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Refinements in surgical care and development of enhanced recovery after surgery protocols aim to improve postoperative outcomes. We assess incidence of 30-day post-surgery mortality following major urologic cancer surgery and identify factors associated with this outcome. Our analytic cohort included patients undergoing cystectomy, prostatectomy, partial nephrectomy (PN) and radical nephrectomy (RN) for cancer and were identified from 2019-2021 NSQIP targeted procedural database. Sociodemographic and clinical characteristics were analyzed according to procedure and according to study outcome (mortality vs no mortality). Univariate analyses were performed using chi square testing for categorical variables and Mann-Whitney U Test for nonparametric continuous variables. For each urologic procedure, a multivariate regression model was developed to test associations of significant factors associated with mortality. Multivariate analysis (MVA) was not performed for PN given the lack of sufficient variables on univariate analysis. 43,134 patients were included in the analysis, 5,433 cystectomies, 21,110 prostatectomies, 7,691 PN, and 8,900 RN. 30-day mortality rate was 1.62% (n=88), 0.13% (n=27), 0.25% (n=19), and 0.73% (n=65) for cystectomies, prostatectomy, PN and RN, respectively (Table 1). MVA identified age (OR 1.06, 95%CI 1.03-1.09), ASA≥3 (OR 3.12, 95%CI 1.25-7.77) and hypertension (OR 1.84, 95%CI 1.09-3.09) as factors significantly associated with 30-day mortality after cystectomy. Hypertension (OR 2.56;95%CI 1.01-6.48), African American (OR 2.63; 95%CI 1.07-6.46) and American Indian/Alaska Native (OR 20.2;95%CI 2.56-159.22) race were associated with increased 30-day mortality after prostatectomy. Mortality for radical nephrectomy patients was associated with age (OR 1.08;95%CI 1.05-1.1), ASA≥3 (OR 2.35;95%CI 1-5.52), Native Hawaiian/Pacific Islander (OR 21.45; 95%CI 1.92-239.04), AJCC Stage III/IV (OR 1.97;95%CI 1.15-3.36) - Table 2. 30-day mortality is rare following major urologic cancer surgery, with cystectomy conferring the greatest risk.; Several potential modifiable risk factors were identified that could reduce 30-day mortality.; Further studies are needed to clarify the disparity in 30-day mortality seen among several racial groups and for patients with specific comorbidities. [ABSTRACT FROM AUTHOR]

Pelvic lymph node dissection (PLND) during radical prostatectomy (RP) is recommended for patients with greater than 2% risk of lymph node involvement per National Comprehensive Cancer Network guidelines. However, the oncologic benefit of pelvic lymph node dissection is unclear and more extended node dissection may lead to increased risk of complications such as lymphoceles and thromboembolic events. We aim to characterize complication rates of RP based on lymph node counts using the National Surgical Quality Improvement Program (NSQIP) Prostatectomy Targeted Database between 2019 to 2021. We hypothesized that higher lymph node counts would be associated with increased rates of complications, specifically lymphoceles requiring intervention and thromboembolic events. We identified 14,794 patients who underwent RP for prostate cancer. Patients were excluded if staging information was not available or if surgical approach was unknown. Patients were divided into five groups based on the number of nodes removed: 0 nodes (2,652 patients), 1-5 nodes (4,799 patients), 6-10 nodes (3,584 patients), 11-15 nodes (1,866 patients) and 16 or more nodes (1,893 patients). Baseline characteristics and complication rates were reported. Chi squared test was used to analyze categorical variables and Mann Whitney U test was used to analyze continuous variables. A multivariable logistic regression was performed to analyze if nodal count was associated with complications and readmission at 30-days. Variables in the multivariable analysis included age, T stage, BMI, ASA Score, prior systemic therapy, prior pelvic radiation, prior pelvic surgery and surgical approach (minimally invasive versus open). The median number of nodes removed was 6. The 30-day complication rate increased as the number of nodes removed increased; 9.2%, 11.1%, 11.1%, 12.3% and 13.2% for 0, 1-5, 6-10, 11-15 and 16+ nodes removed, respectively (Table 1).;Lymphocele rate requiring intervention was 0.3%, 0.7%, 0.9%, 1.1% and 1.7% for 0, 1-5, 6-10, 11-15 and 16+ nodes, respectively. The number needed to harm (lymphoceles requiring intervention) for 1-5, 6-10, 11-15 and 16+ nodes was 287, 181, 127 and 71 patients, respectively. On multivariable analysis, the risk for lymphoceles requiring intervention increased with increasing nodal yield; OR 2.702;(95%CI 1.284-5.697) for 6-10 nodes, OR 3.132 (95%CI 1.416-6.930) for 11-15 nodes and OR 5.202 (95%CI 2.464-10.981) for 16+ nodes (Table 2). 30-day readmission rate increased for 1-5 nodes (OR1.372; 95%CI 1.061-1.773) and 16+ nodes (OR1.683;95%CI 1.254-2.257). Infectious or thromboembolic complication odds did not increase;regardless of lymph node count. As the number of nodes removed during radical prostatectomy increases, the rate of complications also increases. While lymphoceles requiring intervention and readmissions are rare events, there is a significant increase in risk as the number of nodes removed rises. No increases in thromboembolic events and infectious complications were seen with increased nodal removal. Further research must be performed to assess if the slight but significant increase in complications during PLND is worth the unclear oncologic benefit. Patients should properly be counseled regarding the rates of complications during PLND. [ABSTRACT FROM AUTHOR]

