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Objective: To utilize a national dataset to compare outcomes and demonstrate trends in treatment for lymph node positive bladder cancer (N+ BC)., Methods: The National Cancer Database (2006-2014) was queried for cT2-4N1-3M0 N+ BC patients treated with radical cystectomy alone (RC), neoadjuvant chemotherapy (NAC), adjuvant chemotherapy (AC), chemoradiation (CRT), chemotherapy alone (CT), or no definitive treatment (NT). Survival by treatment was analyzed using Kaplan-Meier and multivariable Cox-proportional hazards regression. Pathologic down-staging was analyzed using univariable and multivariable logistic regression models. A univariable logistic regression model of treatment by year identified treatment trends., Results: Among 3241 patients (cN1, 46%; cN2, 44%; cN3 10%), the majority underwent combined chemotherapy and RC (NAC, 418; AC, 591; RC, 567; CRT, 392; CT, 1068; NT, 205). Overall survival did not differ between NAC and AC, but both had improved survival compared to RC. All other treatment groups had worse survival outcomes compared to NAC. Down-staging to pT0 (adjusted odds ratio = 26.39) and pN0 (adjusted odds ratio = 6.88) was higher for NAC than RC. Utilization of NAC has increased, AC and RC has declined, and CRT and NT is unchanged., Conclusion: Combined chemotherapy and RC demonstrates best survival outcomes for N+ BC, with complete pathologic response to pT0N0 after NAC associated with a 5-year overall survival rate of ∼85%. However, there is no significant difference between NAC and AC. CRT is associated with worse oncologic outcomes compared to RC with perioperative chemotherapy, but improved survival compared to RC or CT., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To examine temporal national trends of operative approach for cystectomy and identify demographic or clinical predictive factors that influence choice of approach., Methods: We performed a retrospective cohort study of patients who underwent cystectomy for bladder cancer between 2010 and 2013 using the National Cancer Database. Approach was stratified by open vs minimally invasive (robotic or laparoscopic). Univariate Pearson chi-square and multivariate logistic regression analysis were used to assess the relationships between demographic and hospital factors and the receipt of minimally invasive or open surgical approach., Results: A total of 9439 patients met our inclusion criteria, of which 34.1% received a minimally invasive approach (MIA). Frequency of MIA increased from 26.3% in 2010 to 39.4% in 2013 (P < .0001). Univariate analysis identified statistically significant associations between year of diagnosis, sex, age, race, clinical T stage, insurance status, income, education, distance from hospital, facility type, geographic location, and facility cystectomy volume, and the choice of approach (all P < .01). On multivariate analysis, independent predictors of MIA included increasing year of diagnosis, male gender, lower clinical T stage, private insurance vs Medicaid, nonacademic vs academic program, northeastern geographic region, receipt of neoadjuvant chemotherapy, and lower cystectomy volume., Conclusion: Utilization of MIA for cystectomy has increased nationally over the last several years likely due to increased surgeon familiarity with robotic laparoscopic pelvic surgery. Factors associated with MIA included male sex, locally confined disease, receipt of neoadjuvant chemotherapy, lower cystectomy volume centers, and nonacademic centers., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To describe national trends in cystectomy at the time of urinary diversion for benign indications. Multiple practice patterns exist regarding the necessity for concomitant cystectomy with urinary diversion for benign end-stage lower urinary tract dysfunction. Beyond single-institution reports, limited data are available to describe how concurrent cystectomy is employed on a national level., Materials and Methods: A representative sample of patients undergoing urinary diversion for benign indications with or without concurrent cystectomy was identified from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1998 to 2011. Using multivariate logistic regression models, we identified hospital- and patient-level characteristics associated with concomitant cystectomy with urinary diversion., Results: There was an increase in the proportion of concomitant cystectomy at the time of urinary diversion from 20% to 35% (P < .001) between 1998 and 2011. The increase in simultaneous cystectomy over time occurred at teaching hospitals (vs community hospitals), in older patients, in male patients, in the Medicare population (vs private insurance and Medicaid), and in those with certain diagnoses., Conclusion: There has been an overall increase in the use of cystectomy at the time of urinary diversion for benign indications on a national level, although the indications driving this clinical decision appear inconsistent., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Trimodal bladder preservation therapy (ie, transurethral resection followed by chemoradiotherapy) may be an acceptable treatment alternative to radical cystectomy with urinary diversion in the carefully selected patient with muscle invasive bladder cancer. Although no head-to-head randomized controlled trials have been performed, large retrospective cohort reviews and observational data analyses suggest comparable oncologic outcomes in select patients with the additional benefit of maximizing quality of life and maintaining the patient's native bladder. In this review, we discuss the evolution and clinical outcomes of bladder preservation therapy, highlighting its role in the contemporary management of muscle invasive bladder cancer., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Radical cystectomy (RC) is a complex procedure that can involve long postoperative hospital stays and complicated, burdensome recoveries. Enhanced recovery after surgery is a broad term encompassing an overall approach to perioperative management of postsurgical patients and is becoming more widely accepted for cystectomy patients. This review examines the current evidence for using enhanced recovery protocols for RC as well as current rates of adoption of enhanced recovery among urologists performing RC. We also discuss the next steps for overcoming barriers to the widespread implementation of enhanced recovery for RC., (Copyright © 2016. Published by Elsevier Inc.)

