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Introduction Prior studies noted substantial costs associated with radical cystectomy, however, they lack surgical comparison to a less costly partial cystectomy. We compared costs associated with radical versus partial cystectomy. Methods A total of 2,305 patients aged 66-85 years diagnosed with clinical stage T2-4a muscle-invasive bladder cancer from January 1, 2002 through December 31, 2011 were included. Total Medicare costs within one year of diagnosis following radical versus partial cystectomy were compared using inverse probability of treatment-weighted propensity score models. Cox regression and competing risks analysis were used to determine overall and cancer-specific survival, respectively. Results Median total costs were not significantly different for radical than partial cystectomy in 90 days ($73,907 vs. $65,721; median difference $16,796, 95% CI $10,038 to $23,558), 180 days ($113,288 vs. $82,840; median difference $36,369, 95% CI $25,744 to $47,392), and 365 days ($143,831 vs. $107,359; median difference $34,628, 95% CI $17,819 to $53,558), respectively. Hospitalization, surgery, pathology/laboratory, pharmacy, and skilled nursing facility costs contributed largely to costs associated with either treatment. Patients who underwent partial cystectomy had similar overall survival but had worse cancer-specific survival (Hazard Ratio (HR) 1.45, 95% Confidence Interval (CI), 1.34-1.58, p Conclusions While treatments for bladder cancer are associated with substantial costs, we showed radical cystectomy had similar total costs when compared to partial cystectomy among patients with muscle-invasive bladder cancer. However, partial cystectomy resulted in worse cancer-specific survival further supporting radical cystectomy as a high-value surgical procedure for muscle-invasive bladder cancer.

OBJECTIVE: To develop and validate a nomogram assessing cancer and all-cause mortality following radical cystectomy. Given concerns regarding the morbidity associated with surgery, there is a need for incorporation of cancer-specific and competing risks into patient counseling and recommendations. MATERIALS AND METHODS: A total of 5325 and 1257 diagnosed with clinical stage T2-T4a muscle-invasive bladder cancer from January 1, 2006 to December 31, 2011 from Surveillance, Epidemiology, and End Results-Medicare and Texas Cancer Registry-Medicare linked data, respectively. Cox proportional hazards models were used and a nomogram was developed to predict 3- and 5-year overall and cancer-specific survival with external validation. RESULTS: Patients who underwent radical cystectomy were mostly younger, male, married, non-Hispanic white and had fewer comorbidities than those who did not undergo radical cystectomy (P < .001). Married patients, in comparison with their unmarried counterparts, had both improved overall (hazard ratio 0.76; 95% confidence interval 0.70–0.83, P < .001) and cancer-specific (hazard ratio 0.76; 95% confidence interval 0.68–0.85, P < .001) survival. A nomogram developed using Surveillance, Epidemiology, and End Results-Medicare data, predicted 3- and 5-year overall and cancer-specific survival rates with concordance indices of 0.65 and 0.66 in the validated Texas Cancer Registry-Medicare cohort, respectively. CONCLUSION: Older, unmarried patients with increased comorbidities are less likely to undergo radical cystectomy. We developed and validated a generalizable instrument that has been converted into an online tool (Radical Cystectomy Survival Calculator), to provide a benefit-risk assessment for patients considering radical cystectomy.

Objectives To examine treatment variability, disparities, and quality among newly diagnosed nonmuscle invasive bladder cancer (NMIBC) patients, and to identify factors associated with treatment use in a large, diverse integrated delivery system. Methods Retrospective cohort study of 5386 NMIBC patients diagnosed between January 2001 and June 2015 within Kaiser Permanente Southern California. Electronic health data were used to identify treatment outcomes and patient, provider, and tumor characteristics. Outcomes were use of (1) postoperative intravesical chemotherapy, (2) induction Bacille Calmette-Guerin (BCG) immunotherapy, and (3) any intravesical therapy. Multivariable odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using generalized linear mixed models with a binary outcome and urologist as a random effect. Results From 2001 to 2015, 41% of newly diagnosed NMIBC patients were treated with intravesical therapy. Postoperative chemotherapy use increased significantly over this period (OR per-year = 1.16, 95% CI: 1.07-1.25). BCG use was strongly associated with tumor characteristics: patients with high-grade or carcinoma in situ tumors were more likely to receive BCG (OR = 10.10, 95% CI: 8.39-12.16). Few treatment differences were found by sex or race/ethnicity, but were observed by age. Wide treatment variability across urologists was observed, with some urologists never using intravesical therapy as part of initial treatment while others almost always used it. Differences across urologists accounted for more variability in postoperative chemotherapy (intraclass correlation coefficient = 0.52) than BCG immunotherapy (intraclass correlation coefficient = 0.11) use. Conclusion Substantial variability in initial treatment of NMIBC was observed across urologists, accounting for tumor, patient, and provider characteristics. Results suggest a considerable opportunity for quality improvement programs to reduce unwanted treatment variability and improve care for patients.

