Enhanced Recovery After Surgery (ERAS) pathways, also known as fast-track protocols, have been adopted since the 1990s by various surgical specialties—including colorectal, vascular, and thoracic surgery—with proven effectiveness. More recently, the protocols have been applied to urologic surgical procedures, most notably radical cystectomy. The goals of such protocols are ultimately to improve patient outcomes, achieve earlier recovery, and reduce cost burdens by focusing on specific preoperative, operative, and postoperative elements.

As we know, radical cystectomy is among the most complex urologic operations, and the patients are often of advanced age with numerous medical comorbidities, making them ideal candidates for structured postoperative pathways to enhance recovery. Although literature regarding ERAS protocols in the setting of radical cystectomy remains limited, studies to date support the protocols’ use to improve morbidity and mortality in these patients. Urologists regularly performing these procedures should consider implementation of a multidisciplinary perioperative care protocol at their institution. This article provides general recommendations and a brief organizational framework to consider if pursuing such endeavors.

 The first step in implementing successful ERAS protocols is patient counseling. Through face-to-face discussion and standardized patient information packets, the urologist educates the patient before the operation about the surgical procedure; postoperative expectations, including complications; the length of the hospital stay; the stoma site; and the discharge plan.

It is important that the patient’s support system be present for these initial discussions. The urologist should place an early focus on survivorship and provide the patient with information about advocacy networks. Although there is a paucity of literature exploring the importance of education and counseling, cumulative experience supports both.

 Adequate management of medical conditions and lifestyle modifications with nutritional optimization form the outline of the increasingly popular idea of prehabilitation. There have been numerous studies linking preoperative optimization with improved immediate and long-term postoperative outcomes. Optimal management of medical comorbidities, in conjunction with the patient’s primary care physician and specialists when feasible, is important prior to surgery. The urologist should educate the patient before the operation on the importance of smoking cessation and limiting alcohol use as well as stress reduction techniques. The urologist should encourage the patient to increase their exercise to improve mobility and cardiopulmonary reserve, which can be done with the assistance of physical therapists or simply by engaging in 30 minutes of exercise (ie, walking) daily. Preoperative nutritional intervention with the use of immunonutrition containing key amino and fatty acids has been explored in cystectomy literature, but the results have been inconsistent, although its use is supported in other settings and disease processes.

Preoperative fasting and carbohydrate loading.

 The urologist should encourage all nondiabetic patients to increase their consumption of carbohydrates before the operation. Solid-food intake is recommended up until 6 hours prior to the induction of general anesthesia, with clear liquids allowed up to 2 hours prior to surgery. Colorectal literature states that this intervention has been shown to improve perioperative insulin-related complications, reduce the length of the hospital stay, and maintain muscle strength.

 It is important to involve anesthesiology colleagues in this aspect of protocol development.

 Traditional mechanical bowel preparation can be safely omitted and no longer required. In colorectal surgery, the use of mechanical bowel preparation has been demonstrated to cause dehydration, electrolyte disturbances, and prolonged ileus.

 Alternatives for narcotic analgesics have been investigated in surgical literature, with thoracic epidural and transverse abdominus plane (TAP) blocks showing superior pain control over systemic opioids with the additional benefit of less paralytic ileus.

 The urologist should strongly consider the use of either of these techniques during radical cystectomy.

 Although optimal antimicrobial prophylaxis and duration are still unclear, the urologist’s chosen antibiotic should be effective against both aerobes and anaerobes. The urologist should administer a single dose of antibiotic prior to skin incision within 1 hour before surgery. The urologist should prepare the skin with chlorhexidine-alcohol in standard fashion.

Venous thromboembolism (VTE) prophylaxis.

 Results of randomized controlled trials demonstrate significant decrease in VTE with the use of a single dose of low-molecular-weight heparin with extended prophylaxis continued for 28 days after the operation.

 This is recommended in combination with sequential compression devices.

 The restriction of intraoperative fluids combined with preemptive vasopressor use has been shown to significantly reduce postoperative complications and the length of the hospital stay.

 In conjunction with the anesthesiologist, the urologist should administer individual goal-directed fluid therapy with cardiac output monitoring to allow for maintenance of the patient’s fluid requirements in a near-physiologic state. The urologist may also consider the use of transthoracic echocardiogram Doppler-guided fluid therapy.

 Patient warming through the use of warm-air blankets and warmed IV fluids is recommended given that it is associated with a decrease in both surgical site infections and postoperative cardiac complications.

