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Cancer; Image analysis; Thoracic pathology Càncer; Anàlisi d'imatges; Patologia toràcica Cáncer; Análisis de imágenes; Patología torácica Non–small cell lung carcinoma is currently staged based on the size and involvement of other structures. Tumor size may be a surrogate measure of the total number of tumor cells. A recently revised reporting system for adenocarcinoma incorporates high-risk histologic patterns, which may have increased cellular density. Modern digital image analysis tools can be utilized to automate the quantification of cells. In this study, we tested the hypothesis that tumor cellularity can be used as a novel prognostic tool for lung cancer. Digital slides from The Cancer Genome Atlas lung adenocarcinoma (ADC) data set (n = 213) and lung squamous cell carcinoma (SCC) data set (n = 90) were obtained and analyzed using QuPath. The number of tumor cells was normalized with the surface area of the tumor to provide a measure of tumor cell density. Tumor cellularity was calculated by multiplying the size of the tumor with the cell density. Major histologic patterns and grade were compared with the tumor density of the lung ADC and lung SCC cases. The overall and progression-free survival were compared between groups of high and low tumor cellularity. High-grade histologic patterns in the ADC and SCC cases were associated with greater tumor densities compared with low-grade patterns. Cases with lower tumor cellularity had improved overall and progression-free survival compared with cases with higher cellularity. These results support tumor cellularity as a novel prognostic tool for non–small cell lung carcinoma that considers tumor stage and grade elements. Funding support is gratefully acknowledged from the Megan J. Davey Opportunity Fund used to support a workstation to facilitate the computational analysis in this study and travel costs to present an earlier version of this content at the United States & Canadian Academy of Pathology 111th Annual Meeting (2022).

Relative value units (RVUs) are the measure of value used in United States Medicare and Medicaid reimbursement. The Relative Update Committee (RUC) determines physician work RVU (wRVUs) based on operative time, technical skill and effort, mental effort and judgment, and stress. The primary aim of this study was to assess whether operative time is adequately accounted for in the wRVU system in pediatric urology.The American College of Surgeons National Surgical Quality Improvement Program Pediatric Participant User File (ACS-NSQIPP-PUF) was reviewed from 2012 to 2017. Most common single pediatric urology current procedural terminology (CPT) codes were included. The primary variable was wRVU per hour of operative time (wRVU/h). Linear regression analysis was used to assess the relative influence that operative time had on wRVU/h.25,432 cases were included in the final study population from 45 unique CPT codes. The median operative time was 79 min, and the median RVU/h was 12.2. Procedures with operative time less than 79 min had higher wRVU/h compared with procedures longer than 79 min (14.5 vs 10.5, p 0.001). Procedures with higher than average incidence of any complications had a lower wRVU/h (9.0 vs. 14.6 p 0.001). Linear regression analysis revealed that each additional hour of operative time was expected to decrease wRVU/h by 4.2 (-0.70 per 10 min, 95% CI: -0.71 to -0.69, p 0.001; RThis analysis of contemporary large pediatric population national-level data suggests that the wRVU system significantly favors shorter and less complex procedures in Pediatric Urology. Pediatric urologists performing longer and more complex procedures are not adequately compensated for the increase in complexity.Retrospective comparative study.

