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Purpose Muscle invasive bladder cancer surgical management has been historically a radical cystoprostatectomy in males and an anterior exenteration in females. Uterine, ovarian, and vaginal preservation are utilized, but raise concerns regarding risk to oncologic control, especially in variant histopathology or advanced stage. Materials and Methods A retrospective single institutional analysis identified radical cystectomies performed in women, including those with variant histology, which were defined as reproductive organ sparing (uterine, vaginal, and ovary sparing) or non-organ sparing. The Kaplan-Meier method was used for recurrence-free (RFS) cancer specific survival (CSS) and overall (OS) survival in patients with advanced disease. Results From 2000 to 2020, 289 women were identified, 188 underwent reproductive organ-sparing cystectomy. No statistical differences were noted for clinical parameters or presence of variant histology for organ-sparing (ROS) and non-organ sparing (non-ROS). Positive margin rates did not differ for ROS and non-ROS; 4.3% vs 7.9%, p=0.19, respectively. Median RFS was not statistically significantly different for ROS vs non-ROS (26.1 vs 15.3 months) p=0.937 HR 1.024. CSS was not statistically different for ROS vs non-ROS (36.3 vs 28.6 months), p=0.755 HR 0.9. OS was not statistically different for ROS vs non-ROS (25.8 v 23.8 months), p=0.5 HR=1.178. Variant histology did not change survival (HR 1.1, p=0.643). Conclusions In this analysis, ROS in women with advanced disease did not increase positive margin rates or decrease RFS, CSS, or OS compared to non-ROS. Variant histology did not decrease survival odds. Based on preoperative assessment and intraoperative findings, ROS in patients with variant histology and advanced disease should be considered.

The treatment landscape for advanced urothelial cancer has changed dramatically owing to the US Food and Drug Administration approval and introduction of antibody-drug conjugates (ADCs), including enfortumab vedotin and sacituzumab govitecan. Efforts have begun to use these therapies in earlier disease states, specifically bacillus Calmette-Guérin (BCG)-unresponsive non-muscle-invasive bladder cancer (NMIBC). We assessed gene expression associated with these newly approved therapies in a novel cohort of treatment-naïve NMIBC tumors before and after BCG therapy. Multiple genes, including Nectin-4, Trop-2, and Her-2, exhibited increased expression after BCG therapy compared to baseline. However, few of the tumors with increased expression of ADC targets also exhibited increased PD-L1/PD-1 expression. Taken together, these data demonstrate the heterogeneous genomic landscape of BCG-exposed NMIBC, and provide evidence supporting the evaluation of ADCs in NMIBC. PATIENT SUMMARY: We evaluated the potential role of targeted therapies that have been approved in the USA for advanced non-muscle-invasive bladder cancer (NMIBC) that has recurred after treatment with bacillus Calmette-Guérin (BCG). By assessing levels of specific genes and proteins linked to the targeted therapies, we demonstrate that there is rationale for further evaluation of these therapies in NMIBC.

Objective To assess whether pandemic-related restrictions with video-based interviewing increased geographic clustering of urology applicants matching at a residency program near where they were raised or attended medical school. Materials and Methods We utilized publicly available data from the urology match to compare dispersal patterns between applicants matching during the COVID-19 application cycle (2021) and those matching in the 5 prior application cycles (2016-2020). Variables included home state, undergraduate institution, medical school, and residency. Latitudes and longitudes were obtained for each institution and home state. The primary endpoint was distance (miles, as the most direct path) between medical school and residency program. We also assessed dispersal patterns by American Urological Association section. Results Of the 1965 applicants matching to a urology program between 2016 and 2021, medical school was identified for 1956 (99.7%) applicants, undergraduate program for 1551 (79%) applicants, and home state for 1351 (69%) applicants. Comparing the COVID-19 application cycle to the 5 prior application cycles, there was no significant difference in the median distance between medical school and residency, undergraduate university and residency, or home state and residency. Similarly, there was no significant difference in the proportion of applicants matching at their home institution, matching from medical schools without a home urology program, matching from medical schools with a historically low volume of urology applicants ( Conclusion Virtual interviewing and the loss of in-person clinical rotations did not significantly alter dispersal patterns or hamper an applicant's ability to match at program outside their geographic region.