• Decreased complications and length of stay for radical cystectomy over time may reflect use of enhanced recovery after surgery protocols. • Infectious complications and readmission rates were stable over time. • MIS approach and incontinent diversion were associated with decreased complications. Despite significant morbidity, radical cystectomy (RC) is standard of care for muscle invasive bladder cancer, certain high-risk nonmuscle invasive tumors and after failure of intravesical or trimodal therapy. Modern efforts have hastened the recovery after this surgery without impact on overall complication rates. Our primary aim was to examine changes in complication rates of RC over time. The National Surgical Quality Improvement Program database included 11,351 RC from 2006 to 2018 for nondisseminated bladder cancer. Baseline characteristics and complication rates were studied across time periods: 2006 to 2011, 2012 to 2014, and 2015 to 2018. Thirty-day complications, readmissions, and mortality were identified. Overall complication rates decreased over time (56.5%, 57.4%, 50.6%, P < 0.01). Infectious complications were stable, including UTIs (10.1%, 8.8%, 8.3% respectively, P = 0.11) and sepsis (10.4%, 8.8%, 8.7% respectively, P = 0.20). On multivariable analysis, ASA≥3 (OR 1.399, 95% CI 1.279–1.530) was associated with increased complications, while procedures in 2015 to 2018 (OR 0.825, 95% CI 0.722–0.942), laparoscopic/robotic approach (OR 0.555, 95%CI 0.494–0.622), and ileal conduit (OR 0.796, 95% CI 0.719–0.882) were associated with decreased complication rates. Other outcomes of interest included mean length of stay (LOS), which decreased over time (10.5, 9.8, 8.6 days, respectively, P < 0.01) and readmission (20.0%, 21.3%, 21.0%, respectively, P = 0.84) and mortality rates were stable (2.7%, 1.7%, 2.0%, respectively, P = 0.13). Decreased early complications and LOS after RC over time may reflect beneficial effects of recent advances in bladder cancer treatment such as enhanced recovery after surgery protocols and minimally invasive techniques. Further opportunities to improve long term outcomes, readmissions and infection rates are needed. [ABSTRACT FROM AUTHOR]

Infections remain one of the most common postoperative complications and may lead to post-operative readmission. We perform a contemporary analysis on infectious complications after radical cystectomy (RC), partial nephrectomy (PN), radical nephrectomy (RN), and radical prostatectomy (RP) using the National Surgical Quality Improvement Program (NSQIP) database. Our cohort included 34,896 patients from the NSQIP database who underwent major surgery for urologic malignancies from 2019 to 2021, of which 4,348, 6,339, 7,224, and 16,985 patients underwent RC, PN, RN, and RP, respectively. Infectious complications included surgical site infection (SSI), pneumonia, urinary tract infection, sepsis/septic shock, or Clostridium difficile.;Patients were stratified according to urologic procedure and further sub-stratified according to whether or not infectious complications were present, according to baseline sociodemographic and clinical characteristics.;Univariate analyses were performed to determine factors associated with postoperative infections.; Significant variables were retained in a multivariable regression analysis (MVA) to determine preoperative and operative factors most strongly associated with postoperative infections. Subset analyses were performed to further interrogate risk factors associated with each infectious complication listed above. Among patients undergoing RC, PN, RN, and RP, 22.0%, 4.8%, 6.1%, and 4.7%, respectively, experienced a postoperative infection.;Factors associated with any infection according to procedure are displayed in Table 1.; Sepsis/shock was most common in patients undergoing cystectomy relative to other procedures and was the most common infectious complication (8.7%) experienced in the RC group, followed by organ space infection in 6.2%, SSI in 4.9%, and UTI in 4.6%.;UTI was the most common infectious complication in patients undergoing PN (1.6%), RN (2.0%), and RP (2.6%) (Table 2).;On MVA, factors significantly associated with sepsis/shock in cystectomy patients include those undergoing continent diversions, those with diabetes, prior radiation and extended OR time. Those at higher risk of UTI who undergo:;PN include those with HTN, extended OR time, surgical approach (open);;RN include older age, extended OR time, prior pelvic surgery, prior systemic therapy;;RP include those with higher BMI. Infections following major urologic cancer procedures remain a significant cause of patient morbidity and were highest in patients undergoing radical cystectomy.;Several preoperative and operative risk factors are associated with increased infection risk following cystectomy, partial nephrectomy, radical nephrectomy, and radical prostatectomy and modification of these factors may reduce patient-related morbidities related to infectious complications. [ABSTRACT FROM AUTHOR]