Access to necessary prenatal care is not guaranteed through Medicaid for some people with low income based on their immigration status. Although states have the option to extend emergency Medicaid coverage for prenatal care, many states have not expanded coverage.To evaluate whether the receipt of prenatal care services through the extension of emergency Medicaid coverage is associated with an increase in antidiabetic medication use among Latina patients with gestational diabetes.This cohort study used linked Medicaid claims and birth certificate data on live births to 4869 Latina patients from October 1, 2010, to December 31, 2019, with a difference-in-differences design to compare the rollout of prenatal care and services in Oregon in 2013 with a comparison state, South Carolina, that did not cover prenatal or postpartum care.Medicaid coverage of prenatal care.The main outcome was the receipt of antidiabetic agents. Secondary outcomes included hypertensive disorders, cesarean delivery, postpartum contraception, and a newborn morbidity composite outcome (large size for gestational age, neonatal intensive care unit admission, and preterm birth).The study sample included live births to 4869 Latina patients (mean [SD] age, 32.7 [5.5] years [range, 12-44 years]) enrolled in emergency Medicaid who were mainly aged 25 to 34 years (1499 of 2907 [51.6%]), multiparous (2626 of 2907 [90.3%]), and living in urban areas (2299 of 2907 [79.1%]). After Oregon's policy change to offer prenatal coverage to individuals receiving emergency Medicaid, there was a large and significant increase in the receipt of antidiabetic agents among all people with diabetes during pregnancy (gestational diabetes). Prior to the policy, only 0.3% of all Latina emergency Medicaid recipients with gestational diabetes (2 of 617) received any medication (oral agents or insulin) to manage their blood glucose level. After the policy change, 28.8% of all patients with gestational diabetes (295 of 1023) received medication to manage their blood glucose level, translating to a 27.9-percentage-point increase (95% CI, 24.5-31.2 percentage points) in the receipt of antidiabetic agents in the adjusted model. The policy was also associated with a 10.4-percentage-point (95% CI, 5.3-15.5 percentage points) increase in insulin use during pregnancy among all patients with gestational diabetes. We observed an increase in postpartum contraceptive use (21.2 percentage points; 95% CI, 14.9-27.5 percentage points), the majority of which was due to postpartum sterilization (increase of 16.1 percentage points; 95% CI, 10.4-21.8 percentage points). We did not observe a significant association with gestational hypertension, cesarean births, or newborn health.This retrospective cohort study suggests that expanded emergency Medicaid benefits that included prenatal care were associated with an increased use of antidiabetic medications and postpartum contraception during pregnancy.

To evaluate the patterns of financial transaction between industry and urologists in the first 5 years of reporting in the Open Payments Program (OPP) by comparing transactions over time, between academic and nonacademic urologists, and by provider characteristics among academic urologists.The Center for MedicareMedicaid Services OPP database was queried for General Payments to urologists from 2014-2018. Faculty at ACGME-accredited urology training programs were identified and characterized via publicly available websites. Industry transfers were analyzed by year, practice setting (academic vs nonacademic), provider characteristics, and AUA section. Payment nature and individual corporate contributions were also summarized.A total of 12,521 urologists - representing 75% of the urology workforce in any given year - received $168 million from industry over the study period. There was no significant trend in payments by year (P = .162). Urologists received a median of $1602 over the study period, though 14% received$10,000. Payment varied significantly by practice setting (P.001), with nonacademic urologists receiving more but smaller payments than academic urologists. Among academic urologists, gender (P.001), department chair status (P.001), fellowship training (P.001), and subspecialty (P.001) were significantly associated with amount of payment from industry. Annual payments from industry varied significantly by AUA section.Reporting of physician-industry transactions has not led to a sustained decline in transactions with urologists. Significant differences in industry interaction exist between academic and nonacademic urologists, and values transferred to academic urologists varied by gender, chair status, subspecialty, and AUA section.

Background The microscopic characteristics of vasal fluid at time of vasectomy reversal (VR) guide operative decision making and predict fertility outcomes. The proteomic profile of this vasal fluid has not been described or correlated with the microscopic fluid appearance. To characterize the vasal fluid proteome at time of VR and evaluate the variation of the vasal fluid proteome with respect to microscopic presence of sperm. Methods A prospective cohort study was conducted enrolling twenty-five men undergoing VR for infertility and/or pain at a University-affiliated hospital. Vasal fluid samples obtained at time of VR were grouped based on presence of sperm on light microscopy at time of VR. Proteomic profiles were generated using liquid chromatography/ tandem mass spectrometry, and MS/MS protein spectral counts compared between individuals and treatment groups, controlling for less than 5% protein false discovery rate (FDR). Proteins were matched with the human swissprot database using the Comet search engine, and categorized by Gene Ontology (GO) terms. Results There was large variability between the 46 vasal fluid samples collected, with 1,692 unique proteins detected. The three most abundant proteins were Lactotransferrin, Cysteine-rich secretory protein 1, A-kinase anchor protein 4. There was no correlation between the proteome and microscopic sperm presence. Prevalent GO terms included viral process, signal transduction, innate immune response, protein folding and spermatogenesis. Conclusions We describe the proteome and the most common proteins in vasal fluid at time of VR. Numerable sperm, testis and epididymis specific proteins were present even in the absence of sperm on microscopy. Further evaluation is needed to determine if a protein biomarker may better guide operative decision making and predict VR fertility outcomes.

