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The NCCN Guidelines for Prostate Cancer Early Detection provide recommendations for individuals with a prostate who opt to participate in an early detection program after receiving the appropriate counseling on the pros and cons. These NCCN Guidelines Insights provide a summary of recent updates to the NCCN Guidelines with regard to the testing protocol, use of multiparametric MRI, and management of negative biopsy results to optimize the detection of clinically significant prostate cancer and minimize the detection of indolent disease.

To report the preliminary surgical outcomes for single incision robotic cystectomy (SIRC). Robotic cystectomy is associated with low utilization rates of orthotopic neobladders due to challenges related to intracorporeal sowing and configuration. A new technique that shortens the learning curve and reduces the incisional footprint may improve outcomes and lead to greater utilization of neobladders.Patients undergoing SIRC using the Da Vinci Single Port (SP) robot between March 2021 and March 2022 are included in this retrospective study. We report 30-day perioperative outcomes and test the hypothesis that patients undergoing SIRC have lower analgesic requirements by comparing them to a cohort of patients for whom SIRC was attempted but converted to open during the study period.Forty-one patients underwent SIRC, with 17 (41%) patients undergoing conversion to open. Of the SIRC patients, 50% underwent orthotopic neobladder reconstruction, and 13% underwent concomitant nephroureterectomy or urethrectomy. The median operative time was 480 minutes, and the median length of hospitalization was 7 days. Seventeen percent required readmission to the hospital, 17% developed small bowel obstruction or ileus, and 13% required a blood transfusion. With respect to analgesic requirements, there were no differences in the median morphine milligram equivalents between the 2 cohorts (SIRC: 81.4; converted: 77.0; P = .64).We demonstrate that SIRC is safe and feasible with a high neobladder utilization rate. Wider adoption of this technique may lead to greater utilization of neobladders for patients undergoing robotic cystectomy.

Prostate radiotherapy is associated with worse oncologic outcomes in patients with bladder cancer. The underlying mechanism is incompletely understood but is thought to be related to an altered microenvironment promoting tumorigenesis. However, there is a gap in the literature regarding how the effect of BCG varies according to prior radiotherapy in patients with non-muscle invasive bladder cancer (NMIBC). In this context, we sought to evaluate oncologic outcomes in NMIBC patients who have previously undergone prostate radiotherapy compared to patients with no prior history of pelvic radiotherapy.This is a retrospective cohort study that includes all patients who received intravesical for NMIBC at our institution from 2001 to 2019. Patients were stratified into 3 cohorts: prior radiotherapy (RT), radical prostatectomy (RP), and no prostate cancer (No PCa). The outcomes of interest were recurrence at 1-year, progression to muscle-invasive bladder cancer (MIBC), and progression to metastatic disease. Comparisons were also made between cohorts with respect to elapsed time from radiation therapy. Wilcoxon rank-sum test was used for comparing continuous variables, while χIn 199 total patients who underwent BCG for NMIBC, 23 had a prior history of prostate radiotherapy treatment, while 17 underwent prior radical prostatectomy. Overall, 41.2% of patients had recurrence at 1 year. There was no difference in the number of induction or maintenance BCG administrations received between the cohorts within the first year. There was no significant difference in recurrence at 1 year between the 3 cohorts (P = .56). There was also no difference in progression to MIBC or progression to metastatic disease with P = .50 and 0.89, respectively.The risk of recurrence after induction BCG treatment for high-grade NMIBC does not vary according to prior radiation treatment for prostate cancer.

PURPOSE The utility of blue light cystoscopy (BLC) in patients receiving bacillus Calmette-Guerin (BCG) during post-treatment cystoscopy is not well understood. Our objective was to determine if BLC improves recurrence detection in patients with nonmuscle-invasive bladder cancer (NMIBC) undergoing BCG. MATERIALS AND METHODS Using the prospective multi-institutional Cysview® Registry (2014-2019), patients with NMIBC who received BCG within 1 year prior to BLC were identified. Primary outcomes were recurrences and whether lesions were detected on white light cystoscopy (WLC), BLC or both. We calculated the percentage of cystoscopies with recurrences that were missed with WLC alone. The cystoscopy-level BLC false-positive rate was the proportion of cystoscopies with biopsies only due to BLC suspicious lesions without recurrence. RESULTS Of 1,703 BLCs, 282 cystoscopies were in the analytic cohort. The overall recurrence rate was 45.0% (127). With only WLC, 13% (16/127) of recurrences would have been missed as 5.7% (16/282) of cystoscopies performed had a recurrence only identified with BLC. Among 16 patients with recurrence missed with WLC, 88% (14) had carcinoma in situ. The cystoscopy-level BLC false-positive rate was 5% (15). CONCLUSIONS BLC helped detect recurrences after recent BCG that would have been missed with WLC alone. Providers should consider BLC for high-risk patients undergoing BCG and should discuss the risk of false-positives with these patients. As clinical trials of novel therapies for BCG-unresponsive disease increase and there are no clear guidelines on BLC use for post-treatment cystoscopies, it is important to consider how variable BLC use could affect enrollment in and comparisons of these studies.

Purpose Low-grade intermediate-risk nonmuscle-invasive bladder cancer (LG IR NMIBC) is a recurrent disease, thus requiring repeated transurethral resection of bladder tumor under general anesthesia. We evaluated the efficacy and safety of UGN-102, a mitomycin-containing reverse thermal gel, as a primary chemoablative therapeutic alternative to transurethral resection of bladder tumor for patients with LG IR NMIBC. Materials and methods This prospective, phase 2b, open-label, single-arm trial recruited patients with biopsy-proven LG IR NMIBC to receive 6 once-weekly instillations of UGN-102. The primary end point was complete response (CR) rate, defined as the proportion of patients with negative endoscopic examination, negative cytology and negative for-cause biopsy 3 months after treatment initiation. Patients with CR were followed quarterly up to 12 months to assess durability of treatment effect. Safety and adverse events were monitored throughout the trial. Results A total of 63 patients (38 males and 25 females 33-96 years old) enrolled and received ≥1 instillation of UGN-102. Among the patients 41 (65%) achieved CR at 3 months, of whom 39 (95%), 30 (73%) and 25 (61%) remained disease-free at 6, 9 and 12 months after treatment initiation, respectively. A total of 13 patients had documented recurrences. The probability of durable response 9 months after CR (12 months after treatment initiation) was estimated to be 73% by Kaplan-Meier analysis. Common adverse events (incidence ≥10%) included dysuria, urinary frequency, hematuria, micturition urgency, urinary tract infection and fatigue. Conclusions Nonsurgical primary chemoablation of LG IR NMIBC using UGN-102 resulted in significant treatment response with sustained durability. UGN-102 may provide an alternative to repetitive surgery for patients with LG IR NMIBC.

