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Background: UGN-101 can be used for chemoablation of low-grade upper tract urothelial carcinoma (UTUC). The gel can be administered via a retrograde route through a ureteral catheter or an antegrade route via a nephrostomy tube., Objective: To report outcomes of UGN-101 by route of administration., Design, Setting, and Participants: We performed a retrospective review of 132 patients from 15 institutions who were treated with UGN-101 for low-grade UTUC via retrograde versus antegrade administration., Outcome Measurements and Statistical Analysis: Survival outcomes are reported per patient. Treatment, complications, and recurrence outcomes are reported per renal unit. Statistical analysis was performed for primary endpoints of oncological response and ureteral stricture occurrence., Results and Limitations: A total of 136 renal units were evaluated, comprising 78 retrograde and 58 antegrade instillations. Median follow-up was 7.4 mo. There were 120 cases (91%) of biopsy-proven low-grade UTUC. Tumors were in the renal pelvis alone in 89 cases (65%), in the ureter alone in 12 cases (9%), and in both in 35 cases (26%). Seventy-six patients (56%) had residual disease before UGN-101 treatment. Chemoablation with UGN-101 was used in 50/78 (64%) retrograde cases and 26/58 (45%) antegrade cases. A complete response according to inspection and cytology was achieved in 31 (48%) retrograde and 30 (60%) antegrade renal units (p = 0.1). Clavien grade 3 ureteral stricture occurred in 21 retrograde cases (32%) and only six (12%) antegrade cases (p < 0.01). Limitations include treatment bias, as patients in the antegrade group were more likely to undergo endoscopic mechanical ablation before UGN-101 instillation., Conclusions: These preliminary results show a significantly lower rate of stricture occurrence with antegrade administration of UGN-101, with no apparent impact on oncological efficacy., Patient Summary: We compared results for two different delivery routes for the drug UGN-101 for treatment of cancer in the upper urinary tract. For the antegrade route, a tube is inserted through the skin into the kidney. For the retrograde route, a catheter is inserted past the bladder into the upper urinary tract. Our results show a lower rate of narrowing of the ureter (the tube draining urine from the kidney into the bladder) using the antegrade route, with no difference in cancer control., (Copyright © 2023 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Intracavitary UGN-101 is approved for the treatment of low-grade noninvasive upper tract urothelial carcinoma (UTUC). Post-commercialization studies underscore the benefit of UGN-101 administration for patients with imperative indications for whom radical nephroureterectomy (RNU) is not a viable option., Objective: To describe the use, efficacy, and safety of UGN-101 in patients with UTUC with imperative indications for renal preservation, including high-grade disease., Design, Setting, and Participants: Patients receiving UGN-101 with imperative indications were retrospectively analyzed using a multicenter centralized registry from 15 high-volume academic and community centers., Outcome Measurements and Statistical Analysis: We defined imperative indications as patients with a solitary kidney, the presence of chronic kidney disease (CKD) with a glomerular filtration rate <30 ml/min, bilateral UTUC, and patients unfit for or unwilling to undergo surgical extirpation. Tumor characteristics, disease progression/recurrence, and adverse events were recorded on a per-renal-unit basis., Results and Limitations: UGN-101 was instilled into 52 renal units (38%) in 48 patients for imperative indications, including 29 patients (56%) with a solitary kidney, 11 kidneys (21%) in the setting of bilateral UTUC, six patients (12%) with CKD, and six patients (12%) who were unfit for or unwilling to undergo RNU. Twelve renal units had biopsy-proven high-grade papillary disease. Tumors were completely ablated before induction therapy in 34% of cases, while 66% had tumor present. Following induction therapy, 17 patients (40%) had no evidence of disease (NED) on ureteroscopy, 88% of whom maintained this status at median follow-up of 10.8 mo. In the cohort with high-grade disease, five patients (45%) had NED at initial post-induction primary disease evaluation. Adverse events included pyelonephritis (8%), ureteral stenosis (8%), anemia (6%), and acute renal failure (4%). Limitations include the retrospective study design, the lack of long-term follow up, and patient selection bias., Conclusions: Intracavitary therapy with UGN-101 in patients with UTUC and imperative indications shows promise as a kidney-sparing treatment modality. While long-term follow-up is needed, this intracavitary treatment may help in prolonging time to RNU and delaying the morbidity of hemodialysis in this comorbid population., Patient Summary: We reviewed results for patients