Neoadjuvant chemotherapy is an important adjunct to cystectomy for managing muscle invasive bladder cancer. Using the National Cancer Database we investigated factors that predict failure to undergo surgery following multi-agent chemotherapy for nonmetastatic muscle invasive bladder cancer.We performed a cohort study in patients diagnosed with cT2-4aN0M0 urothelial cell carcinoma of the bladder between 2004 and 2013 who underwent multi-agent chemotherapy. We excluded those with surgery prior to chemotherapy, clinical T4b disease and those who received radiotherapy. Socioeconomic and clinical predictors, including time from diagnosis to treatment, were analyzed using logistic regression for the receipt of surgery after chemotherapy. Cox proportional hazards modeling was applied to perform time dependent analysis.Of the 4,640 patients who met our study inclusion and exclusion criteria 4,244 (91%) proceeded to surgery. Negative predictors of surgery included African American or Hispanic race (OR 0.58, p = 0.007 and 0.48, p = 0.002, respectively), increasing age (OR 0.44, p0.001) and greater time between diagnosis and chemotherapy initiation (fourth quartile greater than 59 days, OR 0.51, p0.001). African American race (HR 0.79, p0.001), Medicare (HR 0.86, p 0.001) and other government insurance (HR 0.73, p0.001) were associated with delayed chemotherapy.Increasing age, African American or Hispanic race and longer time to chemotherapy predicted failure to undergo surgery. Furthermore, African American race was associated with delayed chemotherapy. Chemotherapy was also delayed in patients on Medicare or other government insurance. Longer time to neoadjuvant chemotherapy is a modifiable risk factor that should be closely observed in multimodal cancer treatment.

The objectives of this study are to evaluate if robotic cystectomy demonstrates reduced complications, readmissions, and cost-to-patient compared to open approach 30-day post-operatively, and to identify predictors of complication, readmission, and cost-to-patient. This retrospective cohort study analyzed 249 patients who underwent open (n = 149) or robotic (n = 100) cystectomy from 2009 to 2015 at our institution. Outcomes included 30-day post-operative complication, readmission, and cost-to-patient charges. We used modified Clavien–Dindo/MSKCC classifications. Multivariable logistic and linear regression models were used to evaluate associations to outcomes and to build predictive models. Patient, clinical, and surgical characteristics differed by open and robotic groups, respectively, only for estimated blood loss (median: 600 versus 150 cc, p

Objective To provide pregnancy and live birth rates from a contemporary series of vasectomy reversals in men with female partners aged ≥35 years and to correlate the results with IVF. Setting Tertiary academic referral center. Design Retrospective comparative study of prospectively collected database. Patient(s) Two hundred forty-six men who underwent vasectomy reversal for fertility with female partner aged ≥35 years. Intervention(s) Vasovasostomy or vasoepididymostomy. Main Outcome Measure(s) Correlation of pregnancy and live birth rate of this cohort by age groups with most recently published pregnancy and live birth rate per IVF cycle. Result(s) One hundred thirty-six men who underwent vasectomy reversal between 2006 and 2014 met our inclusion criteria. Overall pregnancy and live birth rates were 35% and 30%, respectively. Subgroup analysis by female age groups (35–37, 38–40, >40 years) demonstrated pregnancy and live birth rates comparable to those per IVF cycle by age groups according to a recently published (2015) national report. Conclusion(s) Vasectomy reversal should be strongly considered in men with a partner aged ≤40 years. Additionally, vasectomy reversal can be considered in carefully selected patients even with a partner aged >40 years.