Objective To describe a new technique for single incision robotic cystectomy and Studer-type ileal neobladder using the single-port (SP) da Vinci SP robotic platform. Methods In April 2021, a 71 year-old patient underwent a single incision robotic cystectomy and orthotopic Studer-type ileal neobladder using the single-port da Vinci SP robotic platform for cT2, cN0 urothelial carcinoma of the bladder. He was not a candidate for neoadjuvant cisplatin-based combination chemotherapy and declined participation in a clinical trial. Results Total operative time was 554 minutes and estimated blood loss was 250 cc. He was discharged on postoperative day six without developing any Clavien complications. He underwent adjuvant chemotherapy for node-positive disease and follow-up through June 2021 was notable for the absence of any significant complications or readmissions. We provide a comprehensive discussion of the required instrumentation, a description of the technique with illustrations, and discuss the advantages and disadvantages of this technology as it pertains to cystectomy and urinary diversion. Conclusion We make no claim regarding the superiority of this technique over others, only that it is technically feasible and that the approach holds promise.

The use of alvimopan at the time of cystectomy has been associated with improved perioperative outcomes. Naloxegol is a less costly alternative that has been used in some centers. This study aims to compare the perioperative outcomes of patients undergoing cystectomy with urinary diversion who receive the mu-opioid antagonist alvimopan versus naloxegol.This was a retrospective review that included all patients who underwent cystectomy with urinary diversion at our institution between 2007-2020. Comparisons were made between patients who received perioperative alvimopan, naloxegol and no mu-opioid antagonist (controls).In 715 patients who underwent cystectomy, 335 received a perioperative mu-opioid antagonist, of whom 57 received naloxegol. Control patients, compared to naloxegol and alvimopan patients, experienced a significantly (p0.05) delayed return of bowel function (4.3 vs. 2.5 vs. 3.0 days) and longer hospital length of stay (7.9 vs. 7.5 vs. 6.5 days), respectively. The incidence of nasogastric tube use (14.2% vs. 12.5% vs. 6.5%) and postoperative ileus (21.6% vs. 21.1% vs. 13.3%) was also most common in the control group compared to the naloxegol and alvimopan cohorts, respectively. A multivariable analysis revealed that when comparing naloxegol and alvimopan, there was no difference in return of bowel function (OR 0.88, p = 0.17), incidence of postoperative ileus (OR 1.60, p = 0.44), or hospital readmission (OR 1.22, p = 0.63).Naloxegol expedites the return of bowel function to the same degree as alvimopan in cystectomy patients. Given the lower cost of naloxegol, this agent may be a preferable alternative to alvimopan.

To assess longitudinal prescribing patterns for patients undergoing urologic surgery in the nearly 2-year time frame before and after implementation of an evidence-based opioid prescribing guideline to accurately characterize the impact on postoperative departmental practices.Historical prescribing data for adults who underwent 21 urologic procedures at 3 academic institutions were used to derive a 4-tiered guideline for postoperative opioid prescribing. The guideline was implemented on January 16, 2018, and prescribing patterns including quantity of opioids prescribed (in oral morphine equivalents [OMEs]) and refill rates were compared for opioid-naïve patients undergoing urologic surgery before (January 1, 2016, through January 15, 2018; N=10,649) and after (January 16, 2018, through September 30, 2019; N=9422) guideline implementation. Univariate analysis was performed using Wilcoxon rank sum and χThe median quantity of opioids decreased from 150 OMEs (interquartile range, 0-225) before guideline implementation to 0 OMEs (interquartile range, 0-90) after guideline implementation (P.001). Median OMEs decreased significantly in each tier and each of 21 individual procedures. Overall guideline adherence was 90.7% (n=8547). Despite this decrease in OMEs prescribed, post-guideline implementation patients obtained fewer refills than the pre-guideline implementation group (614 [6.5%] vs 999 [9.4%]; P.001).In a multi-institutional follow-up prospective study of adult urologic surgery-specific evidence-based guidelines for postoperative prescribing, we demonstrate sustained reduction in OMEs prescribed secondary to guideline implementation and adherence by our providers.

The transversus abdominis plane (TAP) block has been effective in providing adequate pain control, limiting opioid use, and improving perioperative outcomes in patients undergoing major abdominal surgeries. Little is known regarding the efficacy of preoperative (pre-incisional) versus postoperative TAP block in patients who undergo cystectomy. This is a retrospective study that reviewed all patients who underwent cystectomy between January 2011 and January 2020 at a single institution. Patients were stratified into three cohorts: preoperative TAP block, postoperative TAP block, no TAP block. A multivariable linear regression model was constructed that assessed factors associated with total morphine milligram equivalents (MME) per hospital stay. In 463 patients, baseline characteristics were similar. There were 66(14.3%) patients who received a perioperative TAP block, 16 (24.2%) of whom received a preoperative TAP block. There were no significant differences in baseline factors. A TAP block was associated with lower MME used per day (41.8 mg vs 53.1 mg, p = 0.009) and per hospital stay (232 mg vs 320.5 mg, p = 0.001). The median MME per hospital stay and per day was lowest in the preoperative TAP cohort (194.0 mg, p = 0.011 and 38.0 mg, p = 0.042, respectively). On multivariable analysis of a subset of patients who received a TAP block, there was no significant difference in MME use in patients who received a preoperative vs postoperative TAP block (− 84.8, p = 0.339). The use of TAP blocks was associated with lower MME use in the entire population; however, there was no difference in MME use when comparing preoperative and postoperative TAP blocks.