with cancer in the upper urinary tract and an additional condition that would not allow kidney removal who received treatment with a gel called UGN-101. Our results suggest that UGN-101 shows promise as a kidney-sparing treatment. It may delay the time until kidney removal is needed in these patients and avoid the negative effects associated with dialysis., (Copyright © 2023 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Gender disparities in editorial board composition exist across a variety of surgical subspecialties., Objective: To investigate temporal variation in gender representation on the editorial boards of urology journals and assess the relationship between editorial board composition and female authorship., Design, Setting, and Participants: We analyzed female authorship and editorial board composition between 2002 and 2020 among eight high-impact urology journals. Female publication status was assessed using publication records retrieved from PubMed. Editorial board information was manually extracted and titles were grouped for comparison as Editor-in-Chief, mid-level editor, and consulting editors., Outcome Measurements and Statistical Analysis: Female representation across different editorial levels was analyzed via hierarchical logistic regression with additional terms to test for between-journal differences in overall representation and change over time. The relationship between representation on editorial boards and as publication authors was assessed at the journal level via correlation., Results and Limitations: Eight journals and 49 412 articles were analyzed. No female has held the title of Editor-in-Chief for any of these eight journals in 18 yr. Significant growth was seen for mid-level editors, whereas no growth was seen for consulting editors. Neurourology and Urodynamics and Journal of Sexual Medicine had significantly higher than average female editorial board representation (p < 0.05). Across the eight journals, there was a statistically significant correlation between the proportion of overall female authors and female editors (r = 0.93, 95% confidence interval 0.65-0.99). For all journals, the proportion of female contributing authors is greater than the proportion of female editorial board members., Conclusions: Women in urology represent a small but increasing presence as editorial board members. Clear differences exist between journals, potentially attributable to specialty-specific demographics. Despite increasing representation, no female has ever been appointed Editor-in-Chief for any of the eight journals evaluated. At the journal-specific level, a positive correlation was observed between female editorial staff and female authorship. Given the implication of both academic authorship and editorial board assignment on academic advancement, actionable changes are outlined to guide improvement in gender diversity at the journal level., Patient Summary: Females are under-represented on the editorial boards for urology journals, although some roles have seen growth over time. Moreover, female editorial board membership is associated with representation of females among article authors. Gender disparities in both are noteworthy because they affect career paths and contribute to the gender gap in urology., (Copyright © 2022 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Patients who undergo radical cystectomy (RC) are at elevated risk of venous thromboembolism and associated morbidity and mortality. Guidelines recommend extended thromboprophylaxis (ETP), typically with heparins, but adherence is low. Outside urology, low-dose apixaban has been used for postoperative ETP with success. We describe our first experiences with low-dose apixaban for ETP after RC for bladder cancer. In our sample of 72 patients who underwent RC for cancer and subsequently received apixaban 2.5 mg twice daily for ETP, there were no symptomatic thromboembolic events and no major bleeding events. Other complication rates were in line with historical reports. Our experience with apixaban 2.5 mg twice daily for ETP after RC demonstrates safety and potential efficacy. A transition from injectable to oral thromboprophylaxis has the potential to improve adherence and patient satisfaction, while allowing the possibility of further extending prophylaxis beyond 28 d, which may be beneficial in selected patients. Further evaluation of apixaban for thromboprophylaxis in urologic cancer surgery is warranted. PATIENT SUMMARY: Home injectable heparin is used for 4 weeks after bladder removal surgery to prevent blood clots. We evaluated our use of the oral medication apixaban for prevention of blood clots after bladder removal surgery and found that none of our patients had major bleeding events or symptomatic blood clots. We conclude that there should be further evaluation of the use of oral instead of injectable medication to prevent blood clots after urology surgery., (Copyright © 2021. Published by Elsevier B.V.)

