The Association of Tissue Change and Treatment Success During High-intensity Focused Ultrasound Focal Therapy for Prostate Cancer.

BACKGROUND: Tissue preservation strategies have been increasingly used for the management of localized prostate cancer. Focal ablation using ultrasound-guided high-intensity focused ultrasound (HIFU) has demonstrated promising short and medium-term oncological outcomes. Advancements in HIFU therapy such as the introduction of tissue change monitoring (TCM) aim to further improve treatment efficacy. OBJECTIVE: To evaluate the association between intraoperative TCM during HIFU focal therapy for localized prostate cancer and oncological outcomes 12 mo afterward. DESIGN, SETTING, AND PARTICIPANTS: Seventy consecutive men at a single institution with prostate cancer were prospectively enrolled. Men with prior treatment, metastases, or pelvic radiation were excluded to obtain a final cohort of 55 men. INTERVENTION: All men underwent HIFU focal therapy followed by magnetic resonance (MR)-fusion biopsy 12 mo later. Tissue change was quantified intraoperatively by measuring the backscatter of ultrasound waves during ablation. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Gleason grade group (GG) ≥2 cancer on postablation biopsy was the primary outcome. Secondary outcomes included GG ≥1 cancer, Prostate Imaging Reporting and Data System (PI-RADS) scores ≥3, and evidence of tissue destruction on post-treatment magnetic resonance imaging (MRI). A Student's t - test analysis was performed to evaluate the mean TCM scores and efficacy of ablation measured by histopathology. Multivariate logistic regression was also performed to identify the odds of residual cancer for each unit increase in the TCM score. RESULTS AND LIMITATIONS: A lower mean TCM score within the region of the tumor (0.70 vs 0.97, p = 0.02) was associated with the presence of persistent GG ≥2 cancer after HIFU treatment. Adjusting for initial prostate-specific antigen, PI-RADS score, Gleason GG, positive cores, and age, each incremental increase of TCM was associated with an 89% reduction in the odds (odds ratio: 0.11, confidence interval: 0.01-0.97) of having residual GG ≥2 cancer on postablation biopsy. Men with higher mean TCM scores (0.99 vs 0.72, p = 0.02) at the time of treatment were less likely to have abnormal MRI (PI-RADS ≥3) at 12 mo postoperatively. Cases with high TCM scores also had greater tissue destruction measured on MRI and fewer visible lesions on postablation MRI. CONCLUSIONS: Tissue change measured using TCM values during focal HIFU of the prostate was associated with histopathology and radiological outcomes 12 mo after the procedure. PATIENT SUMMARY: In this report, we looked at how well ultrasound changes of the prostate during focal high-intensity focused ultrasound (HIFU) therapy for the treatment of prostate cancer predict patient outcomes. We found that greater tissue change measured by the HIFU device was associated with less residual cancer at 1 yr. This tool should be used to ensure optimal ablation of the cancer and may improve focal therapy outcomes in the future.

A review of artificial intelligence in prostate cancer detection on imaging.

A multitude of studies have explored the role of artificial intelligence (AI) in providing diagnostic support to radiologists, pathologists, and urologists in prostate cancer detection, risk-stratification, and management. This review provides a comprehensive overview of relevant literature regarding the use of AI models in (1) detecting prostate cancer on radiology images (magnetic resonance and ultrasound imaging), (2) detecting prostate cancer on histopathology images of prostate biopsy tissue, and (3) assisting in supporting tasks for prostate cancer detection (prostate gland segmentation, MRI-histopathology registration, MRI-ultrasound registration). We discuss both the potential of these AI models to assist in the clinical workflow of prostate cancer diagnosis, as well as the current limitations including variability in training data sets, algorithms, and evaluation criteria. We also discuss ongoing challenges and what is needed to bridge the gap between academic research on AI for prostate cancer and commercial solutions that improve routine clinical care.

Evaluation of post-ablation mpMRI as a predictor of residual prostate cancer after focal high intensity focused ultrasound (HIFU) ablation.