We developed evidence-based guidelines for postoperative opioid prescribing after urologic surgery and assessed changes in prescribing after implementation.Prescribing data for adults who underwent 21 urologic procedures were used to derive a four-tiered guideline for postoperative opioid prescribing. This was implemented on January 1, 2018, and prescribing patterns including quantity of opioids prescribed (oral morphine equivalents; OME) and refill rates were compared between patients undergoing surgery prior to (January-April, 2017; n equals 1732) and after (January-April, 2018; n equals1376) implementation.The median OME (IQR) prescribed was significantly lower for 2018 compared with 2017 [100 (0; 175) versus 150 (60; 225); p .0001]. The median prescribed OME decreased in 14/21 procedures (67%). The refill rates did not significantly change. Guideline adherence rates after implementation, based on individual procedures, ranged from 33 to 95%.Fewer opioids were prescribed after implementing a prescribing guideline. Additional study is required to assess patient opioid utilization.

We compared the effect of standard office-based consultation (OC) and phone correspondences (PC) on dietary 24-h urinary parameters. The medical record of all patients treated between January and April 2019 was reviewed. Only patients who had at least two consecutive 24-h urine collections were included. Linear and logistic regressions were used to investigate the difference between the changes in urinary parameters after OC and PC. Forty-three patients underwent 135 OC and 34 PC. Twenty-one received OC and PC, and 22 had only OC. Gender, age, the distance to stone clinic, the number of previous stone episodes, and baseline urinary parameters were similar between the groups. Patients who had both OC and PC had a longer follow-up time (51.7 vs 18.5 months, p

Objective To assess whether the beneficial perioperative effects of alvimopan differ with surgical approach for patients who undergo open radical cystectomy (ORC) vs robot-assisted radical cystectomy (RARC). Methods This retrospective study reviewed all patients who underwent cystectomy with urinary diversion at our institution between January 1, 2007, and January 1, 2018. Data were collected on demographic characteristics, comorbidities, surgical approach, alvimopan therapy, hospital length of stay (LOS), days until return of bowel function (ROBF), and complications. Outcomes and interactions were evaluated through regression analysis. Results Among 573 patients, 236 (41.2%) underwent RARC, 337 (58.8%) underwent ORC, and 205 (35.8%) received alvimopan. Comparison of 4 cohorts (ORC with alvimopan, ORC without alvimopan, RARC with alvimopan, and RARC without alvimopan) showed that patients who underwent ORC without alvimopan had the highest rate of postoperative ileus (25.6%, P = .02), longest median hospital LOS (7 days, P Conclusion We observed a diminished beneficial effect of alvimopan among patients undergoing RARC and a statistically significant benefit of alvimopan among patients undergoing ORC. The implications of these findings may permit more selective medication use for patients who would benefit the most from this drug.

Multiparametric magnetic resonance imaging with informed targeted biopsies has changed the paradigm of prostate cancer diagnosis. Randomized studies have demonstrated a diagnostic benefit of clinical significance for targeted biopsy compared to standard systematic biopsies. We evaluated whether multiparametric magnetic resonance imaging informed targeted biopsy has superior diagnosis rates of any, clinically significant, high grade and clinically insignificant prostate cancer compared to systematic biopsy in biopsy naïve men.Data were searched in Medline®, Embase®, Web of Science and Evidence-Based Medicine Reviews-Cochrane Database of Systematic Reviews from database inception until 2019. Studies were selected by 2 authors independently, with disagreements resolved by consensus with a third author. Overall 1,951 unique references were identified and 100 manuscripts underwent full-text review. Data were pooled using random effects models. The meta-analysis is reported according to the PRISMA statement and the study protocol is registered with PROSPERO (CRD42019128468).Overall 29 studies (13,845 patients) were analyzed. Compared to systematic biopsy, use of multiparametric magnetic resonance imaging informed targeted biopsy was associated with a 15% higher rate of any prostate cancer diagnosis (95% CI 10-20, p0.00001). This relationship was not affected by the study methodology (p=0.11). Diagnoses of clinically significant and high grade prostate cancer were more common in the multiparametric magnetic resonance imaging informed targeted biopsy group (risk difference 11%, 95% CI 0-20, p=0.05 and 2%, 95% CI 1-4, p=0.005, respectively) while there was no difference in diagnosis of clinically insignificant prostate cancer (risk difference 0, 95% CI -3 to 3, p=0.96). Notably, the exclusion of systematic biopsy in the multiparametric magnetic resonance imaging informed targeted biopsy arm significantly modified the association between a multiparametric magnetic resonance imaging strategy and lower rates of clinically insignificant prostate cancer diagnosis (p=0.01) without affecting the diagnosis rates of clinically significant or high grade prostate cancer.Compared to systematic biopsy a multiparametric magnetic resonance imaging informed targeted biopsy strategy results in a significantly higher diagnosis rate of any, clinically significant and high grade prostate cancer. Excluding systematic biopsy from multiparametric magnetic resonance imaging informed targeted biopsy was associated with decreased rates of clinically insignificant prostate cancer diagnosis without affecting diagnosis of clinically significant or high grade prostate cancer.

To evaluate whether a restaging transurethral resection of bladder tumor (TURBT) is necessary in high-risk nonmuscle invasive bladder cancer (NMIBC) if the initial TURBT was performed using blue light (BL) technology.Using the multi-institutional Cysview registry between 2014 and 2021, all consecutive adult patients with known NMIBC (Ta and T1 disease) who underwent TURBT followed by a restaging TURBT within 8 weeks were reviewed. Patients were stratified according to their initial TURBT, BL vs. white light (WL), and compared to determine rates of residual disease and upstaging. Univariate analysis was performed using Mann-Whitney U and chi-square tests, with P0.05 considered significant.Overall, 115 patients had TURBT for NMIBC followed by a restaging TURBT within 8 weeks and were included in the analysis. Patients who underwent BL compared to WL for their initial TURBT had higher rates of benign pathology on restaging TURBT, although this was not statistically significant (47% vs. 30%; P = 0.08). Of patients with residual tumors on restaging TURBT, there were no differences in rates of Ta (22% vs. 26.5%; P = 0.62), T1 (22% vs. 26.5%; P = 0.62), or CIS (5.5% vs. 13%; P = 0.49) when the initial TURBT was done using BL compared to WL. Rates of upstaging to muscle invasive disease were also not different when initial TURBT was performed using BL compared to WL (3% vs. 4%; P = 0.78).TURBT using BL does not reduce rates of residual disease or risk of upstaging on restaging TURBT in Ta or T1 disease. Thus, a restaging TURBT is still necessary even if initial TURBT was performed using BL.

