Awareness and Use of ChatGPT and Large Language Models: A Prospective Cross-sectional Global Survey in Urology

BACKGROUND

Since its release in November 2022, ChatGPT has captivated society and shown potential for various aspects of health care.

OBJECTIVE

To investigate potential use of ChatGPT, a large language model (LLM), in urology by gathering opinions from urologists worldwide.

DESIGN, SETTING, AND PARTICIPANTS

An open web-based survey was distributed via social media and e-mail chains to urologists between April 20, 2023 and May 5, 2023. Participants were asked to answer questions related to their knowledge and experience with artificial intelligence, as well as their opinions of potential use of ChatGPT/LLMs in research and clinical practice.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Data are reported as the mean and standard deviation for continuous variables, and the frequency and percentage for categorical variables. Charts and tables are used as appropriate, with descriptions of the chart types and the measures used. The data are reported in accordance with the Checklist for Reporting Results of Internet E-Surveys (CHERRIES).

RESULTS AND LIMITATIONS

A total of 456 individuals completed the survey (64% completion rate). Nearly half (47.7%) reported that they use ChatGPT/LLMs in their academic practice, with fewer using the technology in clinical practice (19.8%). More than half (62.2%) believe there are potential ethical concerns when using ChatGPT for scientific or academic writing, and 53% reported that they have experienced limitations when using ChatGPT in academic practice.

CONCLUSIONS

Urologists recognise the potential of ChatGPT/LLMs in research but have concerns regarding ethics and patient acceptance. There is a desire for regulations and guidelines to ensure appropriate use. In addition, measures should be taken to establish rules and guidelines to maximise safety and efficiency when using this novel technology.

PATIENT SUMMARY

A survey asked 456 urologists from around the world about using an artificial intelligence tool called ChatGPT in their work. Almost half of them use ChatGPT for research, but not many use it for patients care. The resonders think ChatGPT could be helpful, but they worry about problems like ethics and want rules to make sure it's used safely.

Comprehensive analysis of the performance of GPT-3.5 and GPT-4 on the American Urological Association self-assessment study program exams from 2012-2023

INTRODUCTION

Artificial intelligence (AI) applications, specifically generative pre-trained transformers, have shown potential in medical education and board-style examinations. To assess this capability, we conducted a study comparing the performance of GPT-3.5 and GPT-4 on the American Urological Association (AUA) 2022 self-assessment study program (SASP) exams from 2012-2023.

METHODS

We used a standardized prompt to administer questions from the AUA SASP exams spanning 2012-2023, totalling 1679 questions. The performance of the two AI models, GPT-3.5 and GPT-4, was evaluated based on the number of questions answered correctly. Statistical analysis was performed using Fisher's exact test and independent sample t-tests to compare the performance of GPT-4 to that of GPT-3.5 among test years and urology topic areas. Percentile scores were not calculable, however, a score of 50% is required to acquire CME credits on AUA SASP exams.

RESULTS

The analysis showed significantly superior performance by GPT-4, which scored above 50% across all exam years except 2018, with scores ranging from 48-64%. In contrast, GPT-3.5 consistently scored below this threshold, with scores ranging from 26-38%. The total combined score for GPT-4 was 55%, significantly higher than the 33% achieved by GPT-3.5 (odds ratio [OR] 2.5, 95% confidence interval [CI] 2.2-2.9, p<0.001). GPT-4 significantly outperformed GPT-3.5 among AUA SASP test years from 2012-2023 (mean difference 23, t(22) 14, 95% CI 19-26, p<0.001), as well as among urology topic areas (mean difference 21, t(52)=5.5, 95% CI 13-29, p<0.001).

CONCLUSIONS

GPT-4 scored significantly higher than GPT-3.5 on the AUA SASP exams in overall performance, across all test years, and in various urology topic areas. This suggests improvement in evolving AI language models in answering clinical urology questions; however, certain aspects of medical knowledge and clinical reasoning remain challenging for AI language models.

MicroRNA-155-5p Targets JADE-1, Promoting Proliferation, Migration, and Invasion in Clear Cell Renal Cell Carcinoma Cells

Clear cell renal cell carcinoma (ccRCC) incidence has been rising in recent years, with strong association between differential microRNA (miRNA) expression and neoplastic progression. Specifically, overexpression of miR-155-5p has been associated with promoting aggressive cancer in ccRCC and other cancers. In this study, we further investigate the role of this miRNA and one of its protein targets, Jade-1, to better understand the mechanism behind aggressive forms of ccRCC. Jade-1, a tumor suppressor, is stabilized by Von-Hippel Lindau (VHL), which is frequently mutated in ccRCC. Experiments featuring downregulation of miR-155-5p in two ccRCC cell lines (786-O and Caki-1) attenuated their oncogenic potential and led to increased levels of Jade-1. Conversely, knockdown experiments with an anti-Jade-1 shRNA in 786-O and Caki-1 cells showed increased metastatic potential through elevated proliferation, migration, and invasion rates. In a mouse xenograft model, downregulation of miR-155 decreased the rate of tumor implantation and proliferation. Direct interaction between miR-155-5p and Jade-1 was confirmed through a 3'UTR luciferase reporter assay. These findings further elucidate the mechanism of action of miR-155-5p in driving an aggressive phenotype in ccRCC through its role in regulating Jade-1.