Objective: To assess radical cystectomy (RC) outcomes and adjuvant chemotherapy (ACT) use in the elderly in routine practice. Bladder cancer occurs most commonly in the elderly. RC, standard treatment for muscle-invasive bladder cancer, presents challenges in older patients. Suboptimal evidence guides ACT use., Methods: All patients undergoing RC for urothelial cancer in Ontario from 1994 to 2008 were identified using the Ontario Cancer Registry. Pathology reports and treatment records were linked to the database. Patients were age stratified as <70, 70-74, 75-79 and ≥80 years. Logistic regression and Cox proportional hazards identified associations with and effectiveness of ACT use., Results: We identified 3320 patients: 1362 (41%) aged <70 years; 674 (20%) aged 70-74 years; 674 (19%) aged 75-79 years, and 657 (20%) aged ≥80 years. Thirty-day (1%, 2%, 2%, 6%; P <.0001) and 90-day (5%, 8%, 9%, 15%; P <.0001) mortality increased with age. Age-stratified 5-year cancer-specific survival was 42%, 37%, 34%, and 32%, respectively (P <.001); 5-year overall survival was 40%, 34%, 28%, and 23%, respectively (P <.001). ACT decreased with age (27%, 16%, 12%, 5%; P <.0001). Among ACT patients, 87% aged <70 years received cisplatin vs 73% aged ≥70 years (P = .003). ACT was associated with improved cancer-specific survival (hazard ratio [HR] = 0.73 and 95% confidence interval [CI] = 0.59-0.89 for age <70 years and HR = 0.73 [95% CI = 0.59-0.89] for ≥70 years) and overall survival (HR = 0.70 [95% CI = 0.58-0.85] for age <70 years and HR = 0.70 [95% CI = 0.59-0.84] for ≥70 years) across all age groups., Conclusion: Cystectomy carries a higher risk of postoperative mortality in elderly patients in routine clinical practice. ACT is used infrequently in older patients despite a substantial survival benefit observed across all age groups., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objectives: To review the current status and role of robot-assisted laparoscopic pelvic lymphadenectomy. To review the need, extent, lymph node yield, oncological feasibility, and outcome of robot-assisted pelvic lymphadenectomy for invasive bladder cancer in patients undergoing a robot-assisted laparoscopic radical cystectomy., Methods: The National Library of Medicine and the Pub Med were extensively searched for the cases of robot-assisted laparoscopic pelvic lymphadenectomy performed in conjunction with robot-assisted laparoscopic radical cystectomy for bladder cancer using the following keywords: bladder cancer, pelvic lymphadenectomy, cystectomy, laparoscopy, robot, and robot-assisted radical cystectomy. These were reviewed and analyzed (using certain tabulated parameters) to determine the current status of robot-assisted pelvic lymphadenectomy., Results: The search yielded about 12 major published series (278 cases) of "robot-assisted radical cystectomy with pelvic lymphadenectomy," with an overall acceptable mean operating time(s), complication rate, blood loss, and hospital stay., Conclusions: Robot-assisted laparoscopic pelvic lymphadenectomy in conjunction with robot-assisted laparoscopic radical cystectomy is an oncologically feasible and technically safe procedure with acceptable early operative outcomes that appear to be comparable to those achieved with open/laparoscopic surgery., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)