To assess the variation in primary treatment of high-risk prostate cancer (PCa) by different hospital characteristics in the United States.We used the National Cancer Data Base to identify patients diagnosed with pretreatment high-risk PCa from 2004 to 2011. The primary outcomes were different forms of primary therapy or watchful waiting (WW) across different types of hospitals (community, comprehensive cancer community, and academic hospitals). Multivariable logistic regression analyses were used to test for differences in treatment by hospital type.During the study period, we identified 102,701 men diagnosed with high-risk PCa. Overall, the most common treatment was radical prostatectomy (37.0%) followed by radiation therapy (33.2%) and WW (8.5%). Compared with white men with high-risk PCa, black men had lower adjusted odds ratios (OR) for surgery at comprehensive community (OR: 0.64; P .001) and academic (OR: 0.62; P .001) hospitals. Similarly, black men were also more likely to be managed with WW at community (OR: 1.49; P .001), comprehensive cancer community (OR: 1.24; P .001), and academic (OR: 1.55; P .001) hospitals, as well as with radiation therapy at comprehensive cancer community (OR: 1.27; P .001) and academic hospitals (OR: 1.23; P .001).Disparities in the use of WW and different primary treatments among patients with high-risk PCa persisted across different types of hospitals and over time. Our findings highlight a significant racial disparity in the use of curative therapy for high-risk PCa that should be urgently addressed to ensure that all men with PCa receive appropriate care across all racial groups and cancer care facilities.

OBJECTIVE To evaluate contemporary national practice pattern trends in the use of thermal ablation (radiofrequency ablation and cryoablation) in the management of stage I renal cell carcinoma (RCC), and the factors that lead to using thermal ablation (TA) vs partial (PN) or radical nephrectomy (RN) in the United States. METHODS Within the Surveillance, Epidemiology and End Results (SEER) database, we identified subjects with T1-N0M0 RCC treated with either PN, RN, or TA between 2004 and 2007. Proportions, trends, and multivariable logistic regression models tested the predictors of the use of TA. RESULTS In total, 15,145 patients underwent a procedure for an RCC that was organ-confined and 7 cm. Of these, 578 underwent TA, 4402 underwent PN, and 10,165 underwent RN. On unadjusted analyses, patients who received TA were more likely to be older, single, have smaller tumor size, be diagnosed in more recent years, and have more unspecified histologic subtype and tumor grade. In multivariable adjusted analyses, single status (P .02), male gender (P .01), increasing age (P .01), year of diagnosis (P .01), and smaller tumor size (P .01) were strong independent predictors of TA use compared with surgery (PN or RN). Further adjusted analyses showed no statistical difference in cancer-specific or overall survival between TA vs PN or RN. CONCLUSIONS TA use for stage I RCC increased over a relatively short period and was performed more commonly in patients of older age and with smaller tumor size. Longer follow-up is needed to assess the comparative effectiveness of TA vs surgery. UROLOGY 78: 93‐98, 2011. © 2011 Elsevier Inc.