Background: Considering the relatively high 5-yr survival rate (76.9%) for bladder cancer (BC), its overall prevalence will probably continue to increase. Therefore, it is important to understand the effects of BC diagnosis and management, including psychological sequelae., Objective: To determine the prevalence of depression among elderly patients with BC and identify patient characteristics associated with depression., Design Setting and Participants: Survey responses from a population-based sample of 5787 patients older than 65 yr with a history of BC were retrieved from the Surveillance, Epidemiology and End Results-Medicare Health Outcomes Survey registry, spanning 1999-2014., Outcome Measurements and Statistical Analysis: The primary outcome measured is the prevalence of a positive depression screen. Cancer characteristics and demographic, socioeconomic, health-related, and activities of daily living (ADL)-related data were reviewed. Univariate analysis was conducted to identify correlation between a positive depression screen and patient characteristics. Multivariate analysis was performed to identify independent predictors of depression., Results and Limitations: The prevalence of a positive depression screen was 14.0%. Poor general health ( p  <  0.001), impairment of ADL ( p  <  0.001), greater number of comorbidities ( p  <  0.001), and income <$30 000 ( p  <  0.001) were identified as correlates of depression. Univariate analysis found no association between a positive depression screen and time since the initial cancer diagnosis ( p  =  0.858) or cancer stage ( p  =  0.90). Multivariate analysis showed higher levels of education ( p  =  0.0097), increasing age ( p  =  0.0027), and marriage ( p  <  0.0001) were protective against the development of depression. Limitations include the lack of consideration of treatment outcomes and whether patients have active disease or only a history of cancer., Conclusions: Depression affects a substantial percentage (14%) of elderly patients with BC. Poor general health and impaired ability to complete ADL were the greatest risk factors for depression. Acknowledgment of sociodemographic factors may improve awareness of depression in patients with BC and a potential need for psychosocial support., Patient Summary: Depression affects a significant proportion of patients with bladder cancer. Social and demographic factors influence a patient's risk of depression. Acknowledgment of these factors may improve the detection of depression and a possible need for intervention., (© 2021 The Author(s).)

Background: Bladder cancer affects life quality, overall health, and mortality negatively. The effect of bladder cancer on activities of daily living (ADLs) is not well established., Objective: To examine the effect of bladder cancer diagnosis on ADLs, in addition to physical, mental, and overall health measures., Design Setting and Participants: Using data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare Health Outcomes Survey (MHOS) registry, responses regarding ADLs and overall health were evaluated in bladder cancer patients over time. The Short Form 12 health survey responses were analyzed to determine the change in physical and mental health scores following bladder cancer diagnosis., Outcome Measurements and Statistical Analysis: Changes in self-reported ability to perform ADLs and health outcomes following bladder cancer diagnosis were evaluated. Chi-square statistics were used to determine whether the baseline and follow-up surveys were statistically independent for each ADL. Composites scores for physical health (PCS12) and mental health (MCS12) were compared with two-sample t test., Results and Limitations: A total of 498 patients with surveys before and after bladder cancer diagnosis were identified. An increased percentage of patients reported difficulty in all ADL tasks following bladder cancer diagnosis; this increase was statistically significant for bathing ( p  = 0.02) and using the toilet ( p  = 0.03). These patients also reported a significant decline in overall health status ( p  = 0.0002). A significant reduction in the mean PCS12 and mean MCS12 composite scores was observed ( p  < 0.0001 and p  = 0.0003, respectively)., Conclusions: Patients with bladder cancer report a significant decline in functional status and overall health, including both physical and mental well-being after diagnosis. Further study is needed for factors that may be most predictive of the decline in functional independence for this population., Patient Summary: There is a decreased ability to perform daily activities following bladder cancer diagnosis, and patients report a decrease in their physical and mental health. This information can help patients and their caregivers anticipate patient needs following bladder cancer diagnosis, in addition to helping manage their expectations when making decisions regarding treatment options., (© 2020 The Author(s).)