PURPOSE: To evaluate the performance of multiparametric magnetic resonance imaging (mpMRI) and PSA testing in follow-up after high intensity focused ultrasound (HIFU) focal therapy for localized prostate cancer. METHODS: A total of 73 men with localized prostate cancer were prospectively enrolled and underwent focal HIFU followed by per-protocol PSA and mpMRI with systematic plus targeted biopsies at 12 months after treatment. We evaluated the association between post-treatment mpMRI and PSA with disease persistence on the post-ablation biopsy. We also assessed post-treatment functional and oncological outcomes. RESULTS: Median age was 69 years (Interquartile Range (IQR): 66-74) and median PSA was 6.9 ng/dL (IQR: 5.3-9.9). Of 19 men with persistent GG ≥ 2 disease, 58% (11 men) had no visible lesions on MRI. In the 14 men with PIRADS 4 or 5 lesions, 7 (50%) had either no cancer or GG 1 cancer at biopsy. Men with false negative mpMRI findings had higher PSA density (0.16 vs. 0.07 ng/mL2, P = 0.01). No change occurred in the mean Sexual Health Inventory for Men (SHIM) survey scores (17.0 at baseline vs. 17.7 post-treatment, P = 0.75) or International Prostate Symptom Score (IPSS) (8.1 at baseline vs. 7.7 at 24 months, P = 0.81) after treatment. CONCLUSIONS: Persistent GG ≥ 2 cancer may occur after focal HIFU. mpMRI alone without confirmatory biopsy may be insufficient to rule out residual cancer, especially in patients with higher PSA density. Our study also validates previously published studies demonstrating preservation of urinary and sexual function after HIFU treatment.

Prevalence of Postprostatectomy Incontinence Requiring Anti-incontinence Surgery After Radical Prostatectomy for Prostate Cancer: A Retrospective Population-Based Analysis.

PURPOSE: This study aimed to examine the prevalence of surgery for postprostatectomy incontinence (PI) following minimally invasive surgery compared to conventional open surgery for prostate cancer. METHODS: This retrospective cohort study used the Florida State Ambulatory Surgery and State Inpatient Databases, 2008 to 2010, radical prostatectomy (RP) patients were identified using International Classification of Diseases (ICD)-9/10 procedure codes and among this cohort, PI was identified also using ICD-9/10 codes. Surgical approaches included minimally invasive (robotic or laparoscopic) versus open (retropubic or perineal) RP. The primary outcome was the overall prevalence of surgery for PI. The secondary outcome was the association of PI requiring anti-incontinence surgery with the surgical approach for RP. RESULTS: Among the 13,535 patients initially included in the study (mean age, 63.3 years), 6,932 (51.2%) underwent open RP and 6,603 (49.8%) underwent minimally invasive RP. The overall prevalence of surgical procedures for PI during the observation period among the all patients who had received RP was 3.3%. The rate of PI surgery for patients receiving minimally invasive surgery was higher than that for patients receiving open surgery (4.8% vs. 3.0%; risk difference, 1.8%; 95% confidence interval, 0.3%-3.4%). The adjusted prevalence of PI surgery for patients who had undergone laparoscopic RP was higher than that for those with retropubic RP (8.6% vs. 3.7%). CONCLUSION: Among patients undergoing RP for prostate cancer, the prevalence of PI surgery is not negligible. Patients undergoing minimally invasive RP had higher adjusted rates for PI surgery compared to open approaches, which was attributed to high rate of PI surgery following laparoscopic approach and low rate of PI surgery following perineal approach. More studies are needed to establish strategies to reduce the rate of PI surgery after RP.

Prevalence of benign pathology after partial nephrectomy for suspected renal tumor: A systematic review and meta-analysis.

OBJECTIVE: To investigate the overall prevalence of benign pathology after partial nephrectomy (PN) and identify predictive factors for benign pathology after PN. METHODS: A systematic review was performed following the PRISMA guidelines. PubMed/Medline, Embase, and the Cochrane Library were searched up to January 2019PRISMA guidelines. The data for the meta-analysis and network meta-analysis were pooled using a random-effects model. RESULTS: There were 144 studies included in the final analysis, which was comprised of 79 observational studies (n = 37,300) and 65 comparative studies (n = 18,552). The overall prevalence rate of benign pathology after PN was 0.19 (95% CI: 0.18-0.21). According to the procedure types, the prevalence rate of benign pathology was 0.17 (95% CI: 0.15-0.19), 0.24 (95% CI: 0.22-0.27), and 0.16 (95% CI: 0.15-0.18) in open partial nephrectomy, laparoscopic partial nephrectomy, and robot-assisted laparoscopic partial nephrectomy, respectively. The significant moderating factors were gender, publication year, the origin of the study, and procedure types. The three most common benign pathology types were oncocytomas, angiomyolipomas, and renal cysts (44.50%, 30.20%, and 10.99%, respectively). CONCLUSIONS: The overall prevalence of benign pathology after PN was not low and it was affected by female gender, studies published before 2010, studies originating from Western areas, and laparoscopic procedure types.