INTRODUCTION AND OBJECTIVE:Many men who undergo cystectomy have previously been diagnosed and treated for prostate cancer. This study describes the effect of prior prostate cancer treatment on peri...

Objectives To evaluate the role of blue-light cystoscopy (BLC) in detecting invasive tumours that were not visible on white-light cystoscopy (WLC). Patients and methods Using the multi-institutional Cysview registry database, patients who had at least one white-light negative (WL-)/blue-light positive (BL+) lesion with invasive pathology (≥T1) as highest stage tumour were identified. All WL-/BL+ lesions and all invasive tumours in the database were used as denominators. Relevant baseline and outcome data were collected. Results Of the 3514 lesions (1257 unique patients), 818 (23.2%) lesions were WL-/BL+, of those, 55 (7%) lesions were invasive (48 T1, seven T2; 47 unique patients) including 28/55 (51%) de novo invasive lesions (26 unique patients). In all, 21/47 (45%) patients had WL-/BL+ concommitant carcinoma in situ and/or another T1 lesions. Of 22 patients with a WL-/BL+ lesion who underwent radical cystectomy (RC), high-risk pathological features leading to RC was only visible on BLC in 18 (82%) patients. At time of RC, 11/22 (50%) patients had pathological upstaging including four (18%) with node-positive disease. Conclusions A considerable proportion of invasive lesions are only detectable by BLC and the rate of pathological upstaging is significant. Our present findings suggest an additional benefit of BLC in the detection of invasive bladder tumours that has implications for treatment approach.

Objective To describe postoperative opioid prescribing practices in a large cohort of patients undergoing urological surgery. Patients and Methods We identified 11,829 patients who underwent 21 urological surgical procedures at 3 associated facilities from January 1, 2015, through December 31, 2016. After converting opioids to oral morphine equivalents (OMEs), prescribing patterns were compared within and across procedures. Subgroup analysis for opioid-naive patients (those without a history of long-term opioid use) was performed. Statistical analysis was utilized to evaluate variations based on demographic and perioperative/postoperative variables. Results Of the 11,829 patients, 9229 (78.0%) were prescribed an opioid at discharge, and the median (interquartile range [IQR]) OME prescribed was 188 (150-225). The remaining 9253 patients (78.2%) were considered opioid naive. Striking variation in prescribing patterns was observed within and across surgical procedures. For instance, IQR ranges of 150 or greater were observed for open cystectomy (median, 300; IQR, 210-375], open radical nephrectomy (median, 300; IQR, 225-375), retroperitoneal node dissection (median, 300; IQR, 225-375), hand-assisted laparoscopic nephrectomy (median, 225; IQR, 150-300), and penile prosthesis (median, 225; IQR, 150-315). On multivariate analysis, younger age, cancer diagnosis, and inpatient hospitalization were associated with higher likelihood of receiving a highest-quartile OME prescription for opioid naive patients. Thirty-day refill rates varied from 1.6% to 25.9%. Interestingly, refill rates were higher in patients receiving more opioids at discharge. Conclusion The United States is facing an opioid epidemic, and physicians must take action. In this study, we found considerable variation in opioid prescribing patterns within and across surgical procedures. These data provide support for the development of standardized opioid prescribing guidelines for postoperative analgesia.

Introduction The International Classification of Diseases-10-Procedure Coding System (ICD-10-PCS) is markedly more complex than the preceding ICD-9 system, which has increased the difficulty of identifying radical cystectomy (RC) in administrative datasets. Given the absence of a consensus code definition for RC, we sought to develop and internally validate a list of ICD-10-PCS codes for RC. Materials and methods All RCs performed from January 2019 to December 2020 were identified from our prospectively maintained registries and split into training (2019) and validation (2020) cohorts. A list of candidate ICD-10-PCS codes to identify RC were compiled using an online ICD-9 to ICD-10 converter. Codes were used to identify RCs from hospital billing data and referenced against registry cases in the training cohort; when discrepancies were found, the working ICD-10 code definition was iteratively revised. Accuracy of the consensus code list was verified in the validation cohort. Results We identified 459 RCs over the study period, including 225 in 2019 and 234 in 2020. In the training cohort, our codes identified 241 procedures, including 222 of 225 (99%) RCs performed for bladder cancer. Misidentified cases included 15 (6.2%) RCs for benign disease or nonurologic cancers and 4 (1.7%) non-RC cases. In the validation cohort we identified 239 cases, including 227 of 234 (97%) RCs for bladder cancer and 12 (5%) RCs for benign disease or nonurologic cancers. Conclusion Given high fidelity to actual procedures performed, this list of ICD-10-PCS codes may be useful for researchers seeking to identify RC within administrative datasets.

INTRODUCTION Prolonged operative times have been associated with an increased risk in complications in other major abdominal surgeries. This study tests the hypothesis that longer operative times will be associated with an increased risk in perioperative complications after radical cystectomy (RC).Adult patients who underwent RC from January 1, 2012, through December 31, 2016, were identified from the National Surgical Quality Improvement Program (NSQIP) database. A natural log transformation was used to determine cutoff points for operative times at 33rd, 67th, and 90th percentiles: 272, 371, and 479 minutes, respectively. Cohorts were A (≤ 272 min), B (273-371 min), C (372-479 min), and D (479 min). Multivariable logistic regression analysis was performed to identify associations between operative time and perioperative complications.Among 5,610 patients, the distribution across cohorts was A, 1,993 patients; B, 1,818; C, 1,171; and D, 628. Cohort D had a higher incidence of pulmonary embolism (PE), deep vein thrombosis (DVT), urinary tract infection (UTI), sepsis, 30-day readmission, and blood transfusion rate and had a longer median hospital length of stay. Multivariable analysis showed that operative time (per 60 min) was associated with increased risk of DVT (OR 1.10, p = .04), PE (OR 1.15, p = .01), UTI (OR 1.08, p = .004), readmission (OR 1.04, p = .03), and blood transfusion (OR 1.23, p.001).Longer operative times during RC are associated with a higher rate of perioperative complications. These findings may be confounded by disease stage, surgeon experience, variations in perioperative management protocols, or a combination of the above.