 It is key for the urologist to develop an anesthetic plan with anesthesiology colleagues to ensure proper anesthetic depth, adequate pain control, and muscle relaxation with the goal of limiting narcotic use and using short acting agents. The urologist should use epidural opioid infusions (ie, hydromorphone) as needed intraoperatively in addition to the standard bupivacaine. The urologist may also consider a ketamine infusion in patients with preoperative chronic pain. In addition, for appropriate patients, the urologist may administer single doses of 1 g IV acetaminophen and 15 mg IV ketorolac at the culmination of the case.

 The urologist should avoid the use of postoperative nasogastric intubation to shorten time to flatus, limit vomiting, and decrease both wound and pulmonary complications.

Unresolved postoperative nausea and vomiting can result in prolonged hospitalizations and an increase in overall cost. These conditions can be minimized with the use of multimodal antiemetic prophylaxis and minimization of opioids.

 The urologist should emphasize epidural anesthesia over intravenous narcotics. The urologist should provide chewing gum to the patient given that it has the demonstrated benefit of stimulating bowel activity. The urologist should prescribe alvimopan for 5 days postoperatively or until the first stool given that it decreases time to bowel function and shortens the length of the hospital stay.

 Early feeding is well tolerated and safe and does not negatively affect overall postoperative outcomes.

 Therefore, the urologist should start oral nutrition on postoperative day zero and advance it as tolerated.

 As described above, the urologist should use multimodal regimens and avoid long-acting opioids. It is also important to set pain control expectations with the patient. The urologist should schedule adjunctive analgesia with acetaminophen, nonsteroidal anti-inflammatory drugs, and pregabalin/gabapentin when possible along with epidural anesthesia for 2 to 3 days after the operation.

 It is recommended that the urologist set a goal for the patient of 2 hours of ambulatory activity on postoperative day zero and at least 6 hours out of bed per day starting on postoperative day one until discharge to decrease muscle loss, promote insulin sensitivity, improve strength, improve pulmonary function, and decrease risk of VTE. To improve patient motivation, a predetermined daily ambulation plan (ie, distance goals, time-out-of-bed targets) is often helpful. Consultation with inpatient physical and occupational therapy is highly recommended.

Individual components of enhanced recovery pathways remain difficult to evaluate, but there is a large body of evidence reporting numerous measures of improvement for patients treated under such fast-track protocols, including reduced length of hospital stay, fewer wound complications, earlier gastrointestinal recovery, and reductions in readmissions. Ultimately, it is the combined effect of the above elements that leads to positive patient outcomes, not a single “magic bullet.” Therefore, continued protocol refinement and a strong multidisciplinary team commitment are vital for a successful program.

 is a urology resident at the University of Oklahoma, 

 is a urologic oncology fellow at the University of Oklahoma, and 

 is an assistant professor of urology at the University of Oklahoma, Oklahoma City.

1. Pozo C, Shariat SF, D’Andrea D, Fajkovic H, Abufaraj M. Enhanced recovery after radical cystectomy. 

. 2019;29(3):227-238. doi:10.1097/MOU.0000000000000594

2. Nygren J, Thacker J, Carli F, et al. Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations. 

. 2012;31(6):801-816. doi:10.1016/j.clnu.2012.08.012

3. Hughes MJ, Ventham NT, McNally S, Harrison E, Wigmore S. Analgesia after open abdominal surgery in the setting of enhanced recovery surgery: a systematic review and meta-analysis. 

. 2014;149(12):1224-1230. doi:10.1001/jamasurg.2014.210

4. Chiang HA, Cheng PJ, Speed JM, et al. Implementation of a perioperative venous thromboembolism prophylaxis program for patients undergoing radical cystectomy on an Enhanced Recovery After Surgery protocol. 

. 2020;6(1):74-80. doi:10.1016/j.euf.2018.08.025

5. Bazargani ST, Djaladat H, Ahmadi H, et al. Gastrointestinal complications following radical cystectomy using enhanced recovery protocol. 

. 2018;4(6):889-894. doi:10.1016/j.euf.2017.04.003

Articles

Program encompasses patient counseling, anesthetic planning, and early mobilization.