Male and Female Sexual Dysfunction in Pediatric Cancer Survivors.

BACKGROUND: Pediatric cancer survivors suffer indirect long-term effects of their disease; however, there is a paucity of data regarding the effect of pediatric cancer survivorship on sexual function. AIM: To assess the prevalence and risk factors associated with sexual dysfunction among pediatric cancer survivors. METHODS: Pediatric cancer survivors were recruited to complete an online survey using the Female Sexual Function Index (FSFI) or the International Index of Erectile Function (IIEF-5), both validated questionnaires to assess female sexual dysfunction (FSD) and erectile dysfunction (ED). Patient demographics, oncologic history, prior treatment, and sexual habits were also queried. Logistic regression was used to evaluate risk factors for sexual dysfunction, and Mann-Whitney U test was used to identify factors associated with individual domains of the FSFI. OUTCOMES: The main outcome measures were FSFI and IIEF-5 score, which are used to diagnose FSD (FSFI<26.55) and ED (IIEF-5<22). RESULTS: A total of 21 (72.4%) female respondents and 20 (71.4%) male respondents were sexually active and completed the survey and FSFI or IIEF-5 questionnaire, respectively. Mean (±SD) age was 23.7 (4.1) years, and average age at diagnosis was 9.1 (5.0), with no difference between genders. Overall, 25.0% (5/20) of male and 52.4% (11/21) of female pediatric cancer survivors reported sexual dysfunction (P = .11). Oncologic history and prior treatment were not associated with sexual function. Females who reported difficulty relaxing during intercourse in the last 6 months had higher odds of reporting sexual dysfunction (odds ratio: 13.6, 95% confidence interval: 1.2-151.2, P = .03). Subgroup analysis of FSFI domains found that previous radiation therapy was correlated with decreased lubrication and satisfaction during intercourse, whereas previous treatment to the pelvic region significantly reduced satisfaction and increased pain during intercourse. CLINICAL IMPLICATIONS: Female pediatric cancer survivors have higher odds of reporting sexual dysfunction after treatment and should be screened appropriately to provide early intervention and to mitigate risk. STRENGTH & LIMITATIONS: Our study includes validated questionnaires to assess FSD and ED and queries specific characteristics to assess their association with sexual dysfunction. However, the study is limited by sample size and its cross-sectional survey design. CONCLUSIONS: The prevalence of female sexual dysfunction in this cohort is higher than that in the general population of equivalent-aged individuals, and clinicians should be aware of these potential long-term sequelae. Greenberg DR, Khandwala YS, Bhambhvani HP, et-al. Male and Female Sexual Dysfunction in Pediatric Cancer Survivors. J Sex Med 2020;17:1715-1722.

Genital Pain and Numbness and Female Sexual Dysfunction in Adult Bicyclists.

