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These increases emphasize the importance of proper screening and management for pediatric UTIs on the part of the pediatrician in the outpatient setting.

Prostate Cancer: Localized (III) Moderated Poster Session 25 Sunday, May 5, 2013

3:30 PM-5:30 PM

661 POPULATION-BASED STUDY OF UTILIZATION AND DETERMINANTS OF ACTIVE SURVEILLANCE AND WATCHFUL WAITING FOR LOW AND INTERMEDIATE RISK PROSTATE CANCER Stacy Loeb*, NY, NY; Anders Berglund, Uppsala, Sweden; Pär Stattin, Umea˚, Sweden

Source of Funding: None

660 EPIDIDYMOORCHITIS IN PEDIATRIC PATIENTS: ARE ANTIBIOTICS NECESSARY? Evalynn Vasquez*, Brendan Frainey, Michaella Prasad, Bruce Lindgren, Earl Cheng, Chicago, IL INTRODUCTION AND OBJECTIVES: Traditionally, pediatric patients with epididymoorchitis (EO) are treated with antibiotic therapy despite negative results found on urinalysis and urine culture. The purpose of this study is to identify the relationship between urinalysis and urine culture results with treatment of these patients. METHODS: A query was performed for males aged 0-12 years who presented to the Emergency Department from 2000-2010 in which an ICD9 code had been entered for EO, scrotal pain, torsion of testis or appendix epididymis/testis, or unspecified disorder of male genitalia in order to capture all patients with a final diagnosis of EO. Patients with hypervascularity of the epididymis/testis demonstrated on a scrotal ultrasound were included. Exclusion criterion was known congenital urologic abnormalities. Through a retrospective chart review, data was collected regarding patient history, physical examination, laboratory and radiology results, treatment, and follow up. Data was analyzed to determine the correlation between presentation, urinalysis/urine culture, and treatment. RESULTS: 2412 patients were identified using the described ICD9 code query. 161 patients met inclusion criteria. Median age was 9.1 years (range 0.2-12 years). Urine was collected in 144 patients. 135 (94%) had a negative urinalysis and 9 (6%) had a positive urinalysis. Only 3 patients had both positive urinalysis and urine culture. All 3 patients were 6 months old or less, not circumcised, and had urine specimens obtained by catheterization. The remaining 6 patients with a positive urinalysis had negative urine cultures. A total of 74 (46%) patients were treated with antibiotics. 87 (54%) patients were treated with nonsteroidal anti-inflammatories, acetaminophen, and supportive measures. Urinalysis/culture results did not correlate with antibiotic treatment (p⫽0.23). Follow up was available on 59 patients. Median follow up was 3 weeks. 39 patients reported resolution of symptoms, 14 reported persistent symptoms, 5 reported worsening symptoms. There was no statistically significant difference between resolution, persistence, or worsening of symptoms and antibiotic treatment (p⫽0.92). CONCLUSIONS: Our study found that sterile urine is exclusively found in boys greater than 1 year of age diagnosed with EO. This suggests, that in this population, EO is noninfectious in nature and implies an inflammatory response from sterile urine (chemical EO) that does not require antibiotic treatment. Source of Funding: None

INTRODUCTION AND OBJECTIVES: Prostate cancer screening reduces disease-specific mortality but leads to overdiagnosis and overtreatment of low risk tumors. Prior studies have reported low rates of conservative management even among men with low-risk prostate cancer in the United States. Our objective was to examine the trends and predictors of deferred treatment (i.e. active surveillance or watchful waiting) in a contemporary European population. METHODS: Using comprehensive data from the nationwide Prostate Cancer database Sweden (PCBaSe) from 1998-2009, we identified 47,144 men diagnosed with low-risk T1 (clinical stage T1, Gleason score ⱕ6 and PSA ⬍10 ng/ml), low risk T1-2 (clinical stage T1-T2, Gleason score ⱕ6, and PSA ⬍10 ng/ml), and intermediate-risk prostate cancer (clinical stage T1-T2 with Gleason score of 7 and/or PSA level of 10-20 ng/ml). In these men, we evaluated temporal trends in primary treatment selection, as well as patient-specific, hospital and societal predictors of watchful waiting or active surveillance. RESULTS: Over the entire study period, 61%, 44%, and 35% of men with low-risk T1, low-risk T1-T2 and intermediate-risk prostate cancer chose watchful waiting or active surveillance. Across all clinical risk groups, increasing age was associated with a greater likelihood of conservative management compared to definitive treatment. Other factors such as education and marital status were modestly associated with the likelihood of deferring treatment. CONCLUSIONS: Deferred treatment for low and intermediate risk prostate cancer is more frequently utilized among Swedish men compared to previously published data from the United States. The strongest determinant of treatment selection was patient age. Dissociating diagnosis from treatment in men with a low risk of progression can decrease the rate of overtreatment without jeopardizing the benefits of early diagnosis. Source of Funding: The Swedish Research Council 8252008-5910 and The Swedish Cancer Foundation 11 0471, Västerbotten county council and Lion’s Cancer Research Foundation at Umea˚ University. SL is funded by the Louis Feil Charitable Lead Trust.