Stage III (pT3N0M0 or pT1-3N1M0) adrenocortical carcinoma (ACC) encompasses both lymph node positive (LN+) and lymph node negative (LN-) disease. However, in other malignancies, prior data demonstrates that LN+ disease portends outcomes similar to metastatic, stage IV disease. We similarly wanted to examine the impact of clinical LN+ disease on oncologic outcomes in ACC. Patients with clinical stage III and stage IV (M1) disease were identified using the National Cancer Database (NCDB). Stage III patients were stratified as having either LN+ or LN- disease. Kaplan-Meier curves illustrated overall survival of the three groups – stage III LN-, stage III LN+, and stage IV. Further analysis stratified stage III LN+ and stage IV patients by whether or not patients received treatment (systemic therapy, surgery, or both). A total of 917 patients were included in the analysis – 322 stage III LN-, 67 stage III LN+, and 528 stage IV. 3-year OS for patients with stage IV, stage III LN+, and stage III LN – was 15.6% (95% CI, 12.5%-19.4%), 29.4% (95% CI, 19.8%-43.6%), and 48.6% (95% CI, 43.2%-54.6%), respectively (Figure 1). Within the stage III LN+ group 3-year OS was 33.0% (95% CI, 18.5%-58.8%) for those who received treatment and was 27.4% (95% CI, 16.1% - 46.6%) for those who did not (Figure 2). Within the stage IV group 3-year OS was 29.8% (95% CI, 22.7%-39.3%) for those who received treatment and was 10.2% (95% CI, 7.4% - 14.2%) for those who did not (Figure 2). The current staging paradigm of ACC includes LN+ disease as part of the stage III classification. Herein, we see that clinical stage III LN+ disease had a 3-year OS that was more similar to clinical stage IV disease than clinical stage III LN- disease. While the survival curves appear distinct, due to the rarity of the disease and therefore small sample size there was overlapping confidence intervals. In stage IV patients there was a significant difference in OS at 3 years between those who did and did not receive treatment. This same finding was not found in stage III LN + patients. [ABSTRACT FROM AUTHOR]

The intraoperative placement of surgical drains often represents routine practice for most major urologic procedures to drain lymphatic fluid, blood, or urine postoperatively. However, placement of drains may increase patient discomfort and has questionable benefits. Our study aims to correlate drain placement (vs. no drain placement) with postoperative complications following major urologic oncology operations. The National Surgical Quality Improvement Program database included 35,065 patients undergoing major surgery for urologic malignancies from 2019 to 2021. Baseline characteristics and complication rates were stratified by urologic procedure and intraoperative drain placement. Statistical endpoints included thirty-day complications, length of stay (LOS), readmissions, and mortality. Univariable analyses were performed to determine factors associated with postoperative morbidity. Significant variables were retained and backward elimination multivariable regression analyses were performed to characterize if intraoperative drain placement added a significant benefit in patient risk for each postoperative complication. A total of 4,235 (96.29%), 3,640 (57.27%), 1,487 (20.38%), and 9,648 (56.71%) of patients undergoing radical cystectomy, partial nephrectomy, radical nephrectomy, and radical prostatectomy, respectively, had an intraoperative drain placed (Table 1). On multivariable analysis, no drain placement during radical cystectomy was associated with increased LOS (β=0.95; 95% CI 0.33-1.57) and increased wound complications (OR=1.63; 95% CI 1.06-2.50). Patients without a drain placed experienced a decreased rate of any postoperative complication for partial nephrectomy (OR=0.78; 95% CI 0.66-0.92), radical nephrectomy (OR=0.70; 95% CI 0.60-0.82), and radical prostatectomy (OR=0.76; 95% CI 0.68-0.84).;No drain placement was also associated with decreased infectious complications following radical nephrectomy (OR=0.51; 95% CI 0.38-0.69) and radical prostatectomy (OR=0.73; 95% CI 0.60-0.88) (Table 2). The absence of an intraoperative drain following major urologic procedures did not increase 30-day complication rates or hospital readmissions following partial nephrectomy, radical nephrectomy, and radical prostatectomy. Drainless procedures in selected patients may not add to postoperative morbidity and may increase patient recovery. Further analysis regarding the association with drain placement and complications should be completed. [ABSTRACT FROM AUTHOR]