The transversus abdominis plane (TAP) block has been effective in providing adequate pain control, limiting opioid use, and improving perioperative outcomes in patients undergoing major abdominal surgeries. Little is known regarding the efficacy of preoperative (pre-incisional) versus postoperative TAP block in patients who undergo cystectomy.This is a retrospective study that reviewed all patients who underwent cystectomy between January 2011 and January 2020 at a single institution. Patients were stratified into three cohorts: preoperative TAP block, postoperative TAP block, no TAP block. A multivariable linear regression model was constructed that assessed factors associated with total morphine milligram equivalents (MME) per hospital stay.In 463 patients, baseline characteristics were similar. There were 66(14.3%) patients who received a perioperative TAP block, 16 (24.2%) of whom received a preoperative TAP block. There were no significant differences in baseline factors. A TAP block was associated with lower MME used per day (41.8 mg vs 53.1 mg, p = 0.009) and per hospital stay (232 mg vs 320.5 mg, p = 0.001). The median MME per hospital stay and per day was lowest in the preoperative TAP cohort (194.0 mg, p = 0.011 and 38.0 mg, p = 0.042, respectively). On multivariable analysis of a subset of patients who received a TAP block, there was no significant difference in MME use in patients who received a preoperative vs postoperative TAP block (- 84.8, p = 0.339).The use of TAP blocks was associated with lower MME use in the entire population; however, there was no difference in MME use when comparing preoperative and postoperative TAP blocks.

Objectives To test the hypothesis that lymph node yield will vary by pathology assistant (PA) in patients undergoing radical cystectomy (RC) with pelvic lymph node dissection (PLND). Methods This is a single-institution retrospective review that included patients who underwent an RC with PLND for bladder cancer from January 1, 2007, to January 1, 2018. Predicted mean lymph node counts were generated using multivariable regression analysis. Results In a total of 430 patients who underwent RC with PLND, the median lymph node count (interquartile range) was 15.0 (11.0-21.0). The frequency of the limits of lymphadenectomy was as follows: external iliac, internal iliac, and obturator (true pelvis) (33.3%); true pelvis plus common iliac to the level of the aortic bifurcation (47.9%); and inferior mesenteric artery (18.8%). On descriptive analysis, there were differences in lymph node yield when evaluating the following variables: level of dissection, clinical stage, neoadjuvant chemotherapy, surgical approach, surgeon, pathologist, and PA (P < .05). On multivariable analysis, adjusted lymph node counts varied between surgeons, pathologists, clinical stage, and level of dissection but not by PA (P = .18). Conclusions Lymph node yield after RC varies on several known levels, including surgeon, extent of lymphadenectomy, clinical stage, and pathologist. This study found no significant variation in lymph node yield according to PA.

Renal cell carcinoma (RCC) is a malignancy that has been found to be responsive to various immune therapies and immunomodulation. Historic agents such as interleukin-2 and interferon alfa demonstrated some benefit in select patients with advanced disease; however, their use has become limited due to the introduction of targeted novel immunomodulators, such as the checkpoint inhibitors. This chapter reviews the historical development and indications of immune therapies for advanced RCC. Early agents such as interleukin and interferon will be discussed, as well as the newer contemporary checkpoint inhibitors, which are becoming first-line therapies for this patient population.

To assess the trends of neoadjuvant chemotherapy (NAC) use since its introduction in our practice pathway in patients with cT2 + bladder cancer over a 20-year period.This is a retrospective review of patients with cT2 + bladder cancer who underwent RC between 01/01/1998 and 01/01/2018 that aimed to evaluate the trends of NAC use and associated after implementation of a multidisciplinary treatment pathway. Cohorts were stratified into eras: pre-NAC (1998-2007) to NAC eras (2008-2018). Univariate analysis was conducted using Chi-squared test and Kaplan-Meier estimates were used to evaluate survival.In 904 total patients who underwent RC, there were 493 with cT2 + UCC disease. The rate of NAC peaked at 84.2% in the most recent year of analysis in all patients and was 100% in cT2 + patients eligible for NAC. There was an increased rate of complete response (downstage to pT0) from 8.7% to 15.8% (p = 0.018) between the two eras. Unadjusted survival analysis revealed improved overall survival (OS) between eras with 5-year OS 53.2% vs. 42.7% and 10-year OS 42.7% vs. 26.4% in the NAC vs. pre-NAC cohorts, respectively (p = 0.016).In this review of 20 years of experience, we report a dramatic rise in the use of NAC after adoption of a multidisciplinary pathway that is associated with expected survival benefits.

Objectives To compare ureteroenteric stricture rates after radical cystectomy in patients who undergo an intracorporeal urinary diversion versus other surgical approaches. Methods We retrospectively reviewed health records of all patients who underwent cystectomy with urinary diversion at Mayo Clinic Hospital (Phoenix, AZ, USA) from 1 January 2007 through 1 January 2018. Ureteroenteric stricture was identified by surveillance imaging. Patients were stratified by surgical approach: open radical cystectomy, robot-assisted radical cystectomy with extracorporeal urinary diversion and robot-assisted radical cystectomy-intracorporeal urinary diversion. A Cox proportional hazards model was fitted that included independent predictors of stricture development. Results Of the 573 cystectomies assessed, 236 (41.2%) were carried out robotically. In the robot-assisted radical cystectomy cohort, 39 patients (16.5%) underwent intracorporeal urinary diversion. The median follow-up period was 55, 70 and 71 months for the open radical cystectomy, robot-assisted radical cystectomy-extracorporeal urinary diversion and robot-assisted radical cystectomy-intracorporeal urinary diversion groups, respectively. Subgroup stricture rates were as follows: open radical cystectomy, 8.0%; robot-assisted radical cystectomy-extracorporeal urinary diversion, 9.6%; and robot-assisted radical cystectomy-intracorporeal urinary diversion, 2.6% (P = 0.33). The median time to stricture was 5 months (interquartile range 3.3-11.5 months). In the bivariable analysis, factors that were associated with the development of ureteroenteric stricture were postoperative urinary leak (hazard ratio 3.177, 95% confidence interval 1.129-8.935; P = 0.03) and body mass index (hazard ratio 1.078, 95% confidence interval 1.027-1.132; P = 0.002). On multivariable logistic regression analysis, intracorporeal urinary diversion approach was not associated with the development of ureteroenteric stricture (hazard ratio 0.272, 95% confidence interval 0.036-2.066; P = 0.21). Conclusions Ureteroenteric stricture is a complication that typically occurs within the first postoperative year. Although our results did not support major differences in outcomes between intracorporeal urinary diversion and extracorporeal urinary diversion, the small sample size did not exclude the possibility of a type 2 statistical error.

