OBJECTIVE:To assess the reliability of peer-review of TURBT videos as a means to evaluate surgeon skill and its relationship to detrusor sampling.METHODS:Urologists from an academic health system submitted TURBT videos in 2019. Ten blinded peers evaluated each surgeon's performance using a 10-item scoring instrument to quantify surgeon skill. Normalized composite skill scores for each surgeon were calculated using peer ratings. For surgeons submitting videos, we retrospectively reviewed all TURBT pathology results (2018-2019) to assess surgeon-specific detrusor sampling. A hierarchical logistic regression model was fit to evaluate the association between skill and detrusor sampling, adjusting for patient and surgeon factors.RESULTS:Surgeon skill scores and detrusor sampling rates were determined for 13 surgeons performing 245 TURBTs. Skill scores varied from -6.0 to 5.1 [mean: 0; standard deviation (SD): 2.40]. Muscle was sampled in 72% of cases, varying considerably across surgeons (mean: 64.5%; SD: 30.7%). Among 8 surgeons performing >5 TURBTs during the study period, adjusted detrusor sampling rate was associated with sending separate deep specimens (odds ratio [OR]: 1.97; 95% confidence interval [CI]: 1.02-3.81, P = .045) but not skill (OR: 0.81; 95% CI: 0.57-1.17, P = .191).CONCLUSION:Surgeon skill was not associated with detrusor sampling, suggesting there may be other drivers of variability of detrusor sampling in TURBT.

You have accessJournal of UrologyBladder Cancer: Non-invasive II (MP16)1 Sep 2021MP16-16 EVALUATION OF PEER-RATED SURGICAL SKILL AND MUSCLE SAMPLING IN TRANSURETHRAL RESECTION OF BLADDER TUMOR Minh Pham, Oliver Ko, Reiping Huang, Amanda Vo, Kyle Tsai, Jeremy Lai, Matthew Hudnall, Joshua Halpern, Joshua Meeks, Jonas Benson, Ricardo Soares, Ronald Kim, Jonah Stulberg, and Gregory Auffenberg Minh PhamMinh Pham More articles by this author , Oliver KoOliver Ko More articles by this author , Reiping HuangReiping Huang More articles by this author , Amanda VoAmanda Vo More articles by this author , Kyle TsaiKyle Tsai More articles by this author , Jeremy LaiJeremy Lai More articles by this author , Matthew HudnallMatthew Hudnall More articles by this author , Joshua HalpernJoshua Halpern More articles by this author , Joshua MeeksJoshua Meeks More articles by this author , Jonas BensonJonas Benson More articles by this author , Ricardo SoaresRicardo Soares More articles by this author , Ronald KimRonald Kim More articles by this author , Jonah StulbergJonah Stulberg More articles by this author , and Gregory AuffenbergGregory Auffenberg More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002001.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Prior work has shown that detrusor muscle sampling (MS) from transurethral resection of bladder tumor (TURBT) is related to oncologic outcomes. It is unknown if surgeon skill can be assessed with operative videos or if skill is associated with MS. We aim to assess the reliability of peer review of TURBT videos to quantify skill and whether skill is associated with MS. METHODS: Urologists from our health system were recruited to submit a TURBT video. Each was rated by blinded peer surgeons using a structured scoring instrument. Interrater reliability (IRR) was determined for each domain on the instrument (Table 1). Items with IRR ≥0.4 were used to generate a normalized composite skill score. Using retrospective data, we measured surgeon MS rates for TURBTs performed from 9/2018 to 9/2019. A random-intercept logistic regression model was fit, adjusting for surgeon and non-surgeon factors to assess the relationship between surgical skill and MS. RESULTS: 13 surgeons submitted a TURBT video, each reviewed by 10 raters. Of 10 domains assessed, 6 had IRR ≥0.4 and were used for a composite skill score (Table 1). Normalized composite skill score varied significantly among surgeons (Figure 1). With data from 228 TURBTs by 8 surgeons with >5 cases, the overall MS rate was 72%, varying from 50% to 90% across surgeons. Regression modeling showed an association between sending a separate deep sample to pathology and MS (odds ratio [OR]: 1.97; 95% confidence interval [CI]: 1.02 – 3.81; p=0.045) but not between peer-rated skill and MS (OR: 0.81; 95% CI: 0.57 – 1.17; p=0.191; Table 2). CONCLUSIONS: Video-based peer review is a mechanism to assess TURBT performance, with modest IRR and significant variation in skill across surgeons. Surgeon skill was not associated with MS in TURBT. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e303-e304 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Minh Pham More articles by this author Oliver Ko More articles by this author Reiping Huang More articles by this author Amanda Vo More articles by this author Kyle Tsai More articles by this author Jeremy Lai More articles by this author Matthew Hudnall More articles by this author Joshua Halpern More articles by this author Joshua Meeks More articles by this author Jonas Benson More articles by this author Ricardo Soares More articles by this author Ronald Kim More articles by this author Jonah Stulberg More articles by this author Gregory Auffenberg More articles by this author Expand All Advertisement PDF downloadLoading ...