Holmium laser enucleation of the prostate in men on active surveillance for prostate cancer with refractory lower urinary tract symptoms secondary to enlarged prostates

INTRODUCTION

The surgical treatment of men with lower urinary tract symptoms (LUTS) and significantly enlarged symptomatic prostates on active surveillance (AS) for low-risk prostate cancer (PCa) is not well defined. We report our single-institution initial experience with holmium laser enucleation of the prostate (HoLEP) for LUTS in men with low-risk PCa being managed with AS.

MATERIALS AND METHODS

Men on AS who underwent HoLEP between 2013 and 2019 were identified. Data regarding preoperative cancer workup, prostate-specific antigen (PSA), perioperative outcomes, and voiding parameters were analyzed. Postoperative surveillance for PCa including PSA nadir, prostate magnetic resonance imaging, prostate biopsy (PBx), and PSA at last follow-up were evaluated.

RESULTS

Twenty men met the inclusion criteria. Preoperative mean max flow 7.9 ml/s, median postvoid residual 101 cc, and mean transrectal ultrasound prostate size 99 cc. Patients had a median adjusted preoperative PSA of 8.5 (interquartile range [IQR]: 4.8-13.2) ng/ml. Mean resected tissue weight was 65.5 g with improved postoperative flow rate and significantly decreased residual. A total of 5/20 men had PCa in the specimen (all Gleason Grade Group 1). The median postoperative PSA nadir was 1.2 (IQR: 0.5-1.8) ng/ml at median of 5 months. At the last follow-up (median 18.5 months, IQR: 10.5-37.8), the median postoperative PSA was 1.4 (IQR: 0.63-2.48) ng/ml. Nine men underwent postoperative multiparametric magnetic resonance imaging (mpMRI) with the identification of a new prostate imaging reporting and data system 5 lesion in one patient who underwent negative fusion biopsy. Five men underwent post-HoLEP PBx with progression in two patients, who both successfully underwent radical prostatectomy.

CONCLUSIONS

Men on AS for low-risk PCa can safely undergo HoLEP with significantly improved voiding parameters. Postoperative monitoring with PSA, mpMRI, and PBx can detect disease progression requiring definitive treatment. Further research is needed to optimize surveillance strategies and long-term cancer-specific outcomes.

Preoperative PI-RADS scores are associated with prostate cancer upstaging on surgical pathology

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Background: Prostate Imaging Reporting and Data System (PI-RADS) scores can help identify clinically significant prostate cancer and improve patient selection for prostate biopsies. However, the role of PI-RADS scores in patients already diagnosed with prostate cancer remains unclear. The purpose of this study was to evaluate the association of PI-RADS scores with prostate cancer upstaging. Upstaging on final pathology is a surrogate for biochemical recurrence, morbidity, and mortality. Methods: All patients from a single high-volume institution who underwent a prostate multiparametric MRI and radical prostatectomy between 2016-2020 were included in this retrospective analysis. Univariable and multivariable analyses were conducted to investigate potential associations with upstaging events, defined by pT3, pT4, or N1 on final pathology. A logistic regression model and receiver operative characteristic curves were constructed for the prediction of upstaging events based on PI-RADS score, prostate-specific antigen density (PSA-D), and biopsy Gleason grade groups. Results: 294 patients were included in final analysis. Upstaging events occurred in 137 (46.5%) of patients. On univariable analysis, patients who were upstaged on final pathology had significantly higher PI-RADS scores (OR 2.34 95% 1.64 - 3.40, p < 0.001) but similar PSA-D (OR 2.70 95% 0.94 – 8.43, p = 0.188) compared to patients who remained pT1 or pT2 on final pathology. On multivariable analysis, PI-RADS remained independently significantly associated with upstaging, suggesting it is an independent risk predictor for upstaging. Lymph node metastasis only occurred in patients with PI-RADS 4 or 5 lesions (n = 15). Our model using PSA-D, biopsy Gleason grade, and PI-RADS had a predictive AUC of 0.69 for upstaging events, an improvement from 0.59 using biopsy Gleason grade alone. Conclusions: PI-RADS scores are independent predictors for upstaging events and may play an important role in forecasting biochemical recurrence and lymph node metastasis. PI-RADS scores could improve shared decision making and help set expectations with patients. Modern nomograms should be updated to include PI-RADS to predict lymph node metastases and the likelihood of biochemical recurrence more accurately.[Table: see text]

Preoperative MRI PI-RADS scores are associated with prostate cancer upstaging on surgical pathology

INTRODUCTION

Prostate Imaging Reporting and Data System (PI-RADS) scores can help identify clinically significant prostate cancer and improve patient selection for prostate biopsies. However, the role of PI-RADS scores in patients already diagnosed with prostate cancer remains unclear. The purpose of this study was to evaluate the association of PI-RADS scores with prostate cancer upstaging. Upstaging on final pathology harbors a higher risk for biochemical recurrence with important implications for additional treatments, morbidity, and mortality.