Introduction:Low grade, intermediate risk non-muscle invasive bladder cancer (LG IR-NMIBC) is notable for a high rate of disease recurrence yet low risk of disease progression. Patients with LG IR-...

We compared the effect of standard office-based consultation (OC) and phone correspondences (PC) on dietary 24-h urinary parameters.The medical record of all patients treated between January and April 2019 was reviewed. Only patients who had at least two consecutive 24-h urine collections were included. Linear and logistic regressions were used to investigate the difference between the changes in urinary parameters after OC and PC.Forty-three patients underwent 135 OC and 34 PC. Twenty-one received OC and PC, and 22 had only OC. Gender, age, the distance to stone clinic, the number of previous stone episodes, and baseline urinary parameters were similar between the groups. Patients who had both OC and PC had a longer follow-up time (51.7 vs 18.5 months, p 0.0001) as well as more consults (Median 5.4 vs 2.5, p 0.0001). Six (27%) patients who had only OC, and eight (38%) patients who had both OC and PC, experienced stone recurrence during the study period (p = 0.52). Following PC, there was a greater improvement in urine volume in comparison to OC (0.27 l/day vs -0.06 l/day, p = 0.034), but there was no difference in the absolute values after the consults between the groups.In established stone-clinic patients, PC was associated with a better adherence with follow-up. The 24-h urine results were similar between PC and OC. PC may be an effective alternative for urinary stone management.

Purpose: We sought to determine whether bladder neck size is associated with incontinence scores after robot-assisted laparoscopic radical prostatectomy.Materials and Methods: Consecutive eligible patients undergoing robot-assisted laparoscopic radical prostatectomy between July 19 and December 28, 2016 were enrolled in a prospective, longitudinal, observational cohort study. The primary outcome was patient reported urinary incontinence on the EPIC (Expanded Prostate Cancer Index Composite) scale 6 and 12 weeks postoperatively. The relationship between the EPIC score of urinary incontinence and bladder neck size was evaluated by multiple regression. Predicted EPIC scores for incontinence were displayed graphically after using restricted cubic splines to model bladder neck size.Results: A total of 107 patients were enrolled. The response rate was 98% and 87% at 6 and 12 weeks, respectively. Bladder neck size was not significantly associated with incontinence scores at 6 and 12 weeks. Comparing the 90th per...

Using contemporary population based epidemiological data we measured the relationship between the preoperative serum albumin level and hospital length of stay after cystectomy and urinary diversion.Data were acquired from the 2014 to 2015 NSQIPPreoperative serum albumin was independently associated with hospital length of stay after cystectomy. Increasing preoperative serum albumin below a threshold of 4 gm/dl was associated with decreased length of stay (HR 1.05, 95% CI 1.01-1.09, p0.004). Other significant predictors associated with longer length of stay included patient age (HR 0.84, 95% CI 0.77-0.91, p0.001), nonCaucasian race (HR 0.81, 95% CI 0.70-0.93, p = 0.003) and American College of Surgeons classification 4 (class 4 vs 3 HR 0.78, 95% CI 0.62-0.97, p = 0.008). Minimally invasive cystectomy was associated with a shorter length of stay (HR 1.23, 95% CI 1.07-1.42, p = 0.004).This study provides evidence that nutritional optimization prior to cystectomy shortens the length of stay after surgery but there are diminishing returns above a threshold of 4 gm/dl.

Background Relatively little is known about the relationship between race/ethnicity and patient-reported outcomes after contemporary treatments for localized prostate cancer. Objective To test the hypothesis that treatment-related changes in urinary, bowel, sexual, and hormonal function vary by race/ethnicity. Design, setting, and participants The Comparative Effectiveness Analysis of Surgery and Radiation (CEASAR) study is a prospective, population-based, observational study that enrolled 3708 men diagnosed with localized prostate cancer in 2011–2012. Outcome measurements and statistical analysis Patient-reported disease-specific function was measured using the 26-item Expanded Prostate Index Composite (EPIC) at baseline and 6 and 12 mo after enrollment. Mean treatment differences in function were compared by race using risk-adjusted generalized estimating equations. Results and limitations While all race/ethnic groups reported considerable declines in scores for urinary incontinence after radical prostatectomy (RP) when compared to active surveillance, African-American men reported a greater difference than white men did (adjusted difference-in-differences 8.4 points, 95% confidence interval 2.0–14.8; p =0.01). No difference in bother scores was noted and the overall proportion of explained variation attributable to race/ethnicity was relatively small in comparison to primary treatment and baseline function. No clinically significant racial variation was noted for the sexual, bowel, irritative voiding, or hormone domains. Limitations include the lack of well-established thresholds for clinical significance using the EPIC instrument. Conclusion While these data demonstrate that incontinence at 1 yr after RP may be worse for African-American compared to white men, the difference appears to be modest overall. Treatment selection and baseline function explain a much greater proportion of the variation in function after treatment. Patient summary We observed that the effect of treatment for prostate cancer on patient-reported function did not vary dramatically by race/ethnicity. Compared to white men, African-American men experienced a somewhat more pronounced decline in urinary continence after radical prostatectomy, but the corresponding changes in bother scores were not significantly different between the two groups.

In this review, we highlight the use of clinical registries for quality improvement and research purposes in urology. We focus on national and regional clinical database registries, such as the National Surgical Quality Improvement Programme, the Cancer of the Prostate Strategic Urologic Research Endeavor, the Michigan Urological Surgery Improvement collaborative and the American Urological Association Quality Registry programme.It is widely known that claims-based and institutional databases are limited in their capacity to provide granular, real-time data for quality improvement purposes. As a result, clinical registries have emerged as an attractive alternative given their ability to capture large amounts of data across networks of health records. Another added benefit of Federally Qualified Clinical Data Registries (QCDRs) is the ability to meet emerging Medicare quality reporting standards, such as Physician Quality Reporting System and Meaningful Use. Despite the enthusiasm for QCDRs in the field of urology, however, myriad challenges remain in their implementation and widespread adoption including integration of existing health-information technology infrastructure, the accurate measurement of quality measures and the availability of clinically relevant quality measures in subspecialty practices.Quality measurement and improvement have become important aspects of modern clinical practice. Advances in health information technology have ushered in new tools, such as clinical registries, which simultaneously improve the quality of scientific research and clinical care while assisting eligible professionals in meeting federally mandated reporting requirements.