Infections are the most feared complication of transrectal prostate biopsy. Unfortunately, these complications are not infrequent. With antibiotic resistance becoming increasingly common, our institution has transitioned to a transperineal approach without use of perioperative antibiotics or bowel preparation. Given this significant change in practice pattern, we retrospectively analyzed these patients for rates of post-operative complications, 30-day hospital readmissions, and detection of prostate cancer. We retrospectively analyzed 146 patients who underwent a transperineal prostate biopsy at our institution in 2022. We recorded rates of complications including UTIs, sepsis, hematuria, and 30-day hospital readmissions. We also analyzed the percentage of patients found to have prostate cancer. Of the 146 patients analyzed, 8 patients received peri-operative antibiotics (5.47%) - this was at the discretion of the surgeon performing the procedure.;;The reason 8 patients received peri-operative antibiotics was due to a prior infectious complication following a previous transrectal prostate biopsy. No patient received bowel preparation. Pre-procedure MRI was performed in 134 patients who had a MRI-ultrasound fusion biopsy. Hematuria was reported in 12 patients (8.21%) and there were zero infectious complications (UTI or sepsis). There were no 30-day readmissions amongst this cohort. Median procedure time was 24 minutes.;Adenocarcinoma was found in 86 patients (58.9%) while 40 patients had benign pathology (27.39%) (Table 2). Despite a small percentage of patients receiving perioperative antibiotics, we had zero patients develop sepsis or an UTI. Our 30-day readmission rate was also 0%. With the high reported rates of infectious complications after transrectal prostate biopsy and antibiotic resistance becoming increasingly common, our data supports the notion that transperineal prostate biopsies are safe and can largely be done without the use of perioperative antibiotics. [ABSTRACT FROM AUTHOR]

• Pelvic lymph node dissection is crucial for both diagnostic and therapeutic purposes. • Adequate nodal dissection plays a prognostic role in bladder cancer outcomes. • A "dose-dependent" relationship was identified between nodal yield and survival. • Improved survival in nonmuscle invasive cancer indicates possible micrometastases. • Nodal yield allows for accurate staging and can inform subsequent treatment options. Pelvic lymphadenectomy (PLND) alongside radical cystectomy (RC), provides crucial diagnostic and therapeutic value in patients with bladder cancer. With the advent of neoadjuvant chemotherapy and prospective data supporting standard PLND, controversy remains regarding the optimal PLND extent and patient selection. Nearly 40% of patients may not receive adequate PLND, even though 25% of patients have positive lymph nodes (LN) at time of RC. We hypothesized that PLND still remains an important facet of bladder cancer treatment. To clarify the prognostic importance of nodal yield, we performed a retrospective investigation of a heterogenous population (pTanyNx/0M0) of patients undergoing RC. From the Surveillance, Epidemiology, and End Results (SEER) program, we identified pTanyNx/0M0 bladder cancer patients undergoing RC from 2004 to 2015. Kaplan Meier curves and Cox proportional hazards models assessed cancer-specific survival. Patients were analyzed with PLND performed as the primary covariate. Survival analysis then stratified patients undergoing PLND by LN yield, both as a continuous and categorial variable (≤10, 11–20, 21–30, and >30), and T stage. The final cohort included pTanyNx/0M0 patients with urothelial bladder cancer (n = 12,096); median follow up was 39 (IQR: 17–77) months. PLND was performed in 81.45% of patients with a median LN yield of 14 (IQR: 7–23). Most commonly, patients had T2 disease (44.68%). After controlling for age and T stage, patients receiving PLND had improved CSS (HR = 0.56, [95% CI: 0.51–0.62]) compared to those that did not receive PLND. When grouping patients by LN yield, survival improved in a "dose dependent" manner (>30 LN: HR = 0.76, [95% CI: 0.66–0.87]). We noted similar results when stratifying patients into non–muscle-invasive (NMIBC) and muscle-invasive bladder cancer (MIBC). In a large contemporary series of pTanyNx/0M0 bladder cancer patients, we found a significant oncologic benefit to PLND. Higher LN yield correlated to improved CSS in non–muscle-invasive and muscle-invasive disease. Our data support the possibility of occult micrometastasis even in non–muscle-invasive disease. Additionally, in light of recent advances in adjuvant immunotherapy, our results emphasize the importance of adequate nodal yield for accurate staging and optimal treatment. [ABSTRACT FROM AUTHOR]