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Volume 19, Number 1

Review Articles

Use of the 4Kscore Test to Predict the Risk of Aggressive Prostate Cancer Prior to Prostate Biopsy: Overall Cost Savings and Improved Quality of Care to the US Healthcare System

Health Economics

Jeffrey D Voigt Stephen Zappala Yan Dong Vincent Linder

The 4Kscore® Test (BioReference Laboratories, Elmwood Park, NJ) is a blood test that accurately determines the risk of aggressive prostate cancer and significantly reduces prostate biopsies and associated overdiagnosis and overtreatment of indolent cancer. A budget impact model was developed to test the hypothesis that the 4Kscore Test can improve quality of care and deliver cost savings for patients who are suspected of having prostate cancer and would otherwise undergo prostate biopsy under the current standard of care (SOC) in the United States. The direct costs (diagnosis plus treatment) utilized in the model are based on Medicare payment data and were calculated over a 1-year time horizon. The model compares SOC, in which all patients have prostate biopsy, to a “4Kscore strategy,” in which the 4Kscore Test is used to guide the decision to biopsy the prostate. A set of one-way sensitivity analyses was conducted to examine the robustness of the findings. Savings of more than $169 million (15.6% of total SOC costs) were realized in the 4Kscore strategy versus SOC ($917 M versus $1,086 M, respectively) in a cohort of 100,000 patients. Sensitivity analyses demonstrated that the findings are robust. Most cost savings for the 4Kscore strategy were realized in patients who, when managed by SOC, are found to have no prostate cancer or Gleason score 6 pathology. The patients with Gleason score 6 exhibited the greatest benefits from the 4Kscore strategy, avoiding both an unnecessary prostate biopsy and subsequent overtreatment. The 4Kscore Test was shown to significantly reduce costs to the healthcare system while improving patients’ quality of care. Providers and their patients suspected of having prostate cancer should consider using the 4Kscore Test prior to proceeding with prostate biopsy. [Rev Urol. 2017;19(1):1-10 doi: 10.3909/riu0753] © 2017 MedReviews®, LLC

Prostate cancer PSA screening 4Kscore Prostate biopsy Cost savings

Review Articles

Urinary Tract Stone Development in Patients With Myelodysplasia Subjected to Augmentation Cystoplasty

Management Update

Courtney L Shephard Guaqiao Wang Betsy D Hopson Erika B Bunt Dean G Assimos

Patients with myelodysplasia who have undergone augmentation cystoplasty are at risk for urinary tract stones. We sought to determine the incidence and risk factors for stone development in this population. The charts of 40 patients with myelodysplasia who have undergone augmentation cystoplasty were reviewed. None had a prior history of urinary tract stones. All patients were seen on an annual basis with plain abdominal imaging, renal ultrasonography, and laboratory testing. Statistical analysis included a multivariable bootstrap resampling method and Student’s t-test. Fifteen (37.5%) patients developed stones, 14 with bladder stones and 1 with a solitary renal stone, at a mean of 26.9 months after augmentation. Five (33.3%) developed recurrent bladder stones. The patient with a renal stone never developed a bladder stone. The mean follow-up for the stone formers was 117.2 months and for non–stone formers was 89.9 months. The stone incidence per year was 6.8%. Risk factors included a decline in serum chloride after augmentation (P = .02), female sex, younger age at time of augmentation, longer time period since augmentation, and bowel continence. A significant proportion of patients with myelodysplasia subjected to augmentation cystoplasty develop urinary tract stones, predominantly in the bladder. Dehydration may play a role in development of lower urinary tract stones as the decline in serum chloride suggests contraction alkalosis, which could lead to constipation and improved bowel continence. Therefore, improved hydration should be a goal in this cohort. [Rev Urol. 2017;19(1):11-15 doi: 10.3909/riu0741] © 2017 MedReviews®, LLC

Nephrolithiasis Spina bifida Neurogenic bladder augmentation cystoplasty

Review Articles

Revisiting the Role of Testosterone: Are We Missing Something?