Physician work relative value units are determined based on operative time, technical skill, mental effort and stress. In theory, work relative value units should account for the operative time involved in a procedure, resulting in similar work relative value units per unit time for short and long procedures. We assessed whether operative time is adequately accounted for by the current work relative value units assignments.The American College of Surgeons National Surgical Quality Improvement Program database was reviewed from 2015 to 2017. The 50 most frequently coded urology CPT codes were included in the study. The primary variable was work relative value units per hour of operative time (work relative value units per hour). Linear regression analysis was used to assess the associations between work relative value units, operative time and the work relative value units per hour variable.A total of 105,931 cases were included in the study. Among the included urology CPTs the median work relative value units was 15.26, median operative time was 48 minutes and median work relative value units per hour was 11.2. CPTs with operative time less than 90 minutes had higher work relative value units per hour compared with longer procedures (12.2 vs 8.7, p0.001). Univariable analysis revealed that each additional hour of operative time was associated with a decrease in work relative value units per hour by 1.32 (-0.022 per minute, 95% CI -0.037 - -0.001, p0.001) and that work relative value units were not statistically associated with work relative value units per hour (-0.093, 95% CI -0.193 - 0.007, p=0.07).This analysis of large population, national level data suggests that the current work relative value units assignments do not proportionally compensate for longer operative times.

Relative value units (RVU) are the measure of value used in United States Medicare and Medicaid reimbursement. The Relative Update Committee (RUC) determine physician work RVU (wRVU) based on operative time, technical skill and effort, mental effort and judgement, and stress. In theory, wRVU should account for the complexity and operative time involved in a procedure.The primary aim of this study is to assess if operative time and complexity of hypospadias surgery is adequately accounted for by the current wRVU assignments.The American College of Surgeons National Surgical Quality Improvement Program Participant User File (ACS-NSQIP PUF) database was utilized from 2012 to 2017. Single stage hypospadias current procedural terminology (CPT) codes (including acceptable secondary CPT codes) were extracted. Using total wRVU and total operative time, the primary variable of wRVU per hour was calculated (wRVU/hr). Multivariable linear regression analysis was used to assess the relative influence that wRVU and operative time had on the wRVU/hr variable.9810 cases were included in the final study population divided into four categories: simple distal (eg. MAGPI, V-Flap), single stage distal, single stage mid, single stage proximal. On analysis of variance, there was statistically significant different wRVU/hr for the four different types of hypospadias repairs with simple distal having the highest mean wRVU/hr of 19.5 and the lowest being proximal hypospadias repairs at 13.2. Simple distal, distal and midshaft hypospadias had statistically significantly higher wRVU/hr compared to proximal hypospadias (16.2, 95% CI: 15.8-16.5 vs. 13.2, 95% CI 10.9-15.5; p0.001). Multivariable linear regression revealed that each additional hour of operative time was expected to decrease wRVU/hr by 10.5 (-10.5, 95% CI: -11.0 to -10.1, p 0.001); total work wRVU had a statistically significant independent association with wRVU/hr (0.6, 95%CI: 0.5-0.7, p0.001).This the first objective assessment of the current wRVU assignments with regards to one stage hypospadias repairs. More complex and longer hypospadias procedures are not adequately compensated by wRVU. Most notably, simple distal procedures are reimbursed at a mean of 19.5 wRVU/hr compared to 13.2 wRVU/hr for one stage proximal repairs.This analysis of national-level data suggests that the current wRVU assignments significantly favor shorter and simpler procedures in hypospadias surgery.

INTRODUCTION AND OBJECTIVES:MRI fusion biopsy (Fus-Bx) of the prostate improves the overall detection rate of clinically significant prostate cancer (CSPC) compared to standard template biopsy (Std...