OBJECTIVES To evaluate whether the surgical approach influenced the likelihood of a positive surgical margin (PSM) adjusting for known preoperative predictors of PSM, year of radical prostatectomy, body mass index, use of nerve sparing, and patient age at radical prostatectomy. METHODS The study cohort comprised 950 consecutively treated men with clinically localized prostate cancer who underwent open radical retropubic (RRP, n = 346) or robotic-assisted (RALP, N = 604) prostatectomy by a single surgeon (J.P.R., J.C.H.) at the Brigham and Women's Hospital from 2005 to 2008 and had complete information on baseline patient and tumor characteristics. Univariate and multivariate logistic regression analyses were performed to identify clinical factors significantly associated with the likelihood of a PSM. RESULTS Men undergoing RALP compared with RRP were more likely to have a PSM (adjusted odds ratio 1.9; 95% confidence interval: 1.2-3.1, P = .0095). Significant interaction (P = .0085) was noted between the type of surgical approach and whether nerve sparing was performed on the likelihood of a PSM. Specifically, a significantly lower PSM rate was observed for men undergoing nerve sparing and RRP compared with nerve sparing and RALP (7.6% vs 13.5%, P = .007), whereas opposite trend was noted (P = .09) for men undergoing a non-nerve-sparing approach. CONCLUSIONS Men undergoing RALP compared with RRP seem to have a greater likelihood of a PSM. Further study is needed to delineate whether this increase is due to an intrinsic limitation of RALP or unknown confounders.

Objectives Adult cystic nephroma (CN) and mixed epithelial and stromal tumor (MEST) are benign renal tumors readily distinguished from cystic renal cell carcinoma and other malignant variants based on histopathology. Clinical and radiographic data regarding these lesions are sparse, especially with respect to factors providing clinical suspicion for CN or MEST. Methods Pathology of 22 CN (21 patients) and 10 MEST (9 patients) treated between 1987 and 2005 was re-reviewed according to 2004 WHO classification. Results Nineteen CN patients (90%) and 9 MEST patients (100%) were female and median ages were 55 (range: 39 to 79) and 52 (range: 39 to 67) years, respectively. Twenty-two patients (73%) presented symptomatically. CN were commonly Bosniak III lesions (77%), whereas 70% of MEST had solid enhancing components. An intrapelvic component was present in 5 CN (23%) and no MEST. Preoperative radiologic suspicion was documented in 36% of CN, but in only 1 patient with MEST. Nephron-sparing surgery was performed for 16 tumors (50%), including 5 suspected preoperatively and 3 that were 7 cm or greater. There was 1 case each of bilateral CN and MEST. Two patients with CN had concomitant renal cell carcinoma. One patient with MEST had sarcomatous component. At mean follow-up of 4.5 years (range: 1 to 18), no patient had novel or recurrent tumors develop. Conclusions CN and MEST typically present symptomatically in perimenopausal women. Pedunculation of a multiloculated cystic lesion may allow for preoperative suspicion of these lesions in the proper clinical setting. Nephron-sparing surgery is the preferred treatment even for large and/or central lesions, if amenable.

i A72-year-old men presented to his primary care physician with a chief complaint of a painful left scrotal mass of 2 weeks’ duration. He had a medical history of noninvasive bladder cancer for which he had completed a 6-week induction course of bacille Calmette-Guerin (BCG) 5 months before his present presentation. During his treatment, other than mild dysuria, he did not recall any scrotal discomfort, fever, or chills. The urine cultures were negative; however, the patient was treated with a 2-week course of ciprofloxacin antibiotics and nonsteroidal anti-inflammatory drugs. During his urologic consultation, the left scrotum was erythrematous, and an indurated mass was palpable at the lower pole of the left testis involving the epididymis, which had not decreased in size. He denied dysuria, hematuria, fevers, chills, nausea, vomiting, weight loss, or changes in bowel movements. He denied any history of urinary tract infections or other genitourinary complaints. Recent routine blood test results, including hemoglobin, hematocrit, liver function tests, -fetoprotein, human chorionic gonadotropin, and lactate dehydrogenase, were within normal limits. His urinalysis revealed microscopic hematuria and was otherwise unremarkable. The urine culture was negative. A testicular ultrasound scan was obtained and revealed a left 3.5 1.5 cm heterogenous, hypoechoic, lobulated mass originating from the epididymal tail, with a mass effect on the lower pole of the testis (Fig. 1). Definitive invasion into the left testis could not be excluded, and the scrotum appeared indurated, with increased echogenicity suggestive of an inflammatory reaction. The right testis and epididymis were normal in appearance. A computed tomography urogram was also obtained and revealed a mildly thickened bladder wall consistent with the known previous bladder cancer and was otherwise unremarkable.