METHODS

All patients from a single high-volume institution who underwent a prostate multiparametric magnetic resonance imaging and radical prostatectomy between 2016 and 2020 were included in this retrospective analysis. Univariable and multivariable analyses were conducted to investigate potential associations with upstaging events, defined by pT3, pT4, or N1 on final pathology. A logistic regression model was constructed for the prediction of upstaging events based on PI-RADS score, prostate-specific antigen density (PSA-D), and biopsy Gleason grade groups. We built receiver operative characteristic (ROC) curves to measure the area under the curve of different predictive models.

RESULTS

Two hundred and ninety-four patients were included in the final analysis. Upstaging events occurred in 137 (46.5%) of patients. On univariable analysis, patients who were upstaged on final pathology had significantly higher PI-RADS scores (odds ratio [OR] 2.34 95% confidence interval [CI] 1.64-3.40, p < 0.001) but similar PSA-D (OR 2.70 95% 0.94-8.43, p = 0.188) compared with patients who remained pT1 or pT2 on final pathology. On multivariable analysis, PI-RADS remained independently significantly associated with upstaging, suggesting it is an independent risk predictor for upstaging. Lymph node metastasis only occurred in patients with PI-RADS 4 or 5 lesions (n = 15). Our model using PSA-D, biopsy Gleason grade, and PI-RADS had a predictive AUC of 0.69 for upstaging events, an improvement from 0.59 using biopsy Gleason grade alone.

CONCLUSION

PI-RADS scores are independent predictors for upstaging events and may play an important role in forecasting biochemical recurrence and lymph node metastasis. Modern nomograms should be updated to include PI-RADS to predict lymph node metastases and the likelihood of biochemical recurrence more accurately.

Robotic-assisted reconstruction of a ureteral herniation into the psoas major fascia: A unique obstructive etiology and a surgical approach to management

Ureteral herniation has been described in urologic literature. Documented sites of herniation include the femoral and inguinal canals, obturator and sciatic foramen, and the thoracic cavity. Herein, we report what we believe to be the first described case of symptomatic obstruction from ureteral herniation through a defect in the psoas major muscle fascia and detail our approach to definitive robotic-assisted surgical management of this unique entity.

MiRNA-424-5p Suppresses Proliferation, Migration, and Invasion of Clear Cell Renal Cell Carcinoma and Attenuates Expression of O-GlcNAc-Transferase

Simple Summary

The identification of biomarkers that predict the metastatic potential of tumors is a current area of interest in cancer research. A previous study from our laboratory identified numerous microRNA (miRNA) biomarkers that are differentially expressed in pathologic stage I clear cell renal cell carcinoma (ccRCC) tumors that progress to metastatic disease. This study investigated the role of aberrant expression of one of these miRNA, miR-424-5p, and one of its associated protein targets, O-GlcNAc-transferase (OGT). We examined the influence of miR-424-5p and OGT expression on the proliferation, migration, and invasion of ccRCC cells, and confirmed the direct interaction between miR-424-5p and OGT. These findings suggest that the decrease in miR-424-5p expression observed in these small renal masses leads to an increase in OGT, which facilitates metastasis.

Abstract

MicroRNAs (miRNAs) are non-coding post-transcriptional regulators of gene expression that are dysregulated in clear cell renal cell carcinoma (ccRCC) and play an important role in tumor progression. Our prior work identified a subset of miRNAs in pT1 ccRCC tumors, including miR-424-5p, that are associated with an aggressive phenotype. We investigate the impact of this dysregulated miRNA and its protein target O-GlcNAc-transferase (OGT) to better understand the mechanisms behind aggressive stage I ccRCC. The ccRCC cell lines 786-O and Caki-1 were used to assess the impact of miR-424-5p and OGT. Cells were transfected with pre-miR-424-5p, a lentiviral anti-OGT shRNA, or were treated with the demethylating agent 5-Aza-2′-deoxycytidine. Cell proliferation was measured via MT cell viability assay. Cell migration and invasion were analyzed using Transwell assays. The expression of miR-424-5p was determined through qRT-PCR, while OGT protein expression was evaluated through Western blotting. The interaction between miR-424-5p and OGT was confirmed via luciferase reporter assay. The transfection of ccRCC cells with pre-miR-424-5p or anti-OGT shRNA significantly inhibited cell proliferation, migration, and OGT expression, while miR-424-5p also attenuated cell invasion. Addition of the demethylating agent significantly reduced cell proliferation, migration, invasion, and OGT expression, while significantly increasing the expression of miR-424-5p. Altogether, these findings suggest that epigenetic downregulation of miR-424-5p, which in turn augments OGT expression, contributes to the creation of aggressive forms of stage I ccRCC.