INTRODUCTION AND OBJECTIVES:Management of small renal masses (SRMs) has changed over the past two decades with the diffusion of minimally invasive techniques and establishment of thermal ablation a...

OBJECTIVES To examine compliance and clinical outcomes after implementation of a zero antimicrobial prophylaxis protocol for outpatient cystoscopy in an academic centre. PATIENTS AND METHODS Medical records of all patients who underwent diagnostic cystoscopy in the year preceding and year following protocol implementation were evaluated for urinary tract infection (UTI) diagnosis within 30 days of cystoscopy. Variables compared between groups included age, sex, smoking history, benign prostatic hyperplasia (BPH) diagnosis, diabetes mellitus, immunosuppression, catheter use (indwelling, suprapubic, or intermittent), and previous lower urinary tract reconstruction (augmentation cystoplasty or neobladder). UTI was defined using the National Surgical Quality Improvement Program definition. Rates were compared between groups, and statistical analyses were performed using chi-squared and Fisher's exact tests and multivariable logistic regression, with significance defined as α < 0.05. RESULTS In total, 941 patients were included in the analysis (72% men), 513 before protocol initiation, and 427 after. Groups were similar with regard to demographic variables and potential risk factors for infection. After protocol implementation, there was a significant reduction in patients receiving procedural antimicrobial prophylaxis (30% vs 15%; P < 0.001). The incidence of UTI after cystoscopy was slightly higher in the post-protocol group (2.9-3.7%), but the difference was not statistically significant (chi-squared = 0.56, P = 0.45). The incidence of UTI did not significantly differ with procedural antibiotic prophylaxis or with other antibiotic use at time of cystoscopy. Five out of a total of 31 UTIs (16%) over the study period resulted in fever, and four (13%) resulted in urosepsis. The probability of neither complication differed significantly between pre- and post-protocol groups. The only significant patient-level predictor of post-cystoscopy UTI was catheter use (odds ratio 1.48, 95% confidence interval 1.06-2.06). CONCLUSION Protocol implementation led to a significant decrease in procedural antimicrobial prophylaxis, indicating protocols may be effective tools in promoting antibiotic stewardship. UTI incidence did not change significantly under the protocol, and antibiotic prophylaxis did not decrease infection rate. Our results support catheter use as a risk factor for post-cystoscopy infection, but other patient variables, including those present in the American Urological Association Best Practice statement, were not predictive. In total, this analysis suggests that decreasing antibiotic prophylaxis for cystourethroscopy is safe and can be effective in the outpatient setting.

To determine practice patterns for the extent of lymphadenectomy at radical prostatectomy and associations with detection of pN1 prostate cancer, as well as the impact of lymphadenectomy extent on underdetection of pN1 disease and overall survival.Prostatectomy cases in the NCDB from 2004 to 2013 were included. Lymphadenectomy extent was defined by the number of nodes examined. Logistic regression was used to identify risk factors for the top quartile of lymph node count and pN1 disease. This model was created to estimate the expected prevalence of pN1, and generated observed over expected ratios. A Cox regression model was used to evaluate the effect of lymph node count on overall survival.Lymphadenectomy was performed in 209,789 (60%) of 358,522 surgeries, with pN1 in 6,428 (3.08%). Increasing quartiles for lymph node count was associated with pN1 (3-5 nodes OR 2.11; 6-8 nodes OR 3.12; ≥9 nodes OR 5.91, all P0.001). The logistic regression model suggested that 59% of pN1 cases are missed due to low lymph node count. Increased lymph node count was associated with increasing pN1 detection (O/E: 1-2 nodes = 0.18; 3-5 nodes = 0.37; 6-8 nodes = 0.56; ≥9 nodes = 1.01). Cox proportional hazards modeling demonstrated that the top quartile for lymph node count had improved overall survival (HR 0.93, CI 0.87-0.99, P= 0.03).Increasing lymphadenectomy extent was associated with pN1 disease on multivariate analysis, and logistic regression modeling suggested a substantial proportion of pN1 were missed due to low lymphadenectomy extent across all risk groups.