How to implement an ERAS pathway in your urology practice

It is unfathomable to the majority of us that we would have this prolongation of the coronavirus disease 2019 and resulting global shutdown that has made an impact on every facet of our daily lives, both personally and professionally. Compound this with the growing and pervasive push for “social reform,” we truly are in the midst of both rewriting and creating history for decades to come. From a medical educational standpoint, we are now trying to adapt to this new socially distancing environment, but yet still meet the demands that are critical for continuing education and dissemination of the data that we need for optimal patient care. Despite the challenges, I believe this is good and forces us to evaluate and rethink how all of us best learn, especially with the availability of technology that readily allows engagement, regardless of your location.

For those readers who happen to be a sexagenarian like myself, we can all look back on our residency days in the 1980s and recall the first time we were called upon to present cases either at an Morbidity and Mortality conference or a Grand Rounds. The process of learning about patient care (or the management of complications) was lost out of fear of making sure the history was correct for the presentation and what we were to face on the floor once the conference concluded. As I look back, much of that was the case for most of the weekly conferences. As residents, we were either too tired to grasp the importance of what was being presented or concerned about completing all the “scut work” that still needed to done at the hospital. The “true” educational process, to pass the written boards, was hunkering down with 

As we entered into practice, the education was attending live meetings and back in the day, relegated to sectional and national meetings of the American Urological Association. Yes, ostensibly this was about learning new techniques or advancements, but was that really the motive for most? I would contend it was probably first about visiting a city (or country) that the attendee liked, making sure they have their required number of continuing medical education hours for licensing, or catching up/networking with former residents and colleagues.

As our field has progressed and grown, advancements have resulted in urology becoming more subspecialized. And the number of societies and the associated meetings dedicated to these specific areas in urology have become more abundant. Depending on your scope of practice, a provider can truly begin to focus (and become better educated and hopefully provide better care) on their clinical interest(s) and not have to filter through abstracts, talks, and programs that are not their passion or practice population. Even the recertification testing, where the candidate can choose to answer test questions in select areas, reflects the changing environment and understanding of the voluminous amounts of information and data that is required for our specialty.

The 21st century has ushered in technology that has created more access and readily available information at our fingertips. More specialty publications, dedicated websites, daily email blasts, online presentations, and social media are now part of our educational learning process. No longer are we dependent on the “white” or “gold” journals, Campbell’s, etc. And had it not been for these outlets, where would we be educationally during this pandemic, given the cancellation of in-person meetings, advisory boards, and scientific retreats in the face of rapid explosion of new therapies and approvals?

™ is to continue to provide up-to-date information on optimizing patient management and in a format that is unique, facilitates the learning experience but is not redundant to what is already available. We feel the best way to accomplish this is to take what has been successful in the past (case presentations/reports, focused review articles, morbidity and mortality, tumor boards, etc) and adapt using technology and combined with thought leaders. Will this approach be for everyone? Of course not. After all, who doesn’t mind a nice ski meeting in Colorado or Utah or a round of golf in Arizona? Until that time, we all need to make best of what is available and determine what suits our personal needs.

Director, The Comprehensive Prostate Center, Nashville, Tennessee and Clinical Associate Professor of Urology, Vanderbilt University School of Medicine, Nashville, Tennessee

"The 21st century has ushered in technology that has created more access and readily available information at our fingertips," Raoul S. Concepcion, MD, FACS.

Rethinking medical education in urology

The widespread use of telemedicine due to the coronavirus disease 2019 (COVID-19) pandemic has expanded the use of chronic care management beyond the primary care setting. The Centers for Medicare & Medicaid Services (CMS) recognized that chronic care management (CCM) contributes to better health and care for the individual and can result in reduced costs. Since 2015, Medicare has paid separately for CCM services furnished to patients with multiple chronic conditions. Medicare uses the Current Procedural Terminology (CPT) code 99490.

Chronic care management is not simply making a telephone call to a patient. It is an extensive service that includes structured recording of patient health information, an electronic care plan addressing all health issues, access to care management services, management of care transitions, and coordination and sharing of patient information with practitioners and providers outside the practice.

Urologists were slow to use chronic care management services, but with the rise of telemedicine in March 2020, CCM seems to be a natural extension of telemedicine. This is especially true when caring for urology oncology patients, who may be required to follow up for multiple examinations, radiological tests, and to ensure compliance with medications, and monitor monitoring of side effects of treatments.