662 THE SIGNIFICANCE OF FINDING NO PROSTATE CANCER ON THE ACTIVE SURVEILLANCE CONFIRMATORY BIOPSY: IMPLICATIONS FOR PATHOLOGICAL RE-CLASSIFICATION. Lih-Ming Wong*, Greg Trottier, Nathan Lawrentschuk, Narhari Timilshina, Girish Kulkarni, Robert Hamilton, John Trachtenberg, Alexandre Zlotta, Ants Toi, Neil Fleshner, Antonio Finelli, Toronto, Canada INTRODUCTION AND OBJECTIVES: A significant proportion of men are consistently reported to have no cancer on the 2nd, also known as the confirmatory, biopsy (B2) for active surveillance (AS). Intuitively, this group of men may have lower volume disease and could benefit from less intensive follow up. We investigate if men on AS with no cancer found at B2, are less likely to undergo subsequent pathological re-classification.

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METHODS: Patients were identified from our tertiary care referral centre AS database (1997-2012). Eligibility criteria were PSA ⱕ10, clinical stage ⱕT2, ⱕ 3 positive cores involved, no core ⬎50% involved and age ⱕ75. Patients who did not undergo a 3rd or subsequent biopsy, because of either ceasing AS after the 2nd biopsy or having insufficient follow up, were excluded. The patients on AS with ⱖ3 biopsies (n⫽286) were dichotomized on the basis of cancer status (yes or no) at B2. A Cox proportional hazards model was used to examine if absence of cancer at B2 was a predictor for re-classification. Pathological re-classification was defined as grade (GS ⱖ7) and/or volume (PCores ⬎3, ⬎50% single core involved). Re-classification free probability estimates were calculated by the Kaplan-Meier method and comparisons between curves made by the log rank test. RESULTS: Of the 286 patients analysed at B2, 149 (52%) had no cancer and 137 (48%) had cancer satisfying eligibility criteria to remain on AS. The median follow-up for our cohort was 41 months, (IQR 26.5-61.9). The proportion of patients that re-classified on subsequent biopsies were 23.5% (no cancer group) and 40.1% (cancer group). The most common method of re-classification for the no cancer group was grade-only (48.6%), whereas for the cancer group, volumeonly re-classification (41.8%) occurred the most frequently. The probability of remaining free of pathological re-classification at 2 and 5 years, stratified by cancer status on B2, for the no cancer group was 96.6% and 85.2% and the cancer group 92.7% and 67.3% respectively (log rank, p⫽0.002). No cancer at B2 was associated with a 54% reduction in risk of subsequent re-classification (HR 0.46, p⫽0.002). Increasing age (HR 1.06, p⫽0.001) and PSA density (HR 1.49, p⫽0.04) were predictors of re-classification. CONCLUSIONS: Absence of cancer on the 2nd biopsy is associated with a significant decreased risk of pathological reclassification. When re-classification does occur, it tends to be grade-related. Hence, whilst frequency of re-biopsy could be reduced in this group, re-biopsy remains an essential component of follow-up in all patients on AS. Source of Funding: None