INTRODUCTION: Bicycle seat pressure on the perineum may impair arousal and clitoral erection, likely contributing to genital pain and numbness experienced by female cyclists. AIM: We aimed to identify the association between genital pain and numbness experienced by female cyclists and female sexual dysfunction (FSD). METHODS: Female cyclists were recruited to complete an online survey using the Female Sexual Function Index (FSFI), a validated questionnaire to assess FSD. Cyclist demographics, experience, preferred riding style, use of ergonomic cycle modifications, and genital discomfort while riding were also queried. Multivariate logistic regression analysis was used to evaluate risk factors of FSD. MAIN OUTCOME MEASURES: The main outcome was FSFI score, which is used to diagnose FSD when the FSFI score is <26.55. RESULTS: Of the survey respondents, 178 (53.1%) completed the survey and FSFI questionnaire. Mean age was 48.1 years (±0.8 standard error [SE]), and the average riding experience was 17.1 years (±0.9 SE). Overall, 53.9% of female cyclists had FSD, 58.1% reported genital numbness, and 69.1% reported genital pain. After adjusting for age, body mass index, relationship status, smoking history, comorbidities, and average time spent cycling per week, females who reported experiencing genital numbness half the time or more were more likely to have FSD (adjusted odds ratio [aOR], 6.0; 95% CI, 1.5-23.6; P = .01), especially if localized to the clitoris (aOR, 2.5; 95% CI, 1.2-5.5; P = .02). Females that reported genital pain half the time or more while cycling also were more likely to have FSD (aOR, 3.6; 95% CI, 1.2-11.1; P = .02). Cyclists experiencing genital pain within the first hour of their ride were more likely to have FSD (aOR, 12.6; 95% CI, 2.5-63.1; P = .002). Frequency and duration of cycling were not associated with FSD. Analysis of FSFI domains found that the frequency of numbness was correlated with decreased arousal, orgasm, and satisfaction during intercourse, whereas the frequency of pain significantly reduced arousal, orgasm, and genital lubrication. CLINICAL IMPLICATIONS: Female cyclists that experience numbness and/or pain have higher odds of reporting FSD. STRENGTHS & LIMITATIONS: Our study includes a validated questionnaire to assess FSD and queries specific characteristics and symptoms of genital pain and genital numbness; however, the study is limited by its cross-sectional survey design. CONCLUSION: This study highlights the need for cyclists to address genital pain and numbness experienced while cycling, and future studies are required to determine if alleviating these symptoms can reduce the impact of cycling on female sexual function. Greenberg GR, Khandwala YS, Breyer BN, et al. Genital Pain and Numbness and Female Sexual Dysfunction in Adult Bicyclists. J Sex Med 2019; 16:1381-1389.

Association of paternal age with perinatal outcomes between 2007 and 2016 in the United States: population based cohort study.

OBJECTIVE: To evaluate the impact of advanced paternal age on maternal and perinatal outcomes in the United States. DESIGN: Retrospective, population based cohort study. SETTING: US. POPULATION: 40 529 905 documented live births between 2007 and 2016. MAIN OUTCOME MEASURES: Primary perinatal outcomes were gestational age, birth weight, Apgar score at five minutes, admission to a neonatal intensive care unit, need for postpartum antibiotics, and seizures. Primary maternal outcomes were gestational diabetes and pre-eclampsia. Secondary outcome was the number of preventable perinatal events. RESULTS: Higher paternal age was associated with an increased risk of premature birth, low birth weight, and low Apgar score. After adjustment for maternal age, infants born to fathers aged 45 years or older had 14% higher odds of premature birth (odds ratio 1.14, 95% confidence interval 1.13 to 1.15), independent of gestational age, and 18% higher odds of seizures (1.18, 0.97 to 1.44) compared with infants of fathers aged 25 to 34 years. The odds of gestational diabetes was 34% higher (1.34, 1.29 to 1.38) in mothers with the oldest partners. 13.2% (95% confidence interval 12.5% to 13.9%) of premature births and 18.2% (17.5% to 18.9%) of gestational diabetes in births associated with older fathers were estimated to be attributable to advanced paternal age. CONCLUSIONS: Advanced paternal age is associated with negative effects on both mothers and offspring. Given the relatively low prevalence of advanced paternal age in the US, population level impacts are currently modest. Nevertheless, as advanced paternal age has doubled in the US over the past generation, further investigation is warranted of the impact on birth outcomes and public health.

Variation in Practice Pattern of Male Hypogonadism: A Comparative Analysis of Primary Care, Urology, Endocrinology, and HIV Specialists.

The objective of the current study was to measure the adherence of guideline-based evaluation and treatment of hypogonadism by medical specialty. A retrospective review was performed analyzing patients from a single academic institution within the past 10 years. The cohort of 193 men was grouped according to medical specialty of the diagnosing physician (50 urology, 49 primary care, 44 endocrinology, and 50 HIV medicine). Adherence to guidelines was assessed using the Endocrine Society's criteria. Primary care patients were older compared to the rest of the cohort ( p < .001) but BMI and cardiovascular risk factors were similar ( p = .900). Patients treated by urologists and endocrinologists had the highest percentage of low testosterone findings at initial encounter at 72% ( p < .001). Sixty-two percent of urology patients had low LH or FSH compared to 63.6% for endocrinology and 16% for primary care ( p < .001). As for brain MRI findings, no urology patients had positive findings (0/9) while eight pituitary adenomas (40%) were found by endocrinologists. Forty-five percent of men treated by urologists received TRT without repeat confirmation, compared to 58% of endocrinologists, 77% of primary care, and 88% of HIV medicine ( p < .001). All urology patients had PSA checked before TRT compared to 77.5% of primary care and 61.2% of endocrinology patients ( p = .063). Adherence to the guidelines helps prevent undue over-diagnosis and over-treatment of hypogonadism. This study suggests that adherence to guideline-based screening is varied among specialties.