Reducing postoperative opioid pill prescribing via a quality improvement approach

BACKGROUND

The opioid epidemic has been fueled by prescribing unnecessary quantities of opioid pills for postoperative use. While evidence mounts that postoperative opioids can be reduced or eliminated, implementing such changes within various institutions can be met with many barriers to adoption.

OBJECTIVE

To address excess opioid prescribing within our institutions, we applied a plan-do-study-act (PDSA)-like quality improvement strategy to assess local opioid prescribing and use, modify our institutional protocols, and assess the impacts of the change. The opioid epidemic has been fueled by prescribing unnecessary quantities of opioid pills for postoperative use. While evidence mounts that postoperative opioids can be reduced or eliminated, implementing such changes within various institutions can be met with many barriers to adoption. We describe our approach, findings, and lessons learned from our quality improvement approach.

METHODS

We prospectively recorded home pain pill usage after robotic-assisted laparoscopic prostatectomy (RALP) and robotic-assisted partial nephrectomy (RAPN) at two academic institutions from July 2016 to July 2019. Patients prospectively recorded their home pain pill use on a take-home log. Other factors, including numeric pain rating scale on the day of discharge, were extracted from patient records. We analyzed our data and modified opioid prescription protocols to meet the reported use data of 80% of patients. We continued collecting data after the protocol change. We also used our prospectively collected data to assess the accuracy of a retrospective phone survey designed to measure postdischarge opioid use. Our primary outcomes were the proportion of patients taking zero opioid pills postdischarge, median pills taken after discharge and the number of excess pills prescribed but not taken. We compared these outcomes before and after protocol change.

RESULTS

A total of 266 patients (193 RALP, 73 RAPN) were included. Reducing the standard number of prescribed pills did not increase the percentage of patients taking zero pills postdischarge in either group (RALP: 47% vs. 41%; RAPN 48% vs. 34%). The patients in either group reporting postoperative Day 1 pain score of 0 or 1 were much more likely to use zero postdischarge opioid pills. Our reduction in prescribing protocol resulted in an estimated reduction in excess pills from 1555 excess pills in the prior protocol to just 155 excess pills in the new protocol.

CONCLUSION

Our PDSA-like approach led to an acceptable protocol revision resulting in significant reductions in excess pills released into the community. Reducing the quantity of opioids prescribed postoperatively does not increase the percentage of patients taking zero pills postdischarge. To eliminate opioid use may require no-opioid pathways. Our approach can be used in implementing zero opioid discharge plans and can be applied to opioid reduction interventions at other institutions where barriers to reduced prescribing exist.

Clinical Outcomes of a Combined Robotic, Transabdominal, and Open Transperineal Approach for Anastomotic Posterior Urethroplasty

Background: Robotic pelvic surgery is being increasingly utilized for reconstruction proximal to the genitourinary diaphragm. We describe a combined robotic, transabdominal, and open transperineal approach for complex anastomotic posterior urethroplasty. Materials and Methods: We performed a multi-institutional retrospective study of patients who underwent anastomotic posterior urethroplasty by a combined robotic, transabdominal, and open transperineal approach between January 2012 and December 2018. Patient demographics; preoperative, intraoperative, and postoperative clinical data; and complications were reviewed. Urethroplasty success, de novo stress urinary incontinence (SUI), and de novo erectile dysfunction (ED) were evaluated. Results: Twelve patients were identified with a mean follow-up of 596 (range 73-1618) days. Mean patient age was 65.9 (range 53.4-76.8). Reconstruction required corporal splitting, prostatectomy, and gracilis muscle flap use in one (8.3%), eight (66.7%), and four (33.3%) patients, respectively. Postoperative urinary leak, thromboembolic event, and wound abscess occurred in one (8.3%), one (8.3%), and two (16.7%) patients, respectively. Stenosis recurrence occurred in two patients (16.7%) at a mean 187.5 (20-355) postoperative days. De novo ED and de novo SUI were reported in two (16.7%) and four (33.3%) patients, respectively. Nine patients (75.0%) underwent placement of an artificial urinary sphincter at a mean interval of 359.2 (111-1456) days after the index procedure, with no subsequent erosion. Conclusions: Complex posterior urethroplasty by a combined robotic, transabdominal and open transperineal approach is associated with success and complications rates that are comparable to open techniques and may allow for adjunctive procedures such as prostatectomy. This technique allows for the reconstruction of posterior urethral stenoses that would otherwise have been managed conservatively or with urinary diversion.

MicroRNAs MiR-15a and MiR-26a cooperatively regulate O-GlcNAc-transferase to control proliferation in clear cell renal cell carcinoma

BACKGROUND

MicroRNAs (miRNAs), a group of non-coding post-transcriptional regulators of gene expression, are dysregulated in clear cell renal cell carcinoma (ccRCC) and play an important role in carcinogenesis. Our prior work identified a subset of miRNAs in pT1 ccRCC tumors associated with progression to metastatic disease.

OBJECTIVE

To investigate the impact of two of these dysregulated miRNA, miR-15a-5p and -26a-5p, in an effort to elucidate the mechanisms underpinning aggressive forms of stage I ccRCC.