Thereapeutic Update

Michael Scordo Vineet Tyagi Richard S Yoon Frank A Liporace Loren Wissner Greene

Testosterone is a pleiotropic hormone that plays an important role in the human body. Classically, testosterone was thought to be predominantly involved in androgenesis and physiology in boys and men. Through its conversion to estrogen, testosterone affects bone health, including bone density. Recently, there has been a renewed interest in the systemic role of testosterone in pain, well-being, and cardiovascular function in women and men alike. In this review, we discuss the historic significance of testosterone, its traditionally known physiology, and its molecular and cellular effects. We also discuss evidence for testosterone’s lesser known effects, including its role in women’s health. We suggest a need to revisit the clinical role of testosterone given its potential for applications to treat mood, cognitive health, and other illnesses, and its anabolic role in bone and muscle; we also suggest consideration of the current debate on risks of its use. [Rev Urol. 2017;19(1):16-24 doi: 10.3909/riu0716] © 2017 MedReviews®, LLC

Coronary heart disease Testosterone replacement therapy Testosterone

Review Articles

Prostate Biopsy Characteristics: A Comparison Between Pre- and Post-United States Preventive Service Task Force Prostate Cancer Screening Guidelines of 2012

Cancer Screening Assessment

Richard Hum Navin Shah Vladimir Ioffe Thomas Huebner

This article compares prostate cancer (PCa) characteristics diagnosed by prostate biopsy in the years before and after the 2012 United States Preventative Service Task Force (USPSTF) recommendations against PCa screening. We completed a retrospective comparative analysis of 402 sequential PCa biopsy-diagnosed patients in 2010 to 2012 (3 years) with 269 PCa patients diagnosed in 2015 to 2016 (18 months). Data were collected on patient age, total number of biopsies performed, prostate-specific antigen level, Gleason sum score, and digital rectal examination results. The data were analyzed to determine whether the 2012 USPSTF screening recommendations affected PCa characteristics. [ Rev Urol. 2017;19(1):25-31 doi: 10.3909/riu0745] © 2017 MedReviews®, LLC

Prostate cancer Cancer screening

Review Articles

Systematic Review of Open Versus Laparoscopic Versus Robot-assisted Nephroureterectomy

Systematic Review

Kamran Ahmed Emma Mullen Ben Challacombe

Upper tract urothelial carcinoma is a relatively uncommon malignancy. The gold standard treatment for this type of neoplasm is an open radical nephroureterectomy with excision of the bladder cuff. This systematic review compares the perioperative and oncologic outcomes for the open surgical method with the alternative surgical management options of laparoscopic nephroureterectomy and robot-assisted nephroureterectomy (RANU). MEDLINE, EMBASE, PubMed, and Cochrane Library databases were searched using a sensitive search strategy. Article inclusion was then assessed by review of abstracts and full papers were read if more detail was required. In all, 50 eligible studies were identified that looked at perioperative and oncologic outcomes. The range for estimated blood loss when examining observational studies was 296 to 696 mL for open nephroureterectomy (ONU), 130 to 479 mL for laparoscopic nephroureterectomy (LNU), and 50 to 248 mL for RANU. The one randomized controlled trial identified reported estimated blood loss and length of stay results in which LNU was shown to be superior to ONU (P < .001). No statistical significance was found, however, following adjustment for confounding variables. Although statistically insignificant results were found when examining outcomes of RANU studies, they were promising and comparable with LNU and ONU with regard to oncologic outcomes. Results show that laparoscopic techniques are superior to ONU in perioperative results, and the longer-term oncologic outcomes look comparable. There is, however, a paucity of quality evidence regarding ONU, LNU, and RANU; data that address RANU outcomes are particularly scarce. As the robotic field within urology advances, it is hoped that this technique will be investigated further using gold standard research methods. [Rev Urol. 2017;19(1):32-43 doi: 10.3909/riu0691] © 2017 MedReviews®, LLC

Urothelial carcinoma Robot-assisted nephroureterectomy open nephroureterectomy Laparoscopic nephroureterectomy

LUGPA Enhances 2017 Membership Opportunities

[Rev Urol. 2017;19(1):44-45 doi: 10.3909/riu0750] © 2017 MedReviews®, LLC

Practice Profile

Data Analytics in the Large Urology Practice: Patient Identification, Population Management, and Protocol Adherence