Review Article: Is There a Role for Antifibrotics in the Treatment of Urological Disease? A Systematic Review of the Literature.

INTRODUCTION: The discovery of biological targets in the fibrosis pathway has led to the advent of many potential therapies for fibrotic diseases. During the last 2 decades an increasing number of large, randomized studies on antifibrotic medications in urology have evaluated its efficacy, safety and long-term outcomes. Although there are many established therapeutics with antifibrotic properties, we focused on the 6 antifibrotic agents that are most currently relevant to the field of urology, including clostridial collagenase histolyticum, mitomycin C, halofuginone, triamcinolone acetonide, verapamil and interferon. We evaluate and summarize the existing published literature on these antifibrotic drugs with a particular emphasis on their safety and efficacy in urological diseases. METHODS: Using the MEDLINE® database, Cochrane Library Central Search, Web of Science and Google Scholar we reviewed all published articles from 1976 to 2016 using the search terms antifibrotics and urology. The literature was searched for pharmaceuticals with antifibrotic properties and efficacy in urological disease, and the 6 most extensively researched drugs were documented. These antifibrotic drugs were then individually reviewed using the databases previously mentioned, and the safety, efficacy and long-term outcomes of each drug were analyzed and summarized. RESULTS: Our search yielded 63 peer reviewed publications on the use of antifibrotic agents in the field of urology. Clostridial collagenase histolyticum has been studied the most thoroughly in this group, with 19 articles and Food and Drug Administration approval for use in Peyronie's disease. The majority of the publications was prospective or randomized controlled studies. Mitomycin C and triamcinolone acetonide can reduce urethral stricture recurrence at a mean followup period of 1 to 2 years and mitomycin C has been effective in curing recurrent bladder neck contractures. Halofuginone and verapamil have shown efficacy for Peyronie's disease and urethral stricture. CONCLUSIONS: This systematic review summarizes the existing literature on the use of antifibrotic drugs for urological disease. Safety, efficacy and long-term outcomes for each drug are evaluated for various disease types and current recommendations for use are reviewed. This systematic review also details the potential therapeutic roles of several antifibrotic medications for treating common urological conditions and diseases, showing that they can be important, useful and effective additions to the urologist's armamentarium.

Trends in Prevalence, Management and Cost of Scrotal Pain in the United States between 2007 and 2014.

INTRODUCTION: We characterize trends in the prevalence, diagnosis and management of scrotal pain in men in the United States and the financial impact on the health care system. METHODS: We analyzed subjects from the Truven Health MarketScan® claims database from 2007 to 2014. Clinical encounters and diagnoses of scrotal pain were identified using ICD-9 and CPT® codes. Trends in office visits, emergency department encounters, radiological evaluation, scrotal surgeries and pharmaceutical prescription were identified, as well as net financial cost. RESULTS: A total of 1,083,350 men with scrotal pain were analyzed during 8 years, amounting to 4,356,581 patient-years of followup. Overall prevalence increased from 0.8% to 1% between 2007 and 2014. Increasing numbers of varicoceles, hydroceles, spermatoceles and testicular torsion were also noted in these men. The percentage of men with scrotal pain evaluated by ultrasonography increased from 39% to 45%, while the percentage of those with scrotal pain presenting to the emergency department increased from 8% to 10%. Scrotal surgery rates did not change substantially (decreasing from 1.7% to 1.6%). However, prescription of opiates and nonsteroidal anti-inflammatory drugs increased from 14% to 42% and from 13% to 46% for all clinic visits, respectively. Yearly cost attributable to scrotal pain was $55,923,986 and median annual cost per patient increased between 2007 and 2014. CONCLUSIONS: Incidence of scrotal pain and associated use of prescription medication have increased in the last decade, contributing to a high economic burden. A greater understanding of the evaluation and management of scrotal pain is necessary.

Evaluation of external vibratory stimulation as a treatment for chronic scrotal pain in adult men: A single center open label pilot study.