METHODS

The ccRCC cell line 786-O was transfected with pre-miRs-15a-5p and -26a-5p to rescue expression. Cell proliferation was measured via MT Cell Viability Assay. O-GlcNAc-transferase (OGT), a known protein in ccRCC proliferation, was identified by bioinformatics analysis as a target of both miRNA and validated via luciferase reporter assay to confirm binding of each miR to the 3' untranslated region (UTR). OGT protein expression was evaluated via western blotting.

RESULTS

Luciferase assay confirmed specificity of miR-15a-5p and -26a-5p for the OGT UTR. Western blot analysis for OGT showed reduced expression following co-transfection of both miRNAs compared to negative control or individual transfection. Co-transfection of these miRNAs greatly reduced proliferation when compared to negative control or the individual transfections.

CONCLUSION

Our results indicate that the dysregulation of miR-15a-5p and -26a-5p contribute cooperatively to the proliferation of ccRCC through their regulation of OGT. These results give insight into the pathogenesis of aggressive early stage ccRCC and suggest potential therapeutic targets for future research.

Estimating the rate and reasons of clinical trial failure in urologic oncology

OBJECTIVES

Clinical trials are pillars of modern clinical evidence generation. However, the clinical trial enterprise can be inefficient, and trials often fail before their planned endpoint is reached. We sought to estimate how often urologic oncology trials fail, why trials fail, and associations with trial failure.

METHODS

We queried phase 2/3 urologic clinical trial data from ClinicalTrials.gov registered between 2007 and 2019, with status marked as active, completed, or terminated. We extracted relevant trial data, including anticipated and actual accrual, from trial records and ClinicalTrials.gov archives. We manually coded reasons given in the "why stopped" free text field for trial failure into categories (poor accrual, interim results, toxicity/adverse events, study agent unavailable, canceled by the sponsor, inadequate budget, logistics, trial no longer needed, principal investigator left, no reason given, or other). We considered trials terminated for safety or efficacy to be completed trials. Trials marked as terminated for other reasons were considered failed trials. We then estimated the rate of trial failure using competing risks methods. Finally, we assessed associations with trial failure using a Cox proportional hazards model.

RESULTS

A total of 1,869 urologic oncology trials were included. Of these, 225 (12.0%) failed, and 51 (2.7%) were terminated for "good" reasons (e.g., toxicity, efficacy). Of the 225 failed trials, 122 (54%) failed due to poor accrual. Failed trials had a lower anticipated accrual than successfully completed trials (55 vs. 63 patients, P<0.001). A total of 6,832 patients were actually accrued to failed trials. The 10-year estimated risk of trial failure was 17% (95% CI 15%-22%). Single center trials, phase 3 trials, drug trials, and trials with exclusively USA sites were more likely to fail.

CONCLUSION

We estimate that 17%, or roughly 1 in 6, of urologic oncology trials fail, most frequently for poor accrual. Further investigations are needed into systemic, trial, and site-specific factors that may impact accrual and successful trial completion.

Perioperative complications and adverse sequelae of radical nephroureterectomy

Radical nephroureterectomy (RNU) has long been considered the standard of care for treatment of upper tract urothelial carcinoma (UTUC). Despite providing oncologic control, RNU is associated with measurable morbidity and mortality. High quality data is lacking as a result of low disease incidence and very few randomized studies. In this article we will review preoperative nomograms that assist with patient counseling, summarize current knowledge about perioperative complications, and discuss adverse sequelae that may result after surgery.

Incidence and preoperative predictors for major complications following radical nephroureterectomy

Background

Radical nephroureterectomy (RNU) is the referent standard for managing bulky, invasive, or high grade upper-tract urothelial carcinoma (UTUC). The UTUC patient population, however, generally harbor medical comorbidities thereby placing them at risk of surgical complications. This study reviews a large international cohort of RNU patients to define the risk of major complications and preoperative factors associated with their occurrence.

Methods

Patients undergoing RNU at 14 academic medical centers between 2002 and 2015 were retrospectively reviewed. Preoperative clinical, demographic, operative, and comorbidity indices were recorded. The modified Clavien-Dindo index was used to grade complications occurring within 30 days of surgery. The association between preoperative variables and major complications occurring after RNU was determined by multivariable logistic regression.

Results

One thousand two hundred and sixty-six patients (707 men; 559 women) with a median age of 70 years and BMI of 27 kg/m² were included. Over three-quarters of the cohort was white, 50.1% had baseline chronic kidney disease (CKD) ≥ stage III, 22.4% had a Charlson comorbidity index (CCI) score >5, and 17.1% had an Eastern Cooperative Oncology Group (ECOG) performance status ≥2. Overall, 413 (32.6%) experienced a complication including 103 (8.1%) with a major event. Specific distribution of major complications included 49 Clavien III, 44 Clavien IV, and 10 Clavien V. On univariate analysis, patient age (P=0.006), hypertension (P=0.002), diabetes mellitus (P=0.023), CKD stage (P<0.001), American Society of Anesthesiologists (ASA) score (P=0.022), ECOG (P<0.001), and CCI (P<0.001) all were associated with major complications. On multivariate analysis, ECOG ≥2 (OR 2.38, 95% CI, 1.46–3.90), P=0.001), CCI >5 (OR 3.45, 95% CI, 1.41–8.33, P=0.007), and CKD stage ≥3 (OR 3.64, P=0.008) were independently associated with major complications.