Chronic care management using the CPT code 99490 (no it is 99490) requires at least 20 minutes of clinical staff time directed by physician or other qualified health professional per calendar month. It also is required that there must be 2 or more chronic conditions expected to last 12 months or until the death of the patient; the chronic conditions must place a patient at significant risk of death, acute exacerbation, decompensation, or functional decline; and the comprehensive care plan must be established, implemented monitored, and revised as needed.

Examples of chronic conditions include, but are not limited to:

arthritis (osteoarthritis and rheumatoid),

CPT code 99491 requires at least 30 minutes per month a physician or other qualified health care professional time. CPT code 99487 requires at least 60 minutes of clinical staff time directed by physician or other qualified health care professional per calendar month. CPT code 99489 should be use for each additional 30 minutes of clinical staff time directed by physician or other qualified health care professional per calendar month.

Unlike telemedicine, a broad range of clinicians can provide chronic care management services. This list includes:

registered dietitians or nutrition professionals.

In order to establish a relationship for chronic care management, the patient must give consent for a practitioner to provide CCM services. Only 1 practitioner may be paid for chronic care management services per given calendar month. The patient does reserve the right to change practitioners each month. It is important for the urologist to remember that if the primary care doctor is already using the code, then the urologist may not do so during the same month.

There also is no double dipping. For example, if a patient is already enrolled in a program such as Comprehensive Primary Care Plus through their primary doctor, then they cannot be enrolled in chronic care management. Most practices will have a chronic care manager to implement this service line. For practices that have an advanced prostate cancer clinic or an advanced bladder cancer clinic, the nurse navigator is an ideal person to also be the chronic care manager. This individual can ensure the patient is eligible, obtain consent, document the conversations and care plan for each call, and check that there is physician oversight for issues that come up on the phone calls. This may be different from the typical advanced prostate cancer clinic, where the care plan is not always clearly delineated, and patients are not always on a specific visit schedule.

Many cancer patients have a second chronic condition managed by the urology team or the nurse navigator, under the direction of the urologist, who can coordinate care with another specialist such as a cardiologist or endocrinologist. An example of how to implement a CCM program in an advanced prostate cancer clinic would be to have the nurse navigator ensure that all laboratory and imaging tests are performed as scheduled, send appointment reminders, ensure pill compliance and monitor medication side effects, and address complications in real time in order to avoid emergency room visits. They also can assess for pain and look at a patient’s overall health and refer to the appropriate provider. The nurse navigator would review the patient’s results with the urologist to provide oversight and adjust the care plan.

Chronic care management does not have to have a video component, as CMS has ruled that audio communication by itself is sufficient. Typically, telemedicine does have to have a video component; however, this requirement has been waived during the COVID-19 pandemic.

Chronic care management should be viewed as a subservice of telemedicine. It can engage multiple providers in the care of a patient with at least 2 chronic conditions to monitor compliance and outcomes, while reducing the number of in-person visits normally required.

 is director of research, urology division, Premier Medical Group, Poughkeepsie, New York, and clinical assistant professor of urology, New York Medical College, Valhalla, New York.

1. Chronic care management services. Centers for Medicaid & Medicaid Services. July 2019. Accessed July 29, 2020. ​

 https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf​ 

2. Pelosi R. Chronic care management: Delivering effective, profitable services. 

3. Bazzano AN, Wharton MK, Monnette A, et al. Barriers and facilitators in implementing non-face-to-face chronic care management in an elderly population with diabetes: a qualitative study of physician and health system perspectives. 

4.Boehmer KR, Abu Dabrh AM, Gionfriddo MR, Erwin P, Montori V. Does the chronic care model meet the emerging needs of people living with multimorbidity? A systematic review and thematic synthesis. PLoS One. 2018;13(2):e0190852. doi:10.1371/journal.pone.0190852

CCM programs can engage multiple providers to care for patients while reducing in-person visits.

Chronic care management in the urologic oncology setting

For this “Case of the Month” report, 

regarding the usage of renal mass biopsy (RMB) for small renal masses, touching on topics including how to determine the need for an RMB, contraindications to RMB, and how she performs the procedure. Concepcion is chief clinical urologist officer, Integra Connect, West Palm Beach, Florida, and clinical associate professor of urology, Vanderbilt University School of Medicine, Nashville, Tennessee. Scarpato is assistant professor of urology at Vanderbilt University Medical Center, Nashville, Tennessee.

66 y.o. African American male referred for an incidentally discovered solid right renal mass, 2.7 cm, in a work up for back pain. Pre/post contrast 15 HU—> 48 HU. No evidence of fatty attenuation.