BACKGROUND AND AIMS: Chronic scrotal pain is a common yet poorly understood urologic disease. Current treatment paradigms are sub-optimal and include anti-inflammatory drugs and opioids as well as invasive surgical management such as microdenervation of the spermatic cord. In this study, the efficacy of external vibratory stimulation (EVS) was evaluated as an alternative treatment option for idiopathic scrotal pain. MATERIALS AND METHODS: Ten consecutive patients presenting to an academic urology clinic between December 2016 and April 2017 with scrotal pain were prospectively enrolled. After a comprehensive history and physical exam, patients were presented with and oriented to a spherical vibratory device that they were instructed to use topically each day for four weeks. Average and maximum pain severity, frequency, and bother scores were tracked at 2-week intervals using a visual analog scale (0-10) via survey. Descriptive statistics facilitated interpretation of individual changes in pain. RESULTS: Nine men, with a median age of 46 years, completed at least 2 weeks of the study intervention. 78% (7/9) of men achieved some improvement in daily scrotal pain levels. Overall, average pain decreased from 4.9 to 2.7 (p=0.009) while maximum pain severity decreased from 6.3 to 4.0 (p=0.013). The frequency of pain also decreased for 55.6% (5/9) of men. No severe side effects were noted by any of the participants though several patients reported mild paresthesia only during application of the device. The majority of men expressed interest in continuing treatment after conclusion of the study. CONCLUSION: External vibratory stimulation has been suggested as a promising non-invasive tool to alleviate chronic pain. As a proof-of-concept, we implemented EVS to treat men with idiopathic orchialgia. The majority of patients noted benefit in both severity and frequency of pain. Given its low risk profile, EVS deserves further evaluation and inclusion in treatment guidelines as a promising experimental therapy for a disease with few conservative treatment options available to providers. IMPLICATIONS: In this longitudinal study, external vibratory stimulation was found to decrease chronic scrotal pain without any adverse effects. The use of this non-invasive, non-pharmaceutical therapy to treat chronic scrotal pain has the potential to decrease physician and patient dependence on surgical procedures and opioid prescriptions. Future randomized, double blind clinical trials with a placebo arm are required to corroborate these findings and establish the true efficacy of EVS.

Association of Robotic-Assisted vs Laparoscopic Radical Nephrectomy With Perioperative Outcomes and Health Care Costs, 2003 to 2015.

IMPORTANCE: Use of robotic surgery has increased in urological practice over the last decade. However, the use, outcomes, and costs of robotic nephrectomy are unknown. OBJECTIVES: To examine the trend in use of robotic-assisted operations for radical nephrectomy in the United States and to compare the perioperative outcomes and costs with laparoscopic radical nephrectomy. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used the Premier Healthcare database to evaluate outcomes of patients who had undergone robotic-assisted or laparoscopic radical nephrectomy for renal mass at 416 US hospitals between January 2003 and September 2015. Multivariable regression modeling was used to assess outcomes. EXPOSURES: Robotic-assisted vs laparoscopic radical nephrectomy. MAIN OUTCOMES AND MEASURES: The primary outcome of the study was the trend in use of robotic-assisted radical nephrectomy. The secondary outcomes were perioperative complications, based on the Clavien classification system, and defined as any complication (Clavien grades 1-5) or major complications (Clavien grades 3-5, for which grade 5 results in death); resource use (operating time, blood transfusion, length of hospital stay); and direct hospital cost. RESULTS: Among 23 753 patients included in the study (mean age, 61.4 years; men, 13 792 [58.1%]), 18 573 underwent laparoscopic radical nephrectomy and 5180 underwent robotic-assisted radical nephrectomy. Use of robotic-assisted surgery increased from 1.5% (39 of 2676 radical nephrectomy procedures in 2003) to 27.0% (862 of 3194 radical nephrectomy procedures) in 2015 (P for trend <.001). In the weighted-adjusted analysis, there were no significant differences between robotic-assisted and laparoscopic radical nephrectomy in the incidence of any (Clavien grades 1-5) postoperative complications (adjusted rates, 22.2% vs 23.4%, difference, -1.2%; 95% CI, -5.4 to 3.0%) or major (Clavien grades 3-5) complications (adjusted rates, 3.5% vs 3.8%, difference, -0.3%; 95% CI, -1.0% to 0.5%). The rate of prolonged operating time (>4 hours) for patients undergoing the robotic-assisted procedure was higher than for patients receiving the laparoscopic procedure in the adjusted analysis (46.3% vs 25.8%; risk difference, 20.5%; 95% CI, 14.2% to 26.8%). Robotic-assisted radical nephrectomy was associated with higher mean 90-day direct hospital costs ($19 530 vs $16 851; difference, $2678; 95% CI, $838 to $4519), mainly accounted for operating room ($7217 vs $5378; difference, $1839; 95% CI, $1050 to $2628) and supply costs ($4876 vs $3891; difference, $985; 95% CI, $473 to $1498). CONCLUSIONS AND RELEVANCE: Among patients undergoing radical nephrectomy for renal mass between 2003 and 2015, the use of robotic-assisted surgery increased substantially. The use of robotic-assistance was not associated with increased risk of any or major complications but was associated with prolonged operating time and higher hospital costs compared with laparoscopic surgery.