Conclusions

Major complications following RNU occurred in almost 10% of patients. Impaired preoperative performance status and baseline CKD are preoperative variables associated with these major post-surgical adverse event. These easily measurable indices warrant consideration and discussion prior to proceeding with RNU.

Assessing Genitourinary Cancer Clinical Trial Accrual Sufficiency Using Archived Trial Data

PURPOSE

Clinical trials often fail to reach their anticipated end points, most frequently because of poor accrual. Prior studies have analyzed trial termination, but it has not been easy to assess accrual estimates using international databases such as ClinicalTrials.gov because of limitations in accessing accrual information. Specifically, it is not easy to extract both anticipated and actual accrual of clinical trials. We designed a new algorithmic approach to extracting trial accrual data from ClinicalTrials.gov and used it to estimate the sufficiency of patient accrual onto genitourinary (GU) cancer trials.

METHODS

We queried ClinicalTrials.gov for completed/terminated phase II and III clinical trials for prostate, bladder, kidney, testicular, and ureteral cancers registered after 2007. We extracted trial characteristics from available XML files. We then used a Python algorithm to access prior trial registrations on the ClinicalTrials.gov archive site and extract both anticipated and actual accrual numbers. We then compared the actual accrual of each trial to its anticipated accrual and defined sufficient accrual as 85% of anticipated accrual.

RESULTS

The algorithm was 100% accurate compared with hand extraction in a small validation subset. A total of 925 trials were included, of which 840 (91%) had both anticipated and actual accrual. Only 418 (50%) trials had sufficient accrual (≥ 85% of anticipated). Considering only trials marked as successfully completed, 395/597 (66%) reached sufficient accrual.

CONCLUSION

GU cancer trials often do not meet their anticipated accrual goals. New approaches to trial conduct are direly needed. Our reproducible and scalable approach to extracting accrual information can be applied to analysis of ClinicalTrials.gov in future analyses in the hope of improving the efficiency of the clinical trials enterprise.

MicroRNA profile in stage I clear cell renal cell carcinoma predicts progression to metastatic disease

OBJECTIVE

This study sought to identify microRNA (miRNA) profiles of small, pathologically confirmed stage 1 clear cell renal cell carcinoma (ccRCC) tumors that are associated with progression to metachronous metastatic disease.

MATERIALS AND METHODS

Fifty-five pathologic stage 1 ccRCC tumors ≤5cm, from 2 institutions, were examined in a miRNA screening, followed by a validation study. For the screening phase 752 miRNA were evaluated on each sample to identify those with differential expression between tumors that subsequently did (n = 10) or did not (n = 10) progress to metastatic disease. For the validation, 35 additional samples (20 nonprogressors and 15 with distant progression) were utilized to investigate 20 miRNA to determine if a miRNA panel could differentiate aggressive tumors: associations of miRNA expression with cancer specific survival was also investigated.

RESULTS

In the screening analysis, 35 miRNA were differentially expressed (P < 0.05, FDR < 0.1) between the groups. In the validation, 11 miRNA were confirmed to have differential expression. The miRNA -10a-5p, -23b-3p, and -26a-5p differentiated nonprogressive and distant progressive disease with a sensitivity of 73.3% and a specificity of 85% (AUC=0.893). In addition, levels of miR-30a-3p and -145-5p were identified as independent prognostic factors of cancer specific survival.

CONCLUSIONS

This investigation identified miRNA biomarkers that may differentiate between non-progressive ccRCC tumors and those that progress to metastatic disease in this group of stage I tumors. The miRNA profiles determined in this study have the potential to identify patients with small renal masses who are likely to have progressive ccRCC. Such information may be valuable to incorporate into predictive models.

The use of Twitter to facilitate sharing of clinical expertise in urology

The use of social media in the urologic community is common and increasing. Although the potential benefits of platforms like Twitter have been described in the literature, the use of social media in the clinical context of Urology has not been explored.In this case report, we describe how we used Twitter to share ideas about the clinical management of a complex urologic patient. By posting a clinical scenario, a timely discussion was generated with global participation and expert suggestions. This knowledge was applied to the surgical management of a patient with positive clinical outcomes.The ability of Twitter to facilitate rapid communication with a wide network of contributors makes it a potentially useful tool for clinical decision making. Care must be taken to ensure patient confidentiality and caution used appropriately when evaluating the sources and content of the clinical information shared.

The Relationship of Industry Payments to Prescribing Behavior: A Study of Degarelix and Denosumab

INTRODUCTION

The influence of financial ties to pharmaceutical companies remains controversial. We aimed to assess a potential relationship between pharmaceutical payments and prescription patterns for degarelix and denosumab.