Objective To perform bibliometric analysis of the top cited articles in urology as a guide for journal club article selection. Methods Bibliometric citation analysis was performed using Scopus. Tables illustrating the top cited clinical, basic science, and guidelines/position statements papers were constructed. Linear regression was used to determine association between h-index and number of citations. Results A total of 3,188,861 publications from 1788 to 2020 were analyzed. The top 100 cited clinical papers from 1788 to 2020, top 100 cited contemporary clinical papers from 2000 to 2020, top 25 cited basic science papers, and the top 25 cited guidelines/position statement papers were reported. Median number of citations in the top 100 cited clinical papers was 1463 (interquartile range 1186-1821). Memorial Sloan Kettering Cancer Center (12), Johns Hopkins University (6), and Harvard University (6) contributed the most top cited clinical papers in urology. Urologic oncology was the most represented subspecialty in both clinical (75%) and basic science (96%) papers. First author and last author h-index were found to correlate with the number paper citations in the top 100 cited clinical papers from 1788 to 2020 (first author β:5.3, P= .003, last author β:4.5, P= .03). Only 7% of the most cited clinical papers in urology were from female first authors, which was not statistically significantly different from those reported in prior publications published in 2009 and 2013. Conclusion Contemporary citation analysis of indexed manuscripts in urology may serve as a valuable educational tool for urologists and trainees.

Objective To present a novel imaging technique used for rapid, nondestructive histological assessment of renal neoplasias using a dual-component fluorescence stain and structured illumination microscopy (SIM). Materials and Methods After Institutional Review Board approval, 65 total biopsies were obtained from 19 patients undergoing partial or radical nephrectomy. Biopsies were stained with a dual-component fluorescent, and optically sectioned SIM images were obtained from the surface of the intact biopsies. Specimens were subsequently fixed and analyzed using hematoxylin and eosin (H&E) histopathologic methods and compared with SIM images. A single, board-certified pathologist blinded to specimens reviewed all SIM images and H&E slides, and determined the presence or absence of neoplasias. Results of blinded diagnosis of SIM were validated against traditional pathology. Results Of the 19 patients, 15 underwent robotic partial nephrectomies and 4 underwent laparoscopic nephrectomies. Indications included clinical suspicion of renal cell carcinoma. In total, 65 biopsy specimens were available for review. Twenty-one specimens were determined to be neoplastic on H&E, whereas 41 represented benign renal tissue. The final sensitivity and specificity of our study were 79.2% and 95.1%, respectively. Conclusion SIM is a promising technology for rapid, near-patient, ex vivo renal biopsy assessment. By improving the ability to rapidly assess sufficiency of biopsy specimens and enabling immediate diagnostic capability, SIM aids in more effective biopsy performance, tissue triage, and patient counseling regarding management options. Additionally, because tissue is preserved, effective utilization of downstream diagnostic tests and molecular assessments are possible.

Hemorrhage after robotic-assisted partial nephrectomy (RAPN) is uncommon but can cause significant morbidity. We present a case of acute hemorrhage isolated to the collecting system that was managed with renal artery embolization (RAE). A 76-year-old male developed sudden onset transfusion-dependent hematuria and hypotension following uncomplicated RAPN. He had no signs of intra-abdominal bleeding and his hypotension was responsive to volume resuscitation. Renal angiography identified a segmental artery with extravasation into the collecting system. RAE eliminated the patient's hematuria, the need for further transfusion, and allowed preservation of renal function. RAE is a viable option for collecting system hemorrhage following RAPN.