The age of fathers in the USA is rising: an analysis of 168 867 480 births from 1972 to 2015.

STUDY QUESTION: How has the mean paternal age in the USA changed over the past 4 decades? SUMMARY ANSWER: The age at which men are fathering children in the USA has been increasing over time, although it varies by race, geographic region and paternal education level. WHAT IS KNOWN ALREADY: While the rise in mean maternal age and its implications for fertility, birth outcomes and public health have been well documented, little is known about paternal characteristics of births within the USA. STUDY DESIGN, SIZE, DURATION: A retrospective data analysis of paternal age and reporting patterns for 168 867 480 live births within the USA since 1972 was conducted. PARTICIPANTS/MATERIALS, SETTING, METHODS: All live births within the USA collected through the National Vital Statistics System (NVSS) of the Centers for Disease Control and Prevention (CDC) were evaluated. Inverse probability weighting (IPW) was used to reduce bias due to missing paternal records. MAIN RESULTS AND THE ROLE OF CHANCE: Mean paternal age has increased over the past 44 years from 27.4 to 30.9 years. College education and Northeastern birth states were associated with higher paternal age. Racial/ethnic differences were also identified, whereby Asian fathers were the oldest and Black fathers were the youngest. The parental age difference (paternal age minus maternal age) has decreased over the past 44 years. Births to Black and Native American mothers were most often lacking paternal data, implying low paternal reporting. Paternal reporting was higher for older and more educated women. LIMITATIONS, REASONS FOR CAUTION: Although we utilized IPW to reduce the impact of paternal reporting bias, our estimates may still be influenced by the missing data in the NVSS. WIDER IMPLICATIONS OF THE FINDINGS: Paternal age is rising within the USA among all regions, races and education levels. Given the implications for offspring health and demographic patterns, further research on this trend is warranted. STUDY FUNDING/COMPETING INTEREST(S): No funding was received for this study and there are no competing interests. TRIAL REGISTRATION NUMBER: N/A.

The incidence of unsuccessful partial nephrectomy within the United States: A nationwide population-based analysis from 2003 to 2015.

PURPOSE: Partial nephrectomy (PN) remains underutilized within the United States and few reports have attempted to explain this trend. The aim of this study is to evaluate the nationwide incidence of unsuccessful PN and factors that predict its occurrence. METHODS: Using the Premier Healthcare Database, we retrospectively analyzed a weighted sample of 66,432 patients undergoing curative surgery for renal mass between 2003 and 2015. PN intent was denoted by presence of insurance claims for the administration of mannitol. Unsuccessful PN was defined as an event in which patients were administered mannitol but received radical nephrectomy. A multivariate logistic regression model was generated to identify factors predicting unsuccessful PN. RESULTS: Overall rates of unsuccessful PN declined from 33.5% to 14.5% since 2003. Conversion to radical nephrectomy occurred most frequently during laparoscopic (34.7%) and least frequently during robotic approach (13.6%). There was significant difference in the rate of unsuccessful PN between very high and very low volume surgeons (open: 39.4% vs. 13.3%, laparoscopic: 51.2% vs. 32.2%, and robot assisted: 27.1% vs. 9.4%, all P<0.001). After adjustment for patient- and hospital-related factors, surgical approach (laparoscopic vs. open, odds ratio = 1.74, 95% CI: 1.31-2.30, P<0.001) and annual surgeon volume (very high vs. very low, odds ratio = 0.27, 95% CI: 0.21-0.34 P<0.001) were associated with unsuccessful PN. CONCLUSIONS: Although the rate of unsuccessful PN appears to be declining, it still remains common for low volume surgeons and with the laparoscopic surgical approach. Further evaluation of its effect on health care outcomes is necessary.