BACKGROUND: Although bladder cancer is much more common in men than in women, female patients with bladder cancer present with more locally advanced tumors and have worse disease-specific outcomes than male patients, even after controlling for biological differences. There is a paucity of research regarding the optimal approach to caring for female patients with bladder cancer in ways that maximize patient satisfaction, preferences, and values. OBJECTIVE: We sought to explore patient-defined priorities and areas in need of improvement for female patients with bladder cancer from the patient perspective. METHODS: We conducted focus group sessions and semi-structured interviews of women treated for bladder cancer to identify patient priorities and concerns until reaching topic saturation. Transcripts were analyzed thematically. RESULTS: Eight patients with muscle-invasive bladder cancer and six patients with non-muscle-invasive bladder cancer participated in two focus groups and seven interviews total. Three themes emerged as significantly affecting the care experience: physical impacts, mental health and emotional wellbeing, and the patient-provider interaction. Each theme included patient-defined specific recommendations on approaches to optimizing the care experience for women with bladder cancer. CONCLUSIONS: Although most participants were satisfied with the quality of care they received, they identified several opportunities for improvement. These concerns centered around enhancing support for patients' physical and mental needs and strengthening the patient-provider interaction. Efforts to address these needs and reduce gender disparate outcomes via quality improvement initiatives are ongoing.

Background Inflammatory bowel disease (IBD) has been implicated as a risk factor for prostate cancer, however, the mechanism of how IBD leads to prostate tumorigenesis is not known. Here, we investigated whether chronic intestinal inflammation leads to pro-inflammatory changes associated with tumorigenesis in the prostate. Methods Using clinical samples of men with IBD who underwent prostatectomy, we analyzed whether prostate tumors had differences in lymphocyte infiltrate compared to non-IBD controls. In a mouse model of chemically-induced intestinal inflammation, we investigated whether chronic intestinal inflammation could be transferred to the wild-type mouse prostate. In addition, mouse prostates were evaluated for activation of pro-oncogenic signaling and genomic instability. Results A higher proportion of men with IBD had T and B lymphocyte infiltration within prostate tumors. Mice with chronic colitis showed significant increases in prostatic CD45 + leukocyte infiltration and elevation of three pro-inflammatory cytokines—TIMP-1, CCL5, and CXCL1 and activation of AKT and NF-kB signaling pathways. Lastly, mice with chronic colitis had greater prostatic oxidative stress/DNA damage, and prostate epithelial cells had undergone cell cycle arrest. Conclusions These data suggest chronic intestinal inflammation is associated with an inflammatory-rich, pro-tumorigenic prostatic phenotype which may explain how gut inflammation fosters prostate cancer development in men with IBD.