PMH: (+) HTN, NIDDM, Atrial Fibrillation, Obesity

Dr Scarpato, this is a scenario we as urologists encounter quite frequently in our everyday practice, the incidentaloma small renal mass (SRM). Would you walk through with us please what is your working definition of a SRM, and what radiographic and clinical factors do you take into account as you are trying to determine the need for a renal mass biopsy (RMB)?

Yes, this is a common scenario in urology clinic, which has coincided with the rise in abdominal cross-sectional imaging. A small renal mass typically refers to growth on the kidney measuring less than 4 cm (T1a),

 and at many centers refers to incidentally detected masses less than 3 cm. The 3-cm cutoff originated in the VHL (von Hippel-Lindau syndrome) literature, which suggests that malignant tumors less than 3 cm have a very low likelihood of metastatic spread. Similarly, data indicate that patients with sporadic tumors less than 3 cm also have a low rate of progression and metastasis.

 When faced with this scenario, it is important to first consider the patient. What is his overall health, and does he have significant cardiac, pulmonary, renal, or other conditions? Does he have risk factors for RCC (renal cell carcinoma) or history of another primary malignancy that may have metastasized? In this patient, his diabetes and renal failure are important considerations when contemplating future renal mass intervention. When considering the mass, it is important to consider tumor location (central vs. peripheral, anterior vs. posterior, medial vs. lateral), endophytic vs. exophytic, size, solid versus cystic consistency, degree of enhancement and vascularity, as well as any significant necrosis. If prior imaging is available, it is helpful to assess growth kinetics over time.

In your opinion, are there any absolute or relative contraindications to RMB?

When counseling the patient, you need to consider the anatomic complexity of the lesion and the implications of the biopsy result on further management. In some patients, it may not be feasible to perform the biopsy due to truncal obesity and significant skin-to-tumor distance. Similarly, in the case of cystic lesions or solid masses in a challenging location, such as those that are medial and upper pole or perihilar, RMB may be relatively contraindicated.

Also, if results are unlikely to change your management plan, I would recommend against biopsy. Although not necessarily a contraindication, it is important to consider patients requiring anticoagulation for periprocedural management if biopsy is being pursued. And finally, historically, tumor seeding was felt to be a contraindication to the procedure. However, this is more of a theoretical risk as tumor seeding of the biopsy tract has not been significantly demonstrated in practice.

Do you differentiate between a solid SRM versus a Bosniak II, III, or IV in your recommendations for RMB?

Yes. This is important when considering RMB. Cystic masses are more challenging to biopsy. For cystic renal masses with higher malignant potential, those that are Bosniak (classification system) III or IV, biopsy is really only feasible if there is a solid component to target. Even then, there is a risk of a non-diagnostic biopsy result, sampling error, or tumor spillage. Generally, when cystic lesions are suspicious for malignancy, we proceed to surgery without attempted biopsy.

At your institution, when you feel a RMB is indicated, are you personally performing the procedure in an office setting or referring these patients to the interventional radiologist (IR) for percutaneous RMB?

At our institution, all RMB for SRMs concerning for cancer are referred to our interventional radiology colleagues. In the IR suite, the interventionalists provide sedation and local anesthesia unless there is a contraindication in which case an anesthesiologist would be involved.

That said, there are certainly urologists who routinely and successfully perform RMB in the office.

 As a specialty, we are facile with ultrasound and the evolution of ultrasound biopsy platforms makes RMB more accessible for us. It is reasonable for urologists who feel comfortable to offer RMB in the office to appropriately selected candidates, particularly those patients with posterior, subcostal lesions.

Obviously depending on site of service, are these best directed with ultrasound, CT, or MRI guidance?

As with most procedures, it comes down to the comfort and experience of the proceduralist and institution. He or she should perform the biopsy in the manner that is most appropriate for him or her. I don’t think one modality has been shown to be superior to the other. Most commonly RMB is performed with CT or ultrasound guidance. Ultrasound may be advantageous for characterization of some lesions, particularly endophytic renal masses, and it avoids contrast exposure, while perhaps being more convenient and cost-effective.

Would you please walk us through operationally the preferred technique you have adopted?