Surgeon preference of surgical approach for partial nephrectomy in patients with baseline chronic kidney disease: a nationwide population-based analysis in the USA.

PURPOSE: To examine trends in utilization of open, laparoscopic and robot-assisted surgical approaches for treatment of patients with chronic kidney disease (CKD) undergoing partial nephrectomy (PN) within the USA. METHODS: We analyzed a weighted sample of 112,117 patients from the Premier administrative dataset who underwent PN for renal mass between 2003 and 2015. Proportions of surgical approach utilization were evaluated by CKD status and further stratified by surgery year and surgeon volume. A multivariate logistic regression model was created to predict receipt of minimally invasive PN. RESULTS: Seven thousand five hundred and sixty-five (6.7%) patients with CKD were identified. The proportion of CKD patients receiving open PN decreased from 72.4% in 2003-2007 to 36.1% in 2012-2015 (p < 0.001). Although the robot-assisted PN was the dominant surgical approach for both patients with and without CKD in 2012-2015, the proportion receiving open PN was higher in patients with CKD compared to those without CKD (p = 0.018). Multivariate analysis showed that the presence of CKD was independently associated with lower odds of receiving a minimally invasive approach (OR 0.47 for the entire study cohort, OR 0.27 for high volume robot-assisted PN surgeons, and OR 0.51 for recent years, all p < 0.001). These trends remained when CKD stages were evaluated individually. CONCLUSION: Patients with CKD undergoing PN were preferentially treated with open surgery despite an overall increase in robot-assisted PN use over the past 13 years. Further studies evaluating surgical outcomes in this population are warranted for determination of optimal approach and construction of evidence-based guidelines.

Validity of Claims Data for the Identification of Male Infertility.

PURPOSE OF REVIEW: We sought to determine whether infertile men can accurately be identified within a large insurance claims database to validate its use for reproductive health research. RECENT FINDINGS: Prior literature suggests that men coded for infertility are at higher risk for chronic disease though it was previously unclear if these diagnostic codes correlated with true infertility. We found that the specificity of one International Classification of Disease (9th edition) code in predicting abnormal semen parameters was 92.4%, rising to 99.8% if a patient had three different codes for infertility. The positive predictive value was as high as 85%. The use of claims data for male infertility research has been rapidly progressing due to its high power and feasibility. The high specificity of ICD codes for men with abnormal semen parameters is reassuring and validates prior studies as well as future investigation into men's health.

Burden of Urolithiasis: Trends in Prevalence, Treatments, and Costs.

CONTEXT: The recent evolution of management options for urolithiasis has presented a unique dilemma for the modern urologist. A comprehensive understanding of epidemiological trends along with current provider preferences in treating urinary stones would be beneficial. OBJECTIVE: To review trends in the prevalence, treatments, and costs of urolithiasis worldwide. EVIDENCE ACQUISITION: A literature review was performed using the MEDLINE database, the Cochrane Library Central search facility, Web of Science, and Google Scholar between 1986 and 2016. Keywords used for the search were "urolithiasis" and "prevalence; treatment; and cost". EVIDENCE SYNTHESIS: The incidence and prevalence of urinary stones are rising around the world, including regions that have historically had low rates of urolithiasis. Common theories explaining this trend involve climate warming, dietary changes, and obesity. Shockwave lithotripsy (SWL) has been the preferred mode of treatment since its introduction in the 1980s. However, ureteroscopy (URS) has become increasingly popular for small stones regardless of location because of lower recurrence rates and costs. Developing countries have been slower to adopt URS technology and continue to use percutaneous nephrolithotomy at a steady rate. CONCLUSIONS: URS has recently challenged SWL as the treatment modality preferred for small upper urinary tract stones. In some cases it is less expensive but still highly effective. As the burden of stone disease increases worldwide, appropriate selection of stone removal therapies will continue to play an important role and will thus require further investigation. PATIENT SUMMARY: Urinary stones are becoming more prevalent. Recent advances in technology have improved the management of this disease and have decreased costs.