You have accessJournal of UrologyHealth Services Research: Quality Improvement & Patient Safety II (MP34)1 Sep 2021MP34-20 INITIAL ASSESSMENT OF QUALITY OF NMIBC CARE ACROSS AN INTEGRATED ACADEMIC HEALTH SYSTEM Oliver Ko, Minh Pham, Kyle Tsai, Amanda Vo, Anuj Desai, Jake Miller, Joshua Meeks, Joshua Halpern, and Gregory Auffenberg Oliver KoOliver Ko More articles by this author , Minh PhamMinh Pham More articles by this author , Kyle TsaiKyle Tsai More articles by this author , Amanda VoAmanda Vo More articles by this author , Anuj DesaiAnuj Desai More articles by this author , Jake MillerJake Miller More articles by this author , Joshua MeeksJoshua Meeks More articles by this author , Joshua HalpernJoshua Halpern More articles by this author , and Gregory AuffenbergGregory Auffenberg More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002043.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Non-muscle invasive (NMIBC) bladder cancer relies heavily upon high quality transurethral resection, re-resection when indicated, and appropriate use of intravesical therapy. We sought to characterize baseline performance across various bladder cancer quality measures and to evaluate predictors of variation in performance as a basis for future quality improvement interventions. METHODS: We identified all transurethral resection of bladder tumor procedures (TURBT) performed from 9/2018 – 9/2019 across our health system comprised of over 70 credentialed urologists and 9 acute care hospitals. Manual chart abstraction was used to create a clinicopathologic database of procedural findings and outcomes. We evaluated surgeon-specific performance across three NMIBC quality measures (detrusor sampling on TURBT, re-resection for high-grade (HG) Ta/T1 disease within 8 weeks, and post-operative intravesical chemotherapy use). Multivariable logistic regression models were fit to evaluate the relationship between detrusor sampling, clinicopathologic features, and surgeon. RESULTS: During the study period, 343 TURBTs were performed in 295 patients for urothelial carcinoma by 21 surgeons. Among these procedures, detrusor muscle was sampled in 71.1% (244/343). Figure 1a displays regression results evaluating the relationship between clinicopathologic parameters and detrusor muscle sampling. After adjusting for these factors significant variation in surgeon-specific rates of sampling detrusor muscle remained (Figure 1b). Of these TURBTs, the highest stage present was 7% (24/343) CIS only, 49.9% (171/343) Ta, 32.4% (111/343) T1, and 10.8% (37/343) T2 or higher with 32.4% being low grade and 67.6% high grade. Re-resection was performed for 44.8% (64/143) with HG Ta or T1 disease. By stage, re-resection occurred 30.3% (17/56) in HG Ta, and 54% (47/87) in HG T1. The surgeon-specific rate of re-resection for HG Ta/T1 patients varied from 0 to 100%, p=0.04. Post-operative intravesical chemotherapy was used for 19.5% (67/343) of resections. CONCLUSIONS: We demonstrate significant surgeon-specific variability in three TURBT quality measures across a large integrated health system. This presents an opportunity for quality improvement to reduce surgeon-specific variation and improve outcomes for patients with NMIBC. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e624-e625 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Oliver Ko More articles by this author Minh Pham More articles by this author Kyle Tsai More articles by this author Amanda Vo More articles by this author Anuj Desai More articles by this author Jake Miller More articles by this author Joshua Meeks More articles by this author Joshua Halpern More articles by this author Gregory Auffenberg More articles by this author Expand All Advertisement Loading ...

OBJECTIVES To evaluate patient, provider, and facility factors associated with variation in opioid prescribing after endoscopic procedures for benign prostatic hyperplasia across a large academic health system to drive improvement efforts. METHODS Opioids prescribed at discharge for patients who underwent an endoscopic prostate procedure March 2018-November 2019 were analyzed. Multivariable logistic and linear regression were used to evaluate the relationship between patient, provider, and facility factors and the receipt of any opioid prescription and the quantity prescribed. RESULTS We included 724 patients who had surgery with one of 26 urologists across five facilities. 222 (30.7%) received an opioid prescription, and the average morphine milligram equivalents (MMEs) prescribed was 97.9 +/- 33.5. We found wide variation in the proportion of patients who received an opioid prescription across surgeons (range 0%-88.9%) and facilities (range 19.9%66.7%) and the average MMEs prescribed (range 25-188.5). Outpatient surgery (OR 2.32; 95% confidence interval [CI] 1.22-4.40, P = .010) and preoperative opioid use (OR 15.04; CI 9.6523.45, P < .001) were associated with higher rates of opioid prescribing, while prescribing decreased with increasing patient age (OR 0.97; CI 0.95-0.99, P = 0.016). Multivariable linear regression analysis demonstrated an association between surgery at satellite facilities, having a surgeon in practice for at least 20 years, and higher surgeon volume with increased MMEs prescribed. CONCLUSIONS Opioid prescribing following endoscopic prostate procedures varied widely. Targeted interventions tailored to younger patients, those taking opioids preoperatively, recipients of outpatient surgery and those undergoing surgery at satellite facilities may be particularly high yield given the association between these factors and increased postoperative prescribing. (C) 2021 Elsevier Inc.