At our institution, patients are most often given sedation and local anesthesia. We are routinely taking core biopsies rather than FNAs (fine needle aspirations) because of the higher diagnostic yield. FNA is often inadequate unless biopsies are performed in conjunction with a cytopathologist on site who can assess the samples immediately. The number of cores taken depends on the quality of the cores, as assessed by the proceduralist. Often, we see 3 to 5 cores per sample. Following the procedure, patients are observed as an outpatient in the radiology suite with close attention to vital signs including pulse oximetry. Some centers may check urinalysis or renal ultrasound prior to discharge5. For complex patients, an overnight stay may be required for additional monitoring.

What are the major complications that have been reported with RMB?

Fortunately, major complications are rare. The literature indicates about a 2% risk of complication overall, with major complications occurring less than 1% of the time.

 Risks include hematoma, pain, infection, with more significant complications of pseudoaneurysm, pneumothorax, and the one we probably all think of first—bleeding. However, even in the face of anticoagulation or antiplatelet medications, the bleeding risk is still quite low. We can’t forget about the risk of nondiagnostic biopsy either, which can occur in up to 15% of RMBs.

Besides histopathology, do you typically send the tissue for any other type of biomarker/genomic testing?

At this point, we are utilizing RMB histopathology results for distinguishing cancer vs noncancer and 

 sending this tissue for biomarker or genomic testing, although that may be the future state, particularly as we learn more about the genomics of RCC. Recent data highlight the impact of determining histologic subtype at the time of RMB, which may have implications on progression.

 We are practicing in the era of precision medicine and personalized care. We are certainly seeing genomics in management of other urologic cancers, like prostate, and in some cases of advanced RCC. However, even for advanced RCC there is a lack of guidance or consensus about the use of genomic testing given the absence of definitive literature.

In your experience, if a patient undergoes RMB and ultimately proceeds to surgical extirpation, have you found the procedure, whether it be open or minimally invasive, to be more difficult due to the inflammation? If so, do you prefer to wait a set period of time before taking the patient to the operating room in hopes that the inflammation will subside?

I am not aware of any literature demonstrating that renal mass biopsy prevents future partial or radical nephrectomy or that it is associated with a higher complication rate. Generally, I would wait a minimum of 4 to 6 weeks from the time of biopsy to allow the patient time to heal. Anecdotally, if a patient develops a bleed with perinephric hematoma following biopsy, the tissue planes can be distorted and the surgery more challenging. In those patients, I may wait longer—months if possible—before proceeding with surgical extirpation.

For our audience, what would you say are the key take-home messages when contemplating percutaneous biopsy for patients with a SRM?

RMB is an important tool in the management of SRMs and should be utilized for patients in whom the results would impact management decisions, typically not the young and healthy or the old and frail. RMB should be performed following shared decision-making.

RMB may be utilized for differentiating benign from malignant tumors but less readily characterizes low grade from high grade. No biomarker or genomic testing is recommended following biopsy of SRMs, although with advancing technology and increasing knowledge of RCC, this is likely on the near horizon.

RMB can be safely performed in the interventional radiology suite or in the urologist’s office depending on physician comfort and experience and SRM characteristics.

Both CT and ultrasound guidance are effective in RMB, with the benefits of ultrasound being potentially improved characterization of endophytic lesions, more readily accessible technology, and cost savings.

1. Campbell S, Uzzo RG, Allaf ME, et al. Renal mass and localized renal cancer: AUA guideline. 

 2017;198(3):520–529. doi:10.1016/j.juro.2017.04.100

2. Crispen PL, Viterbo R, Boorjian S, et al. Natural history, growth kinetics, and outcomes of untreated clinically localized renal tumors under active surveillance. 

 2009;115(13);2844-2852. doi:10.1002/cncr.24338

3. Frank I, Blute ML, Cheville JC, et al. Solid renal tumors: an analysis of pathological features related to tumor size.

. 2003;170(6 Pt 1):2217-2220. doi:10.1097/01.ju.0000095475.12515.5e

4. Dave CN, Seifman B, Chennamsetty A, et al. Office-based ultrasound-guided renal core biopsy is safe and efficacious in the management of small renal masses. 

 2017;102:26–30. doi:10.1016/j.urology.2016.12.026

5. Dutta R, Okhunov Z, Vernez SL, et al. Cost comparisons between different techniques of percutaneous renal biopsy for small renal masses. 

 2016;30(suppl 1):S28-33. doi:10.1089/end.2016.0015

6. Posielski NM, Bui A, Wells SA, et al. Risk factors for complications and nondiagnostic results following 1,155 consecutive percutaneous core renal mass biopsies.