Adenomatoid tumors are rare benign neoplasms thought to be of mesothelial origin. Although most reported cases arise from the epididymis, rare cases have been reported in the spermatic cord, testicular tunica, ejaculatory ducts, prostate, and suprarenal recess. In female subjects, adenomatoid tumors are commonly found in the uterus and fallopian tubes. Because of the benign nature of this tumor, the treatment of choice is local excision. We describe a rare case of adenomatoid tumor of the testis treated by local excision.

CASE An 84-year-old female presented to the emergency department with a chief complaint of painless gross hematuria for 2 days. She had a past medical history of pancreatic adenocarcinoma status post–Whipple procedure in 2004 followed by adjuvant chemoradiotherapy, diabetes mellitus, diastolic congestive heart disease, and osteoporosis. Regarding her pancreatic cancer, she developed further recurrence of her disease at her umbilicus, for which she received salvage gemcitabine and further radiotherapy. Her umbilical mass did not reduce in size and she had further progression of her disease with metastases to the liver, lungs, and spine. During urological consultation, the patient reported no prior episodes of gross hematuria but a significant history of chronic nocturia and urinary frequency. She denied any history of urinary tract infections, nephrolithiasis, or other genitourinary complaints. She had no history of tobacco use or occupational/chemical exposure. She denied dysuria, fevers, chills, nausea, vomiting, flank pain, weight loss, or changes in bowel movements. On examination, she was noted to have a well-healed chevron incision and palpable umbilical mass, and she voided wine-colored urine with small clots. The remainder of the physical examination was otherwise unremarkable. Recent routine blood tests, including hemoglobin, hematocrit, liver function tests, and coagulation studies, were within normal limits. Her urinalysis revealed microscopic hematuria and was otherwise unremarkable. A computed tomography urogram was obtained and revealed extensive blood clots within the urinary bladder and a suspicious mass along the posterior wall just medial to the left ureterovesical junction (Fig. 1). The kidneys and ureters were normal in appearance. Her umbilical mass was stable in size and there was an interval increase in her metastatic disease.

Objectives Luteinizing hormone releasing hormone (LHRH) agonist therapy is one of the mainstays of prostate cancer treatment. Three dosing regimens currently exist: calendar-based, intermittent, and a testosterone (T)-based (T-based) regimen. We investigated the differences in development of early castrate resistance rates between these different regimens. Methods We evaluated 1617 patients with prostate cancer who received LHRH-agonist monotherapy in the Kaiser Permanente Southern California Cancer Registry between January 2003 and December 2006. Patients who had undergone surgery and/or radiation were excluded. Patients were grouped according to their dosing regimen: calendar-based, intermittent dosing, and T-based. Cox proportional hazard-regression analysis was used to estimate the hazards ratio (HR) for treatment failure. Results A total of 692 patients who received an LHRH agonist as primary monotherapy for prostate cancer fit our criteria. Calendar-based dosing was used in 325 patients; 252 received T-based dosing and 115 received intermittent dosing. On multivariate analysis controlling for demographic and prostate cancer–related variables, the T-based dosing group showed a significantly lower relative risk of treatment failure (HR = 0.65, P = .02). The intermittent-dosing group trended toward a lower risk treatment failure (HR = 0.80, P = .3). Among the variables analyzed, only a Gleason score >8 (HR = 2.05, P = .01) and a pretreatment prostate-specific antigen >20 (HR = 2.00, P