One in 5 patients who undergo surgical resection for clinically localized renal cell carcinoma (RCC) develop local and/or distant recurrences which, when detected early, may be amenable to salvage local and systemic therapies. When considering that approximately half of these recurrences will occur during the first 2 years, a clear rationale exists for optimizing surveillance strategies after surgery. Although there is a notable dearth of high-quality data on this subject, clinical principles can guide clinicians as they attempt to balance the burden of surveillance strategies with potential clinical benefit. The objective of this review is to summarize the evidence regarding optimal surveillance protocols after surgery for RCC. We provide an overview of the rationale supporting surveillance after surgery, a summary of the American Urological Association and NCCN guidelines, reasons against routine long-term surveillance, surveillance costs, and ancillary issues, such as the utility of bone scan, PET/CT scan, and surveillance after thermoablation.

PURPOSE OF REVIEW In this review, we summarize the core principles in the management of nonmuscle invasive bladder cancer (NMIBC) with an emphasis on new developments that have emerged over the last year. RECENT FINDINGS NMIBC has a propensity to recur and progress. Risk stratification has facilitated appropriate patient selection for treatment but improved tools, including biomarkers, are still needed. Enhanced cystoscopy with photodynamic imaging and narrow band imaging show promise for diagnosis, risk stratification, and disease monitoring and has been formally recommended this year by the American Urological Association. Attempts at better treatment, especially in refractory high-risk cases, include the addition of intravesical hyperthermia, combination and sequential therapy with existing agents, and the use of novel agents such as mycobacterial cell wall extract. New data are emerging regarding the potential role of early cystectomy in bacillus Calmette-Guerin-refractory NMIBC patients. SUMMARY NMIBC represents an assortment of disease states and continues to pose management challenges. Continued research is needed to bolster the evidence needed for patients and providers to make data-driven treatment decisions.

Objective To evaluate the influence of psychosocial factors such as prostate cancer (PCa) anxiety, social support, participation in medical decision-making (PDM), and educational level on patient decisions to discontinue PCa active surveillance (AS) in the absence of disease progression. Methods The Comparative Effectiveness Analysis of Surgery and Radiation study is a prospective, population-based cohort study of men with localized PCa diagnosed in 2011-2012. PCa anxiety, social support, PDM, educational level, and patient reasons for discontinuing AS were assessed through patient surveys. A Cox proportional hazards model examined the relationship between psychosocial variables and time to discontinuation of AS. Results Of 531 patients on AS, 165 (30.9%) underwent treatment after median follow-up of 37 months. Whereas 69% of patients cited only medical reasons for discontinuing AS, 31% cited at least 1 personal reason, and 8% cited personal reasons only. Patients with some college education discontinued AS significantly earlier (hazard ratio: 2.0, 95% confidence interval: 1.2, 3.2) than patients with less education. PCa anxiety, social support, and PDM were not associated with seeking treatment. Conclusion We found that 31% of men who choose AS for PCa discontinue AS within 3 years. Eight percent of men who sought treatment did so in the absence of disease progression. Education, but not psychosocial factors, seems to influence definitive treatment-seeking. Future research is needed to understand how factors unrelated to disease severity influence treatment decisions among patients on AS to identify opportunities to improve adherence to AS.

The primary goal of modern prostate cancer treatment paradigms is to optimize the balance of predicted benefits associated with prostate cancer treatment against the predicted harms of therapy. However, given the limitations in the existing evidence as well as the significant tradeoffs posed by each treatment, there remain myriad challenges associated with individualized prostate cancer treatment decision-making. In this review, we summarize the existing comparative effectiveness evidence of treatments for localized prostate cancer with an emphasis on oncologic control. While we focus on the major treatment categories of radical prostatectomy, radiation therapy, and observation, we also provide a review of emerging therapies such as cryotherapy and high-intensity frequency ultrasound (HIFU).

Objectives Cystectomy with urinary diversion is associated with decreased long-term kidney function due to several factors. One factor that has been debated is the type of urinary diversion used: ileal conduit (IC) vs. neobladder (NB). We tested the hypothesis that long-term kidney function will not vary by type of urinary diversion. Methods and Materials We retrospectively identified all patients who underwent cystectomy with urinary diversion at our institution from January 1, 2007, to January 1, 2018. Data were collected on patient demographics, comorbid conditions, perioperative radiotherapy, and complications. Creatinine values were measured at several time points up to 120 months after surgery. Glomerular filtration rate (GFR) (ml/min per 1.73 m2) was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. A linear mixed model with inverse probability of treatment weighting (IPTW) was used to compare GFR between the IC and NB cohorts over time. Multiple sensitivity analyses were performed based on 2 different calculations of GFR (Chronic Kidney Disease Epidemiology Collaboration equation vs. Modification of Diet in Renal Disease), with and without excluding patients with preoperative GFR less than 40 ml/min per 1.73 m2. Results Among 563 patients who underwent cystectomy with urinary diversion, a NB was used for 72 (12.8%) individuals. Patients who had a NB were significantly younger, had a lower American Society of Anesthesiologists score, greater baseline GFR, better Eastern Cooperative Oncology Group performance status, lower median Charlson comorbidity index, and were less likely to have received preoperative abdominal radiation (all P Conclusions Among highly selected patients with an NB, deterioration of kidney function may potentially be lower over time than among IC patients. However, the statistical significance varied between analyses and we cautiously attribute these observed differences to patient selection.

