Eklund M, Jäderling F, Discacciati A et al: MRI-targeted or standard biopsy in prostate cancer screening. N Engl J Med 2021; doi: 10.1056/NEJMoa2100852.

The role of using magnetic resonance imaging (MRI) targets alone or in addition to standard biopsy templates continues to be controversial. In this study, the authors conducted a population-based noninferiority trial of prostate cancer screening in which men 50 to 74 years of age from the general population were invited by mail to participate; participants with prostate specific antigen (PSA) levels of 3 ng/ml or higher were randomly assigned to undergo a standard biopsy (standard biopsy group) or MRI, with targeted and standard biopsy if the MRI results suggested prostate cancer (experimental biopsy group). The primary outcome was the proportion of men in the intention-to-treat population in whom clinically significant cancer (Gleason score ≥7) was diagnosed. A key secondary outcome was the detection of clinically insignificant cancers (Gleason score 6). Of 12,750 men enrolled, 1,532 had PSA levels of 3 ng/ml or higher and were randomly assigned to undergo biopsy: 603 were assigned to the standard biopsy group and 929 to the experimental biopsy group. In the intention-to-treat analysis, clinically significant cancer was diagnosed in 192 men (21%) in the experimental biopsy group, as compared to 106 men (18%) in the standard biopsy group (p <0.001 for noninferiority). The percentage of clinically insignificant cancers was lower in the experimental biopsy group than in the standard biopsy group (4% [41 participants] vs 12% [73 participants]; difference, –8 percentage points; 95% CI, –11 to –5).

The authors conclude that MRI with targeted and standard biopsy in men with MRI results suggestive of prostate cancer was noninferior to standard biopsy for detecting clinically significant prostate cancer in a population-based screening trial and resulted in less detection of clinically insignificant cancer.

Hakam N, Sadighian M, Nabavizadeh B et al: Contemporary trends and end-results of National Institutes of Health grant funding to departments of urology in the United States: a 10-year Analysis. J Urol 2021; 206: 427–433.

The National Institutes of Health (NIH) is a crucial source of funding for clinical and translational research, and urology as a specialty has had variable success in securing it. In this study, the authors queried the NIH grant database for all grants awarded to urology departments between 2010 and 2019. Information regarding the value of the grant, funded institution, successful publication of the research and category of urological subspecialty were collected. Data on principal investigators were extracted from publicly available information. There were 509 grants awarded to urology between 2010 and 2019, for a total value of $640,873,867 and a median per-project value of $675,484 (IQR 344,170–1,369,385). Over the study period, total funding decreased by 15.6% and was lower compared to other surgical subspecialties. Most grants were awarded by the National Cancer Institute and National Institute of Diabetes and Digestive and Kidney Diseases (85%) to Western or North Central institutions (52.5%) and had principal investigators who specialized in urologic oncology (56.4%), followed by general urologists (21.5%). Female principal investigators led 21.6% of urology grants and were more likely PhD basic scientists than males (64.4% vs 38.2%, p=0.001). In total, 10,404 publications linked to the 509 grants were produced, of which 28.5% were published in journals with an impact factor ≥10.

The authors conclude that urology is underrepresented in NIH grant funding compared to other surgical fields. During the past decade, there was a further decrease in the total budget of NIH grants to urology.

Baker Z, Bhaskar N, Herbst KW et al: Sample size, power, and risk of misclassification in pediatric urology hospital rankings. J Urol 2021; 206: 436–446.

The U.S. News & World Report rankings are widely used as marketing tools and measures of quality. As its methodology has shifted from reputational scores to clinical outcomes, it is fair game to question the validity and rigor of those analyses. In this study, the authors investigated 2019 and 2020 U.S. News & World Report methodologies of assessing pediatric urology surgical revision rates for distal hypospadias, pyeloplasty and ureteral reimplantation to evaluate statistical power and misclassification risks. Median annual volumes of distal hypospadias, pyeloplasty and ureteral reimplantation procedures by hospital from 2016 to 2018 were calculated using the Pediatric Health Information System® database. U.S. News & World Report 2019 and 2020 methodologies were assessed to calculate power required to detect differences between hospitals and risk of hospital misclassifications. Median (IQR) annual hospital procedure volume was 72 (43–97) for distal hypospadias procedures, 19 (9–34) for pyeloplasties and 35 (19–50) for ureteral reimplantations. Based on 2019 methodology, in order to achieve 80% power, 764 cases/hospital are required to distinguish between a 1% vs 3% surgical revision rate, 1,500 cases/hospital are required to distinguish between a 3% vs 5% revision rate and 282 cases/hospital are required to distinguish between a 1% vs 5% revision rate. Based on 2020 methodology, 98.0% of hospitals do not have adequate ureteral reimplantation volume to achieve full points even when reporting no revisions; similarly, 66.0% do not have adequate pyeloplasty volume and 10.9% do not have adequate distal hypospadias volume. Risks of misclassification exceed 50% in several instances among hospitals reporting distal hypospadias and pyeloplasty revisions using both 2019 and 2020 methodology.

The authors conclude that based on median-volume hospitals, current U.S. News & World Report methods for classifying revision rates for distal hypospadias, pyeloplasty and ureteral reimplantation have insufficient power and are at high risk for misclassification.