MATERIALS AND METHODS

Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File (Medicare B) data containing 2012 claims compared to OpenPayments (Sunshine Act) data for the second half of 2013. Urologists and medical oncologists who billed Medicare for degarelix or denosumab were cross referenced in both databases and payments were aggregated into a consolidated dataset. Adjusted beneficiary count and total Medicare reimbursement were compared according to receipt of Sunshine payment, and an association between Sunshine payment amount and total Medicare reimbursement was also assessed.

RESULTS

Of the 160 prescribers of degarelix and 1,507 prescribers of denosumab, 91 (57%) and 854 (57%) received Sunshine payment, respectively. Degarelix prescribers who received Sunshine payment had higher median total Medicare reimbursement ($13,257 vs. $9,554, p = 0.01). Denosumab prescribers who received Sunshine payment had both higher median adjusted beneficiary count (55 vs. 50, p < 0.001) and median total Medicare reimbursement ($69,620 vs. $60,732, p < 0.001). On multivariable analysis, both receipt of Sunshine payment (adjusted median difference $5,844, 95% CI $937 - $10,749) and oncology specialty (adjusted median difference $34,380, 95% CI $26,715 - $42,045) were independently associated with total Medicare reimbursement for denosumab.

CONCLUSIONS

In the case of degarelix and denosumab, there is a weak association between pharmaceutical company payments on prescribers' prescription behavior patterns.

Preoperative nomogram to predict the likelihood of complications after radical nephroureterectomy

OBJECTIVES

To construct a nomogram based on preoperative variables to better predict the likelihood of complications occurring within 30 days of radical nephroureterectomy (RNU).

PATIENTS AND METHODS

The charts of 731 patients undergoing RNU at eight academic medical centres between 2002 and 2014 were reviewed. Preoperative clinical, demographic and comorbidity indices were collected. Complications occurring within 30 days of surgery were graded using the modified Clavien-Dindo scale. Multivariate logistic regression determined the association between preoperative variables and post-RNU complications. A nomogram was created from the reduced multivariate model with internal validation using the bootstrapping technique with 200 repetitions.

RESULTS

A total of 408 men and 323 women with a median age of 70 years and a body mass index of 27 kg/m² were included. A total of 75% of the cohort was white, 18% had an Eastern Cooperative Oncology Group (ECOG) performance status ≥2, 20% had a Charlson comorbidity index (CCI) score >5 and 50% had baseline chronic kidney disease (CKD) ≥ stage III. Overall, 279 patients (38%) experienced a complication, including 61 events (22%) with Clavien grade ≥ III. A multivariate model identified five variables associated with complications, including patient age, race, ECOG performance status, CKD stage and CCI score. A preoperative nomogram incorporating these risk factors was constructed with an area under curve of 72.2%.

CONCLUSIONS

Using standard preoperative variables from this multi-institutional RNU experience, we constructed and validated a nomogram for predicting peri-operative complications after RNU. Such information may permit more accurate risk stratification on an individual cases basis before major surgery.

Safer Surgery by Learning from Complications: A Focus on Robotic Prostate Surgery

BACKGROUND

The uptake of robotic surgery has led to changes in potential operative complications, as many surgeons learn minimally invasive surgery, and has allowed the documentation of such complications through the routine collection of intraoperative video.

OBJECTIVE

We documented intraoperative complications from robot-assisted radical prostatectomy (RARP) with the aim of reporting the mechanisms, etiology, and necessary steps to avoid them. Our goal was to facilitate learning from these complications to improve patient care.

DESIGN, SETTING, AND PARTICIPANTS

Contributors delivered videos of complications that occurred during laparoscopic and robotic prostatectomy between 2010 and 2015.

SURGICAL PROCEDURE

Surgical footage was available for a variety of complications during RARP.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Based on these videos, a literature search was performed using relevant terms (prostatectomy, robotic, complications), and the intraoperative steps of the procedures and methods of preventing complications were outlined.

RESULTS AND LIMITATIONS

As a major surgical procedure, RARP has much potential for intra- and postoperative complications related to patient positioning, access, and the procedure itself. However, with a dedicated approach, increasing experience, a low index of suspicion, and strict adherence to safety measures, we suggest that the majority of such complications are preventable.

CONCLUSIONS

Considering the complexity of the procedure, RARP is safe and reproducible for the surgical management of prostate cancer. Insight from experienced surgeons may allow surgeons to avoid complications during the learning curve.

PATIENT SUMMARY

Robot-assisted radical prostatectomy has potential for intra- and postoperative complications, but with a dedicated approach, increasing experience, a low index of suspicion, and strict adherence to safety measures, most complications are preventable.

Underutilization of immediate intravesical chemotherapy following TURBT: results from NSQIP

INTRODUCTION

A single perioperative dose of intravesical chemotherapy (IVC) following transurethral resection of bladder tumors (TURBT) for non-muscle invasive bladder cancer has demonstrated a reduction in tumor recurrence. In this study, we investigate the contemporary (2010) utilization of IVC following TURBT using a prospective national database.