 2019;201(6):1080-1087. doi:10.1097/JU.0000000000000113

7. Finelli A, Cheung DC, Al-Matar A, et al. Small renal mass surveillance: histology-specific growth rates in a biopsy characterized cohort. 

2020;78(3):460-467. doi:10.1016/j.eururo.2020.06.053

Renal mass biopsy should be used for patients in whom results would impact management decisions.

The small renal mass and in-office biopsy: An overview

Radiographic imaging has played a key role in the diagnosis and staging of patients with prostate cancer for decades. Transrectal ultrasound and multiparametric magnetic resonance imaging are important in diagnosis and local staging of the primary tumor, while axial imaging, bone scintigraphy, and molecularly targeted positron emission tomography contribute for distant staging. However, only a few decades ago, none of these approaches was widely utilized. Although multiparametric MRI (mpMRI) has revolutionized imaging of the prostate and substantially changed the diagnostic algorithm for prostate cancer, perhaps even greater changes have occurred in the imaging for distant disease.

Initially, radiographic diagnosis of bony prostate cancer metastasis was made on the basis of plain radiographs; however, this is a very insensitive approach, requiring extensive bone mineral loss (exceeding 30% to 50%) before changes are radiographically apparent.

Following plain projectional radiography, skeletal scintigraphy was the next imaging modality widely adopted for the assessment of bony metastases in patients with prostate cancer. To date, it remains widely utilized and is currently recommended, along with abdominal and pelvic computed tomography, for the staging of patients, according to many guideline bodies. Skeletal scintigraphy, when performed in patients with known cancer in the absence of bony pain, has a sensitivity of 86% and specificity of 81% for the detection of metastatic lesions.

 As with any imaging modality, these characteristics differ somewhat on the basis of the patient population being tested (eg, the pretest probability or population-based disease prevalence). Among patients with prostate cancer, prostate-specific antigen (PSA) levels are predictive of the likelihood of positive bone scan. Across a number of different cancers, Yang et al found that bone scintigraphy had a specificity of 81.4% and sensitivity of 86.0%, on a per patient basis, for the detection of bony metastases.

Computed tomography has been utilized for the assessment of nodal metastatic disease, visceral disease, and bony metastasis. CT is highly sensitive for both osteoblastic tumors (such as prostate cancer) and osteolytic lesions in the cortical bone but is less sensitive in tumors that are restricted to the marrow space.

 As a result, CT is of relatively limited utility as a screening test for bony metastasis due to a relatively low sensitivity (73%) despite excellent specificity (95%)–numbers based on a large scale meta-analysis from Yang and colleagues.

 For this reason, conventional staging recommendations for patients with prostate cancer include bony scintigraphy for the detection of bony lesions along with computed tomography for identification of nodal/visceral lesions and correlation of any bony lesions.

In addition to its role in the local staging of the prostate and guidance of prostate biopsy, mpMRI may also assist with evaluation for distant metastatic disease. Routine pelvic/prostate MRI typically allows for assessment of local/regional nodal involvement, including obturator and external iliac nodal chains. However, the high soft tissue contrast and high spatial resolution afforded by MRI could also allow for the identification of bony metastasis in marrow spaces much early than would be apparent based on CT scan.

 Further, use of T1-weighted sequences and short tau inversion recovery (STIR) sequences can allow for adequate assessment for bony metastasis without the need for intravenous contrast agents; use of MRI for staging does not require the use of ionizing radiation. Thus, abdominal/pelvic or whole body MRI may be considered for the identification of distant metastatic disease. Additionally, MRI with contrast has become the imaging modality of choice for the evaluation of liver metastases.

 This approach may be particularly valuable in patients at high risk of visceral metastatic disease.

In recent years, there has been growing interest in the use of positron emission tomography (PET) imaging to diagnose prostate cancer. While traditional PET/CT utilizing fluorodeoxyglucose is not typically effective, however, at least 4 other PET imaging approaches have been assessed and employed in patients with prostate cancer, including 

F-NaF PET/CT, choline-based PET/CT, fluciclovine (Axumin) PET/CT, and PSMA-targeted PET/CT.

 These modalities have been used in staging of both primary and recurrent prostate cancer. Although clearly improved compared with bony scintigraphy, the limitations are similar, in that sensitivity is highly dependent on PSA levels. Choline-based PET/CT is not widely available in the United States.