Controversy persists regarding the adequacy of pelvic lymph node dissection (PLND) and cancer control when comparing minimally invasive radical prostatectomy (MIRP) and open radical prostatectomy (RRP). We characterized determinants of performance and extent of PLND during radical prostatectomy in elderly men.A population-based study was conducted comprised of 5448 men ≥65 years undergoing RRP and MIRP during 2004 to 2006 from Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked data. Multivariable logistic regression was used to assess the effect of demographic and tumor characteristics, surgical approach, and surgeon volume on the likelihood of performing PLND.PLND was performed for 87.6% vs. 38.3% of men undergoing RRP vs. MIRP (P.001). Among RRP, 82.6% vs. 4.6% underwent extended vs. limited PLND, with a median yield of 4 vs. 3 lymph nodes (P.001). Median MIRP PLND yield was 3 lymph nodes. In adjusted analyses, men undergoing RRP vs. MIRP (odds ratio [OR] 16.7; 95% confidence interval [CI], 11.1-25.0), those with few vs. multiple comorbidities (OR 1.4, 95% CI 1.02-1.91), intermediate (OR 1.87; 95% CI 1.48-2.37), and high (OR 2.77; 95% CI 2.02-3.78) vs. low-risk features, and men treated by high-volume surgeons (OR 1.008; 95% CI 1.004-1.011) were more likely to undergo PLND. Conversely, Hispanic (OR 0.68, 95% CI 0.49-0.96) vs. white men were less likely to undergo PLND.Independent of tumor characteristics, men undergoing RRP vs. MIRP were more likely to undergo PLND with greater lymph node yield and racial variation observed. Further studies are needed to determine the appropriate use of PLND.

OBJECTIVES To prospectively compare outcomes during robotic prostatectomy between surgeons with formal training in either robotic prostatectomy (RALP) or laparoscopic prostatectomy (LRP). METHODS A total of 286 robotic prostatectomies were performed by 12 urologists between August 2008 and March 2009 as part of a new robotic surgery program at one of the largest health maintenance organizations in the United States. Four surgeons had formal training in RALP and 8 had formal training in LRP. We prospectively compared surgical and pathologic outcomes between these 2 groups of surgeons. RESULTS The 4 RALP surgeons performed 121 RALPs and the 8 LRP surgeons performed 165 RALPs. Patient demographics were similar between groups. The robot-naive group had significantly more clinical stage T1c than the robot-trained group (87.9% vs 74.4%, P = .003). Prostatectomy parameters were similar between the 2 groups of surgeons in terms of prostate size, Gleason score, pathologic stage, and estimated blood loss. The robot-trained surgeons had significantly lower overall positive margin rates (24% vs 34.6%, P = .05) and lower margin rates in T3 tumors (38.5% vs 61.8%, P = .07), which were approximately statistically significant. There was no difference in margin rates in T2 tumors. The robot-trained surgeons had significantly lower apical margin rates (8.3% vs 21.2%, P = .003) and lateral margin rates (1.7% vs 7.3%, P = .05). The robot-trained surgeons had 10%-15% shorter procedure times. There was no difference in complication rates. CONCLUSIONS Formal RALP training may be beneficial for surgical and pathologic outcomes of RALP compared with formal LRP training during the initial implementation of a new robotics program.

Objectives. To evaluate the feasibility and activity of paclitaxel, carboplatin, and methotrexate in advanced transitional cell carcinoma (TCC) of the urothelium and to relate the activity of this combination to the mutational status of p53. Methods. In the Phase I portion, paclitaxel 200 mg/m2 (3-hour infusion), carboplatin dosed to an area under the curve (AUC) of 6 mg/mL · min, and methotrexate 10 mg/m2, increasing in 10-mg/m2 increments, were administered on day 1 and every 21 days thereafter with granulocyte colony-stimulating factor (G-CSF) and leucovorin support. Subsequently, a Phase II study was initiated in which the carboplatin dose was lowered to an AUC of 5 to allow treatment without G-CSF. p53 expression was evaluated using immunohistochemistry. Results. Thirty-three patients were accrued. Median age was 66 years. No dose-limiting toxicities were seen in the Phase I portion despite escalation of the methotrexate to 60 mg/m2. Principal toxicities were myelosuppression and neuropathy. The overall response rate (Phase I and II) was 56% (95% confidence interval 38% to 74%). Median survival was 15.5 months; 88% of patients overexpressed p53 at the primary site. Conclusions. Paclitaxel, carboplatin, and methotrexate were well tolerated and active in advanced TCC. The high response rate to this regimen despite frequent p53 mutation is consistent with the p53-independent mechanism of paclitaxel. Whether this regimen is superior to methotrexate/vinblastine/doxorubicin/cisplatin, other paclitaxel-based regimens, or to paclitaxel alone will require comparative trials.