MATERIALS AND METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, we identified patients with bladder cancer using ICD-9 codes. From this group, patients undergoing TURBT based on Current Procedural Terminology (CPT) codes were analyzed. We then identified those patients who underwent TURBT and also received intravesical therapy. Operative time, length of hospital stay, and perioperative complications were evaluated.

RESULTS

From January 1 to December 31, 2010, 1273 patients at participating ACS-NSQIP sites underwent TURBT for bladder cancer. There were 417 (33%) small, 486 (38%) medium, and 370 (29%) large tumors treated. In total, 33 (2.6%) patients received IVC. When comparing patients who received perioperative IVC to those who did not, there was no difference in median operative times (27 mins versus 28 mins, p = 0.899). There was one urinary tract infection in the IVC group.

CONCLUSIONS

IVC remains greatly underutilized despite current data documenting its efficacy in reducing tumor recurrence for TaT1 bladder cancer. Instillation of IVC following TURBT does not increase morbidity. Our findings support the continued need to explore ways of improving rates of perioperative IVC administration following TURBT.

Comparison of positive surgical margin rates in high risk prostate cancer: open versus minimally invasive radical prostatectomy

OBJECTIVE

We compared positive surgical margin (PSM) rates for patients with high risk prostate cancer (HRCaP) who underwent open radical retropubic (RRP), robotic (RALP), and laparoscopic (LRP) prostatectomy at a single institution.

MATERIALS AND METHODS

We performed a retrospective review of our prospectively maintained IRB approved database identifying prostate cancer patients who underwent RRP, RALP, or LRP between January 2000 and March 2010. Patients were considered to have HRCaP if they had biopsy or final pathologic Gleason score ≥ 8, or preoperative PSA ≥ 20, or pathologic stage ≥ T3a. A positive surgical margin (PSM) was defined by the presence of tumor at the inked surface of the specimen. Patients who received neoadjuvant hormonal therapy and those who underwent a perineal prostatectomy were excluded from the study.

RESULTS

Of the 445 patients in this study, surgical technique for prostatectomy included RRP (n = 153), RALP (n = 152), and LRP (n = 140). PSM rate for the three groups were not different: 52.9% RRP, 50% RALP, and 41.4% LRP, (p = 0.13). The PSM rate did not differ when comparing RRP to a combined group of RALP and LRP (p = 0.16). Among patients with a PSM, there was no statistical difference between the three groups in terms of the number of patients with a pathologic stage of T3 or higher (p = 0.83). On univariate analysis, a higher preoperative PSA value was associated with a positive margin (p = 0.04).

CONCLUSION

In this HRCaP series, the PSM rate did not differ based on the surgical approach. On univariate analysis, patients with a higher preoperative PSA value were more likely to have a PSM.

Unidirectional barbed suture versus standard monofilament for urethrovesical anastomosis during robotic assisted laparoscopic radical prostatectomy

PURPOSE

V-Loc™180 (Covidien Healthcare, Mansfield, MA) is a new unidirectional barbed suture that may reduce loss of tension during a running closure. We evaluated the use of the barbed suture for urethrovesical anastomosis (UVA) during robotic assisted laparoscopic prostatectomy (RALP). Time to completion of UVA, post-operative anastomotic leak rate, and urinary incontinence were compared in patients undergoing UVA with 3-0 unidirectional-barbed suture vs. 3-0 Monocryl™ (Ethicon, Somerville, NJ).

MATERIALS AND METHODS

Data were prospectively collected for 70 consecutive patients undergoing RALP for prostate cancer between November 2009 and October 2010. In the first 35 patients, the UVA was performed using a modified running van Velthoven anastomosis technique using two separate 3-0 monofilament sutures. In the subsequent 35 patients, the UVA was performed using two running novel unidirectional barbed sutures. At 7-12 days postoperatively, all patients were evaluated with a cystogram to determine anastomotic integrity. Urinary incontinence was assessed at two months and five months by total daily pad usage. Clinical symptoms suggestive of bladder neck contracture were elicited.

RESULTS

Age, PSA, Gleason score, prostate size, estimated blood loss, body mass index, and clinical and pathologic stage between the 2 groups were similar. Comparing the monofilament group and V-Loc™180 cohorts, average time to complete the anastomosis was similar (27.4 vs. 26.4 minutes, p = 0.73) as was the rate of urinary extravasation on cystogram (5.7 % vs. 8.6%, p = 0.65). There were no symptomatic bladder neck contractures noted at 5 months of follow-up. At 2 months, the percentage of patients using 2 or more pads per day was lower in the V-Loc™180 cohort (24% vs. 44%, p < 0.02). At 5 months, this difference was no longer evident.

CONCLUSIONS

Time to complete the UVA was similar in the intervention and control groups. Rates of urine leak were also comparable. While the V-Loc™180 was associated with improved early continence, this difference was transient.