663 THE HAROW STUDY- AN OBSERVATIONAL HEALTH SERVICE STUDY, CAPTURING CURRENT LOW-RISK-PROSTATE CANCER TREATMENT PRACTICE PATTERNS IN GERMANY Andreas Becker*, Hamburg, Germany; Daniel Seiler, Franz Recker, Aarau, Switzerland; Sandra Beermann, Berlin, Germany; Felix Chun, Hamburg, Germany; Lothar Weissbach, Berlin, Germany INTRODUCTION AND OBJECTIVES: We present the first 3-year results of a prospective observational health service study (HAROW), capturing current LRPCa treatment practice patterns in Germany, with specific focus on active surveillance (AS). METHODS: From 2008- 2012, 2482 patients were included in an prospective open, non-interventional, multi centric, observational study. For AS inclusion, either PRIAS criteria or localized non-metastatic LRPCa(⬍cT3) was recommended. AS discontinuation was suggested following PRIAS. Follow-Up (FU) visits (digital rectal examination, PSA) were scheduled every 3 months in the first 2 years and bi-annual afterwards with recommended repeat biopsies at 1, 4, 7 and 10 years. Office- based urologists were asked to record FU visits. For analyses, 297 AS patients with sufficient FU were available. RESULTS: Primary LRPCa treatment consisted of RP, AS, WW and RT in 1281 (52%), 376 (15%), 123 (5%), and 311 (13%), respectively. All other patients underwent combined treatment regimens (8%). Median age and PSA, was 69years and 5.3ng/ml, respectively. PRIAS LRPCa definition was fulfilled in 64.4%. Accordingly 1, 2 or ⬎2 positive biopsy cores were reported in 58.0, 22.3 and 4.9%. Gleason sum was ⱕ6 and 7a in 84.5 and 4.5%. Clinical stages were cT1 (86.4%) and cT2 (13.6%), M0 stage was radiologically confirmed in 48.1%. Of these, 297 patients completed at least 1 visit after inclusion (84.6%) with a median FU of 20months. No AS patient experienced metastatic progression within the FU period. Overall, 3 patients died

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due to non-PCa related causes. Local clinical progression was recorded in 28/297 patients (9.4%) at a median FU of 10.5 months. Active treatment was chosen by 47/297 patients (15.8%) based on clinical progression (28/47; 59.6%), patientsÆ decision/anxiety (7/47; 14.9%), physicians’ advice (5/47; 10.6%) and unknown reasons (7/47; 14.9%). Active treatments were RP (33/47; 63.8%), RTx (9/47; 19.1%), androgen deprivation therapy (3/47; 6.4%) and WW (2/47; 4.2%), respectively. After prostatectomy, upstaging to pT3 or upgrading to Gleasonscoreⱖ7 was found in 36% of all cases. CONCLUSIONS: Despite excellent cancer-specific mortality rates, our prospectively recorded practice pattern data reveal that AS in Germany is used only in roughly every tenth LRPCa patient. Several reasons may be advanced to explain this underuse of AS. Specifically, stringent inclusion criteria as well as triggers for active treatment are lacking, potentially creating a certain degree of reluctance within urologists and patients. Source of Funding: Financial support is provided by GAZPROM GERMANIA.

664 TESTOSTERONE THERAPY IN MEN ON ACTIVE SURVEILLANCE FOR PROSTATE CANCER Mariam Hult*, Abraham Morgentaler, Brookline, MA INTRODUCTION AND OBJECTIVES: Testosterone therapy (TTh) in men with prostate cancer (PCa) is controversial. Only one prior study, involving 13 men, has evaluated TTh in men on active surveillance for PCa. We here report our experience in a larger group of these men. METHODS: A chart review was performed for all men in our practice who received TTh during active surveillance for PCa for a minimum of 6 months. Charts were assessed for patient age, pathology, prostate specific antigen (PSA), endocrine results, and cancer progression. Progression was defined by increased number of cores by 3 or more, or persistent increase in Gleason score of 1 or greater. RESULTS: A total of 33 men received TTh while on active surveillance. Five received TTh for ⬍ 6 months and were excluded from further analysis. The remaining 28 patients had a mean age of 66.8 years (range 54 to 91) and received TTh for a mean of 36.2 ⫹ 22.6 months (range 7-81.6). Initial Gleason score was 6 in 26 men, and 7 (3⫹4) in 2 men. These men underwent an average of 1.1 follow-up biopsies. Testosterone therapy increased mean testosterone from 338 ng/dl at baseline to 594 ng/dl at 6 months (P ⬍ 0.0001). No significant increase in mean PSA was noted from baseline to last follow-up (2.8 ng/ml vs 3.0 ng/ml, respectively; P⫽0.41). No individual demonstrated definite clinical progression. A biopsy revealing an upgrade in Gleason score was noted in 7 men, all of whom had at least one subsequent biopsy revealing the original Gleason score, or no malignancy at all. Two men elected radical prostatectomy despite lack of clinical progression, and 2 discontinued TTh due to lack of efficacy. Of 28 evaluable men, 24 continue with TTh on active surveillance. CONCLUSIONS: Testosterone therapy does not appear to cause PCa progression over the short-to-medium term in men with active surveillance. Source of Funding: None