The appropriate use of adjuvant targeted therapy (TT) for high-risk locoregional renal cell carcinoma (RCC) after nephrectomy is currently unclear due to mixed results from the relevant randomized controlled trials. National-level survival outcomes and practice trends for the use of adjuvant TT in the United States have not been reported.To compare overall survival for patients who did and did not receive adjuvant TT after nephrectomy for high-risk locoregional RCC.This cohort study reviewed the National Cancer Database from 2006 to 2015. Patients with nonmetastatic clear cell RCC who underwent nephrectomy with either stage pT3a or greater or pN+ were included.Adjuvant TT was defined as receipt of TT within 3 months of nephrectomy. The primary end point was overall survival from initial diagnosis to date of death or censored at last follow-up. Baseline characteristics were described, and a multivariable analysis identified associations for receipt of adjuvant TT. Nearest-neighbor propensity matching was performed to create similar groups for comparison. A survival analysis was performed using Kaplan-Meier analysis and log-rank test.The final study population included 41,127 patients. Two thousand seventy-one patients (5.04%) received off-label adjuvant TT. Younger age, white race, private insurance, positive margins, pT4, and pN+ were associated with receipt of adjuvant TT. After nearest-neighbor propensity matching for clinically and statistically relevant covariates, 1,604 patients remained in the matched cohort, with statistically nonsignificant differences between the groups for all baseline characteristics. Median overall survival was 52 months for patients in the Adjuvant TT group versus 79 months for those who did not receive adjuvant TT (P0.001). Decreased overall survival for patients receiving adjuvant therapy was also seen in pathologic subgroups with and without lymph node involvement.The propensity matched survival analysis revealed significantly decreased overall survival in patients who received off-label adjuvant TT for high-risk locoregional RCC.

Summary Introduction There are no large multi-institutional studies reporting on perioperative complications of hypospadias repairs. We sought to determine perioperative complications of hypospadias repairs from the National Surgical Quality Improvement Program Pediatrics (NSQIP-P) to aid in patient counseling. Study design This cohort study from 2012 to 2017 was conducted using NSQIP-P database. Pediatric patients undergoing hypospadias surgery were identified and compared based on 4 major categories: distal/midshaft repair, one-stage repair proximal, stage one repair, and stage two repair. Baseline demographics between the four groups and perioperative parameters were compared. Multivariable logistic regression analysis models including type of repair was used to determine associations with overall complications, infectious complications, and dehiscence. Discussion There were 11,292 patients identified in the study population. Overall, 78% underwent distal/midshaft hypospadias repair, 12% underwent one-stage proximal repair, 1.4% underwent proximal first stage repair and 9% underwent proximal second stage repair. Multivariable logistic regression analysis revealed that proximal first stage procedures had similar overall complications to distal/mid repairs but proximal one-stage and proximal second stage procedures were associated with significantly more overall complications, local infectious complications, and dehiscence. Age, race, operative time, prematurity were also independently associated with increased overall complications. As expected, complication rates are higher in those with proximal hypospadias. In staged hypospadias, first stage has a lower complication rate compared to second stage. All complications, especially of infectious and dehiscence are the highest in the one-stage proximal and proximal second stage repairs. Conclusion We report large multi-institutional analysis of 30-day peri-operative hypospadias repair complications; this information is useful for patient counseling and education. Summary Table . Parameter All Distal/mid hypospadias One-stage Proximal Proximal First Stage Proximal Second Stage P-value SSI 58 (0.5%) 28 (0.3%) 13 (1.0%) 0 17 (1.8%) UTI 78 (0.7%) 45 (0.5%) 13 (1.0%) 0 20 (2.1%) Dehiscence 293 (2.6%) 149 (1.7%) 59 (4.3%) 4 (2.5%) 81 (8.4%) PNA 8 (0.1%) 3 (0.03%) 2 (0.2%) 1 (0.6%) 2 (0.2%) Return to OR 88 (0.8%) 49 (0.6%) 22 (1.6%) 2 (1.2%) 15 (1.6%) Readmission 157 (1.4%) 96 (1.1%) 28 (2.1%) 3 (1.9%) 30 (3.1%) Infectious comp 127 (1.1%) 67 (0.8%) 25 (1.8%) 0 (0%) 35 (3.6%) Any complication 467 (4.1%) 250 (2.8%) 93 (6.8%) 7 (4.3%) 117 (12.1%)

