0.57-1.74], p=0.99). CONCLUSIONS: Patients completing 3 cycles of cisplatin-based NAC have similar pathologic response and short-term survival compared to 4 cycles. Further evaluation of patients experiencing toxicity as a potential marker of tumor chemosensitivity is needed.

Axial Diameter is Superior to Volumetric Measurement in Predicting Ureteral Stone Passage.

INTRODUCTION: We sought to investigate the clinical utility of volumetric measurements in predicting passage of symptomatic ureteral calculi. METHODS: We performed a retrospective review of patients seen in the emergency department for computerized tomography-confirmed symptomatic ureteral calculi with a subsequent discharge for trial of passage. Patient demographics and results of the passage trial were recorded. Stone parameters including location, 2-dimensional linear measurements and 3-dimensional volume measurements were calculated. Univariate and multivariate analyses were performed to evaluate the association between the aforementioned stone parameters and stone passage. RESULTS: A total of 70 patients were analyzed, of whom 37 (53%) passed their stones. On univariate analysis, patients who passed their stones had shorter axial diameters (mean±SD 3.3±1.3 mm vs 5.1±1.7 mm, p <0.01) and smaller volumes (0.03±0.02 cm3 vs 0.10±0.08 cm3, p <0.01). Stones that passed had traversed 79% of the ureter on presentation, compared to 41% for the stones that did not pass (p <0.01). Multivariate analysis demonstrated that shorter axial diameter was independently associated with stone passage (OR 0.46 [CI 0.29-0.71], p <0.01). Inclusion of stone volume measurements into the logistic regression model, however, provided no additional benefit for predicting stone passage rates (p=0.28). CONCLUSIONS: Although a stone's volume is expectedly correlated with passage, it does not seem to provide additional benefit when the stone's axial diameter and location within the ureter are known. Based on our findings, additional investment of time and resources into 3-dimensional modalities may not be warranted in this setting.

Initial Extracorporeal Shockwave Lithotripsy versus Ureteroscopy: A Re-treatment and Cost Analysis Using a Longitudinal, Population-Based Database.

INTRODUCTION: We sought to compare re-treatment rates between shockwave lithotripsy and ureteroscopy to evaluate the effectiveness of these modalities. Additionally, we aimed to compare costs associated with re-treatment. METHODS: The Healthcare Cost and Utilization Project State Ambulatory Surgery Database for Florida from 2009 to 2015 was used to identify patients who underwent shockwave lithotripsy or ureteroscopy. Patients were tracked for subsequent stone surgeries within 3 months, 6 months and 1 year. Costs of care were estimated and descriptive analyses were performed. A multivariable logistic regression model was used to determine predictors of a second procedure. RESULTS: A total of 98,011 patients underwent initial shockwave lithotripsy or ureteroscopy. Of those who underwent initial shockwave lithotripsy 21.2% had a second surgery (shockwave lithotripsy or ureteroscopy) within 3 months compared to 10% of patients who underwent initial ureteroscopy (p <0.01). On multivariable analysis, patients who underwent initial shockwave lithotripsy were more than twice as likely (OR 2.4, 95% CI 2.3-2.5) to undergo a second procedure within 3 months. Older patients were also more likely to undergo a second surgery, while African Americans, Hispanics, uninsured patients and patients with more comorbidities had decreased odds of undergoing a second surgery (all p <0.05). The per patient cost of the initial procedure plus re-treatment at the 3-month mark was $6,239 for initial shockwave lithotripsy and $5,319 for initial ureteroscopy (p <0.01). CONCLUSIONS: Patients undergoing shockwave lithotripsy are more likely than those undergoing ureteroscopy to have additional stone procedures, making shockwave lithotripsy a more expensive intervention.

Association of race and margin status among patients undergoing robotic partial nephrectomy for T1 renal cell carcinoma: Results from a population-based cohort.

OBJECTIVE: To assess the relationship of race and margin status among patients undergoing robotic partial nephrectomy (RPN) for T1 renal tumors from a contemporary population-based cohort. METHODS: Using the National Cancer Database, we identified patients with localized renal cell carcinoma (RCC) (clinical T1N0M0) who underwent RPN from 2010 to 2013. The primary outcome was positive surgical margins (PSM). Multivariable logistic regression analyses were used to assess the association between race and PSM adjusting for patient clinicopathologic and hospital factors. RESULTS: Among 12,515 patients undergoing RPN in our cohort, 8.3% had PSM (n = 1,045). When compared to white patients undergoing RPN for T1 RCC with PSM (7.9%), we observed a higher proportion of PSM among African American (AA) (10.8%; P = 0.005) and Hispanic/Latino patients (8.8%; P = 0.005), respectively. On multivariable analysis, AA patients had higher odds of PSM compared to white patients (odds ratio = 1.40; P = 0.008). Other factors associated with higher odds of PSM were treatment at nonacademic centers relative to academic centers (10.4% vs. 6.9%; odds ratio = 1.57; P<0.001). CONCLUSIONS: In this contemporary population-based cohort, AA patients undergoing RPN for localized RCC tumors are at higher risk for PSM. These results suggest potential differences in quality of care and patient selection of RPN by race.