John J Azzolina

[Rev Urol. 2017;19(1)46-48 doi: 10.3909/riu1901PP] © 2017 MedReviews®, LLC

NYU Case of the Month

Urinary Incontinence in a Noncatheterizing Woman With Multiple Sclerosis

Benjamin M Brucker

[Rev Urol. 2017;19(1):49-51 doi: 10.3909/riu0751] © 2017 MedReviews®, LLC

NYU Case of the Month

Management of Complex Urethral Stricture

[Rev Urol. 2017;19(1):52-55 doi: 10.3909/riu0752] © 2017 MedReviews®, LLC

NYU Case of the Month

Management of Testicular Cancer

[Rev Urol. 2017;19(1):56-59 doi: 10.3909/riu0757] © 2017 MedReviews®, LLC

Xanthogranulomatous Pyelonephritis Presenting as a Type IV Renal Cyst

Bosniak class IV renal cyst • Radical nephrectomy • Xanthogranulomatous pyelonephritis

Nachiket Vyas Shyam Talreja Vinay Tomar Sher Singh Yadav Indraneel Banerjee

A 20-year-old woman presented to our outpatient clinic with a 5-week history of recurrent right lumbar back pain. Contrast-enhanced computed tomography scan showed a Bosniak class IV renal cyst. She was treated with radical nephrectomy. Histopathology revealed xanthogranulomatous pyelonephritis. [Rev Urol. 2017;19(1):60-63 doi: 10.3909/riu0715] © 2017 MedReviews®, LLC

Radical nephrectomy Bosniak class IV renal cyst Xanthogranulomatous pyelonephritis

Penile Ossification: A Reconstructive Challenge

Nirmish Singla Arthi Satyanarayan Allen F Morey

Penile ossification is a rare condition that occurs most commonly in acquired cases of penile deformity. We report the case of a 43-year-old man with Peyronie disease who was incidentally found to have significant ossified tissue in his penile corpora during complex placement of an inflatable penile prosthesis (IPP). His clinical course was later complicated by impending distal extrusion of his IPP laterally, necessitating corporoplasty. Penile ossification remains a poorly understood, unusual entity that may pose a reconstructive challenge for urologists. We discuss evaluation and management of this condition, focusing on important considerations for preoperative counseling and intraoperative pearls. [Rev Urol. 2017;19(1):64-67 doi: 10.3909/riu0722] © 2017 MedReviews®, LLC

Peyronie’s disease Penile ossification Inflatable penile prosthesis Corporoplasty

Bladder Cancer That Metastasized to the Skin: A Unique Presentation That Signifies Poor Prognosis

Tal Cohen Mark Memo Daniel Ricchiuti

In the United States in 2015, an estimated 74,000 new cases of bladder cancer were diagnosed and approximately 16,000 deaths were due to bladder cancer. We present a rare case of a patient with aggressive bladder cancer who presented with multiple inguinal and scrotal skin lesions that were proven to be metastatic urothelial malignancy. Bladder malignancy can involve the skin by direct tumor invasion, hematogenous routes, lymphatic spread, and direct seeding due to iatrogenic implantation. The cutaneous lesions have an extremely variable appearance, are resistant to therapies, and signify a dismal prognosis. [Rev Urol. 2017;19(1):68-71 doi: 10.3909/riu0740] © 2017 MedReviews®, LLC

Bladder cancer Cutaneous metastasis Urothelial malignancy

Perineal Urethrostomy: Still Essential in the Armamentarium for Transurethral Surgery

Dimitri Papagiannopoulos Leslie A Deane

A 69-year-old morbidly obese man presented with hematuria caused by a large anterior wall bladder tumor. The mass was inaccessible for resection by standard means due to the patient’s obesity and phallic length. A perineal urethrostomy was required to enable complete resection. This age-old technique is revisited for the benefit of this generation’s urologists. [Rev Urol. 2017;19(1):72-75 doi: 10.3909/riu0742] © 2017 MedReviews®, LLC

Bladder tumors Transurethral resection Perineal urethrostomy