The increase of the length of freight trains in operation across EU corridors is a key objective to achieve to increase the capacity and strengthen the competitiveness of rail freight transport by decreasing the cost of rail haulage without affecting safety standards. Research projects such as MARATHON-FP7 aimed at developing technical solutions for the regular operation of 1,500 metres long freight trains. The definition of technical and homologation requirements, together with safety standards and protocols for radio-remote controlling is of paramount importance to ensure that longer freight trains are put in operation across rail networks in EU Member States and beyond. Shift2Rail project DYNAFREIGHT (whose activities are carried out in cooperation with the Shift2Rail project FF4LE) is now an ongoing project and full results will be available in late 2018. This paper shows the results achieved at the current intermediate stage on the definition of longer train requirements and tests. Functional and technical requirements of longer trains, including the radio controlled traction and braking are going to be defined with the aim to develop a radio system for long train operation ready for certification. This paper reports the results of the safety analysis performed with full-scale tests and first indications for functional requirements. Moreover, the paper reports the results of pneumatics and multibody dynamics simulations performed to provide guidelines on how to reduce the risk of derailment of long freight trains. The analyses will deal with different train configurations (vehicles and payloads), initial speed and brake applications, as well as different track layouts including gradients and horizontal curves. Finally, a thorough analysis of infrastructure requirements has to be developed to derive common technical specification and quality requirements for rail infrastructure to accommodate long freight train operations. The present paper reports the analysis made on the Spanish rail network leading to preliminary identification of lines where 1500m long trains could be tested, while identifying current infrastructure constraints that constitute barriers against a full implementation of longer train traffic.

The objectives of this study are to evaluate if robotic cystectomy demonstrates reduced complications, readmissions, and cost-to-patient compared to open approach 30-day post-operatively, and to identify predictors of complication, readmission, and cost-to-patient. This retrospective cohort study analyzed 249 patients who underwent open (n = 149) or robotic (n = 100) cystectomy from 2009 to 2015 at our institution. Outcomes included 30-day post-operative complication, readmission, and cost-to-patient charges. We used modified Clavien-Dindo/MSKCC classifications. Multivariable logistic and linear regression models were used to evaluate associations to outcomes and to build predictive models. Patient, clinical, and surgical characteristics differed by open and robotic groups, respectively, only for estimated blood loss (median: 600 versus 150 cc, p 0.01), operative time (mean: 6.19 versus 6.85 h, p 0.01), and length of stay (median: 7 versus 5 days, p 0.01). Complication: frequency of patients with at least one 30-day complication was 85% compared to 66% (p 0.01). Minor gastrointestinal and bleeding complications were increased in the open group (50% versus 41%, p = 0.01; 52% versus 11%, p 0.01, respectively). Fifty percent of patients required blood transfusion in open compared to 11% (p 0.01). Patients in the open group experienced more major complications (19% versus 10%, p = 0.04). Robotic approach was a predictor for fewer complications (OR 0.44, 95% CI 0.20-0.99, p = 0.049). Readmission: no significant difference in number of patients readmitted was found. Cost-to-patient: Robotic approach predicted an 18% reduction in total cost-to-patient compared to open approach (p 0.01). Robotic cystectomy demonstrated reduced total cost-to-patient when taking into account all 30-day post-operative services with fewer complications compared to open cystectomy.