Our recently reported phase III trial demonstrated that patients undergoing nephron-sparing surgery (NSS) with an estimated glomerular filtration rate (eGFR) of ≥45 ml/min/1.73 m 2 who received mannitol had no improvement in renal function at 6 mo compared with those who received placebo. Some authors have suggested that benefit is restricted to subgroups, such as those with comorbidities. We assessed whether preoperative eGFR, or other patient and surgical factors modified the effect of mannitol on postoperative outcomes at 6 mo and with extended follow-up. We also assessed whether mannitol was associated with differences in long-term GFR years after surgery. No significant difference between the mannitol or placebo groups (mean eGFR difference: 1.4; 95% confidence interval: -2.6, 5.3; p = 0.5) was found in the 134 patients with known eGFR at 3 yr after NSS. At both 6 mo and 3 yr, the effect of mannitol was not significantly modified by patient or surgical factors including preoperative eGFR. In summary, we validated our original trial conclusions by finding that intraoperative use of mannitol does not improve either short- or long-term renal function in patients undergoing NSS. Specifically, there is no evidence that comorbidities, including lower preoperative eGFR, modify the effect of mannitol. PATIENT SUMMARY: Use of mannitol at the time of partial nephrectomy does not improve either short- or long-term renal function even in patients with comorbidities, including lower preoperative renal function. The routine use of intraoperative mannitol should be discontinued., (Copyright © 2019. Published by Elsevier B.V.)

Urothelial carcinoma of the upper tract (UTUC) presents specific challenges regarding accurate staging and tumor sampling. We aimed to assess the feasibility of applying next-generation sequencing to biopsy specimens and gauged the concordance of their genetic profiles with matched radical nephroureterectomy (RNU) specimens. Of the 39 biopsy specimens collected, 36 (92%) had adequate material for sequencing using a hybridization-based exon capture assay (MSK-IMPACT). The most frequently altered genes across the patient cohort were consistent with the urothelial carcinoma-associated alterations identified in a cohort of 130 RNU specimens previously sequenced at our center, including mutations in the TERT promoter (64%), hotspot activating mutations in FGFR3 (64%), and frequent mutations in chromatin remodeling genes. For 12 patients, a matching tumor sample from a subsequent RNU was sequenced. We found a high level of concordance between matched biopsy and RNU specimens, up to 92% for the likely pathogenic alterations. PATIENT SUMMARY: We evaluated the feasibility of genomic characterization of tumor tissue collected at the time of ureteroscopic biopsy and found high concordance with subsequent radical nephroureterectomy specimens. Molecular characterization of urothelial carcinoma of the upper tract biopsies could guide treatment decision-making and identify high-risk patients who could benefit from neoadjuvant chemotherapy and low-risk patients who could benefit from conservative or organ-sparing strategies., (Copyright © 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Treatment choice for muscle invasive bladder cancer continues to be radical cystectomy. However, radical cystectomy carries a relatively high risk of morbidity and mortality compared with other urological procedures., Objective: To compare surgical complications following radical cystectomy in septuagenarians and octogenarians., Design, Setting, and Participants: The National Surgical Quality Improvement Program database (2009-2013) was used to identify patients who were 70 yr and older and underwent radical cystectomy., Outcome Measurements and Statistical Analysis: The data were analyzed for demographics and comorbidities, and compared for complications, including pulmonary, thromboembolic, wound, and cardiac complications. Patients who were 70-79 yr of age were compared with those 80 yr and older. Univariate and multivariate analyses were completed., Results and Limitations: A total of 1710 patients aged ≥70 yr met our inclusion criteria. Of them, 28.8% (n=493) were 80 yr and older, while 71.2% (n=1217) were between 70 and 79 yr old. Operative time (338.4 vs 307.2min, p=0.0001) and the length of stay (11.9 vs 10.4 d, p=0.0016) were higher in the octogenarian group. The intra- and postoperative transfusion rates, reoperative rates, wound dehiscence rates, and pneumonia, sepsis, and myocardial infarction rates were similar between the two groups. The wound infection rate (7.3% vs 4.1%, p=0.01) was higher in the septuagenarians and mortality rate (4.3% vs 2.3%, p=0.04) was higher in the octogenarian group., Conclusions: Radical cystectomy can safely be performed in octogenarians without increased cardiac, pulmonary, and thromboembolic complications when compared with septuagenarians. These patients need to be counseled that the mortality rate is slightly higher compared with that in septuagenarians. Chronological age alone should not be used to decide on offering radical cystectomy., Patient Summary: We looked at complications following radical cystectomy in patients aged 80 yr and older. We found that there was no significant difference for wound, cardiac, or pulmonary complications, but there was an increased risk of mortality in this age group., (Copyright © 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.)