However, fluciclovine PET/CT (also known as Axumin PET/CT), which utilizes the proliferation of tumor cells for localization, is much more available. Fluciclovine (

F-flurocyclobutane-1-carboxylic acid) is a synthetic amino acid analogue with the advantage of negligible renal uptake and no activity in the urinary tract.

 Nevertheless, nonspecific prostate uptake limits its utility in identification of primary prostate tumors due to an inability to distinguish from benign prostatic inflammation. Instead, fluciclovine-PET/CT has proven efficacy in the detection of recurrent prostate cancer with biochemical recurrence following local therapy, with a sensitivity of 90% and specificity of 40% (higher in distant, 97%, and nodal disease, 55%, than locally).

 Compared with choline-PET/CT, fluciclovine-PET/CT demonstrated lower false negative and false positive rates in patients with biochemical recurrence.

Finally, receptor targeted PET imaging has recently been examined, most notably, PSMA-based PET/CT. PSMA is a transmembrane glycoprotein found on prostatic epithelium. The ratio of PSMA to its truncated isoform (PSM’) is proportional to tumor aggressivity. The most well-examined PSMA-based approach is 68Ga-PSMA-PET/CT. In patients with biochemical recurrence following radical prostatectomy, 68Ga-PSMA-PET/CT has demonstrated superior detection rates of metastatic disease (56%) compared with fluciclovine-PET/CT (13%).

 This benefit was consistent in detecting pelvic nodal disease and extrapelvic disease. PSMA-based PET/CT demonstrated particular benefit in the evaluation of patients with low absolute PSA levels. Further, 

Ga-PSMA-PET/CT appears to be superior to MRI in primary staging of patients prior to local therapy.

Most recently, the proPSMA trial compared the utility of 68Ga-PSMA-PET/CT with conventional imaging with CT and bone scan in a multicenter, 2-arm randomized controlled trial among men with histologically confirmed prostate cancer who were being considered for curative intent radical prostatectomy or radiotherapy.

 Patients were randomized to the conventional or PSMA-based staging, with crossover for those with fewer than 3 sites of unequivocal metastatic disease. Among 300 randomized patients, 295 of whom had assessment of the reference standard, PSMA PET-CT had a 27% absolute greater area under the receiver operating curve for accuracy compared with conventional imaging (95% CI 23-31): 92% (95% CI 88% to 95%) versus 65% (60% to 69%). Conventional imaging had both a lower sensitivity (38% versus 85%) and also a lower specificity (91% versus 98%). Further, equivocal findings were more common in men undergoing conventional imaging (23%) compared with those undergoing PSMA PET-CT (7%).

Prior to treatment, the results of conventional imaging studies resulted in treatment change for 23 men (15%, 95% CI 10-22) while the results of PSMA PET-CT resulted in treatment change for 41 (28%, 95% CI 21-36). These changes included both a transition from curative intent to palliative intent treatment in 20 patients (14%) and also a change in treatment approach in 22 (14%). These data demonstrate the clinical utility of utilizing PSMA PET-CT in this clinical space.

Finally, conventional imaging was associated with a higher radiation dose (19.2 mSv compared with 8.4 mSv; absolute difference 10.9 mSv, 95% CI 9.8-12.0 mSv0). PSMA PET-CT was not associated with any adverse events, and reporter agreement was high for both nodal (κ 0.87, 95% CI 0.81-0.94) and distant metastatic disease (κ 0.88, 95% confidence interval 0.94-0.92).

Ga-PSMA is the best studied and most well-known radiotracer utilized in this disease space, there are, as of October 2019, at least 25 different radiotracers under evaluation, based on studies registered at ClinicalTrials.gov.

Lu-PSMA-617 were the most commonly used after 

Recent work also has assessed the role of PET/MRI, rather than PET/CT. This approach leverages the advantages of the sensitivity of receptor targeted imaging and the spatial resolution of MRI.

The evolution of imaging in prostate cancer has allowed a more nuanced understanding of the disease. Ongoing advances in receptor targeted PET imaging continue to refine the identification of metastatic disease. This has important implications for what we understand to be M0 and M1 prostate cancer. Whether early detection of metastatic disease utilizing these modalities translates into improvements in patient outcomes, or simply lead-time bias, remains to be assessed.

is a fellow in urologic oncology at Vanderbilt University Medical Center, Nashville, Tennessee.

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Advances in receptor targeted PET imaging continue to refine the identification of metastatic disease.

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