Item does not contain fulltext CONTEXT: Currently, there is no standard of care for patients with non-muscle-invasive bladder cancer (NMIBC) who recur despite bacillus Calmette-Guerin (BCG) therapy. Although radical cystectomy is recommended, many patients decline to undergo or are ineligible to receive it. Multiple agents are being investigated for use in this patient population. OBJECTIVE: To systematically synthesize and describe the efficacy and safety of current and emerging treatments for NMIBC patients after treatment with BCG. EVIDENCE ACQUISITION: A systematic literature search of MEDLINE, Embase, and the Cochrane Controlled Register of Trials (period limited to January 2007-June 2019) was performed. Abstracts and presentations from major conference proceedings were also reviewed. Randomized controlled trials were assessed using the Cochrane risk of bias tool. Data for single-arm trials were pooled using a random-effect meta-analysis with the proportions approach. Trials were grouped based on the minimum number of prior BCG courses required before enrollment and further stratified based on the proportion of patients with carcinoma in situ (CIS). EVIDENCE SYNTHESIS: Thirty publications were identified with data from 23 trials for meta-analysis, of which 17 were single arm. Efficacy and safety outcomes varied widely across studies. Heterogeneity across trials was reduced in subgroup analyses. The pooled 12-mo response rates were 24% (95% confidence interval [CI]: 16-32%) for trials with two or more prior BCG courses and 36% (95% CI: 25-47%) for those with one or more prior BCG courses. In a subgroup analysis, inclusion of >/=50% of patients with CIS was associated with a lower response. CONCLUSIONS: The variability in efficacy and safety outcomes highlights the need for consistent endpoint reporting and patient population definitions. With promising emerging treatments currently in development, efficacious and safe therapeutic options are urgently needed for this difficult-to-treat patient population. PATIENT SUMMARY: We examined the efficacy and safety outcomes of treatments for non-muscle-invasive bladder cancer after bacillus Calmette-Guerin therapy. Outcomes varied across studies and patient populations, but emerging treatments currently in development show promising efficacy.

Mitomycin-C (MMC) and thiotepa are intravesical agents effective in reducing the recurrence of low-grade noninvasive bladder cancer when instilled perioperatively. No studies have compared these agents as a single-dose perioperative instillation. This study tests whether there is a difference in recurrence-free survival in patients with low-grade noninvasive bladder cancer who received intravesical MMC versus thiotepa.A retrospective review was performed of patients who underwent cystoscopic excision of a bladder mass identified as a small, low-grade, treatment-naïve, noninvasive, wild-type urothelial carcinoma of the bladder and who received either intravesical thiotepa (30 mg/15 cc) or MMC (40 mg/20 cc) between January 1, 2002, and January 1, 2016. Data were collected for demographic characteristics, comorbid conditions, operative information, surveillance, and recurrence. The primary outcome was disease-free survival. Cohorts were compared via the doubly robust estimation approach, which used logistic regression to model the probability of recurrence.Of 154 total patients, 84 received intravesical MMC; 70, thiotepa. No statistical differences were shown between groups for age, sex, race, body mass index, smoking status, or baseline comorbid conditions; mass size, tumor multifocality, or tumor grade; and unadjusted recurrence rates (MMC, 36.0%; thiotepa, 46.0%; p = .33) at similar median follow up (MMC, 20.4; thiotepa, 22.8 months; p = .46). The robust logistic regression analysis yielded no differences in recurrence rates between MMC and thiotepa (OR, 0.65 [95% CI, 0.33-1.31]; p = .23). No episodes of myelosuppression or frozen pelvis were identified.As single-dose perioperative agents, both thiotepa and MMC were associated with similar recurrence-free survival rates.

To compare the perioperative and oncologic outcomes associated with open radical nephrectomy with tumor thrombus (O-RNTT) vs robot assisted radical nephrectomy with tumor thrombus (RA-RNTT). Renal cell carcinoma with venous tumor thrombus has traditionally been managed through an open surgical approach. The robot assisted approach may offers improved perioperative outcomes compared to open, but there are few studies comparing these 2.We analyzed patients with renal cell carcinoma and inferior vena cava tumor thrombus between 1998 and 2018, comparing perioperative and oncologic outcomes of these patients with Level I and Level II thrombus. Cohorts were stratified by surgical approach: O-RNTT vs RA-RNTT. Univariate analysis was conducted using chi-squared test and t tests when appropriate. Kaplan-Meier estimates were used to evaluate survival.Twenty-seven patients were in the O-RNTT group, and 24 in the RA-RNTT group. Patients in the RA-RNTT group, compared to the O-RNTT group, demonstrated shorter length of stay (3 vs 7 nights, P = .03), lower estimate blood loss (450 vs 1800 mL, P.01), and lower transfusion rate (21% vs 82%, P.01). The RA-RNTT group had 26% fever complications compared to the open (17% vs 43%, P.01). There was no significant difference in estimated overall survival or recurrence-free survival between the O-RNTT and RA-RNTT groups.RA-RNTT produced a shorter length of stay, less transfusions, and a lower rate of complications with no significant difference in overall survival.

The management of malignant mesothelioma of the tunica vaginalis (MMTVT) is not clearly defined. Retroperitoneal lymph node dissection has been reported as a potential management option. Herein we present our experience with robot-assisted retroperitoneal lymph node dissection (RARPLND) in our series of patients with MMTVT.The Mayo Clinic cancer registry was queried from 1972-present for all patients who had a diagnosis of MMTVT. Six patients were identified, five of whom were treated with RPLND, where four underwent RARPLND.In five patients who underwent RPLND, the median age was 50 years (IQR 34-51). Four patients originally presented with right sided symptomatic hydroceles, while one presented with right sided chronic epididymitis. Orchiectomy (one simple, two inguinal radical) was performed in three patients prior to presentation. Preoperative cross-sectional imaging, including PET-CT scan in three patients, was negative for lymphadenopathy or metastasis. RARPLND was performed in 4/5 (80%) cases and concomitant hemiscrotectomy in 4/5 (80%) cases. Full bilateral template was performed in three patients and right modified template was performed in the remaining two. Median lymph node yield was 29 (IQR 22-32) and median blood loss was 275 cc (IQR 200-300). Positive retroperitoneal lymph nodes were found in 3/5 (60%) cases. All patients who underwent RARPLND were discharged home on postoperative day one. Mean follow up was 27 months (range 3-47). No patients recurred.Regardless of the approach, RPLND may provide a diagnostic benefit in patients who present with MMTVT, with the robotic approach affording a potentially expedited recovery.

INTRODUCTION AND OBJECTIVES:The United States faces an opioid epidemic, and surgeons must take action. However, a one-size fits all approach to opioid prescribing is sub-optimal. Here, we sought to...