BACKGROUND:Despite consensus guidelines, many men with low-grade prostate cancer are not managed with active surveillance. Patient perception of the nomenclature used to describe low-grade prostate cancers may partly explain this discrepancy. METHODS:A randomized online survey was administered to men without a history of prostate cancer, presenting a hypothetical clinical scenario in which they are given a new diagnosis of low-grade prostate cancer. The authors determined whether diagnosis nomenclature was associated with management preference and diagnosis-related anxiety using ratings given on a scale from 1 to 100, adjusting for participant characteristics through multivariable linear regression. RESULTS:The survey was completed by 718 men. Compared with Gleason 6 out of 10 prostate cancer, the term grade group 1 out of 5 prostate cancer was associated with lower preference for immediate treatment versus active surveillance (β = -9.3; 95% CI, -14.4, -4.2; P < .001), lower diagnosis-related anxiety (β = -8.3; 95% CI, -12.8, -3.8; P < .001), and lower perceived disease severity (β = -12.3; 95% CI, -16.5, -8.1; P < .001) at the time of initial diagnosis. Differences decreased as participants received more disease-specific education. Indolent lesion of epithelial origin, a suggested alternative term for indolent tumors, was not associated with differences in anxiety or preference for active surveillance. CONCLUSIONS:Within a hypothetical clinical scenario, nomenclature for low-grade prostate cancer affects initial perception of the disease and may alter subsequent decision making, including preference for active surveillance. Disease-specific education reduces the differential impact of nomenclature use, reaffirming the importance of comprehensive counseling and clear communication between the clinician and patient.

Background Upfront chemotherapy prolongs overall survival for men with metastatic, hormone-sensitive prostate cancer (mHSPC) based on data from clinical trials. We sought to assess the association between upfront chemotherapy and overall survival in men with mHSPC in a real-world cohort. Methods We performed a retrospective cohort study of men with de novo, treatment-naïve metastatic prostate cancer from a large, national cancer database in the United States (2014–2015). Men in the upfront chemotherapy group received chemotherapy within 4 months of diagnosis ( n = 1033, 28%) versus no chemotherapy or chemotherapy later than 12 months after diagnosis (controls; n = 2704, 72%). Overall survival was assessed using Kaplan–Meier estimates and compared using multivariable Cox regression analysis. Results After a median follow-up of 23 months, median overall survival was 35.7 months in the upfront chemotherapy group and 32.5 months for controls (log-rank p < 0.001). After adjusting for patient and clinical variables, upfront chemotherapy was associated with longer overall survival (hazard ratio 0.78, 95% confidence interval 0.68–0.89, p < 0.001). In exploratory analyses, the association between upfront chemotherapy and overall survival did not differ by age groups, race, or number of comorbidities (all interaction p > 0.2). Conclusions In this real-world cohort, upfront chemotherapy for mHSPC was associated with longer overall survival. These data support the continued use of chemotherapy for men with mHSPC regardless of race or age if they are fit for chemotherapy and underscore the importance of evaluating cancer therapeutics outside of clinical trials to demonstrate treatment efficacy in populations that may be underrepresented in clinical trials.

BackgroundThe objective of this study was to determine the effect of Medicaid expansion under the Patient Protection and Affordable Care Act (January 1, 2014) on the epidemiology of high‐risk prostate‐specific antigen (PSA) levels (≥20 ng/mL) at the time of prostate cancer (PCa) diagnosis. The authors hypothesized that better access to care would result in a reduction of high‐risk features at diagnosis.MethodsA retrospective cohort study was performed of 122,324 men aged <65 years who were diagnosed with PCa within the National Cancer Database. Difference‐in‐difference (DID) analyses adjusting for sociodemographic variables using linear regression compared PSA levels at diagnosis before expansion (2012‐2013) and after expansion (2015‐2016) between men residing in states that did or did not expand Medicaid.ResultsFrom 2012 to 2016, the proportion of men with PSA levels ≥20 ng/mL increased (from 18.9% to 19.8%) in nonexpansion states and decreased (from 19.9% to 18.2%) in expansion states. Compared with men in nonexpansion states, men in expansion states experienced a decline in PSA ≥20 ng/mL (DID, −2.33%; 95% CI, −3.21% to −1.44%; P < .001). Accordingly, the proportion of men presenting with high‐risk disease decreased in expansion states relative to nonexpansion states (DID, −1.25%; 95% CI, −2.26% to 0.25%; P = .015). A similar statistically significant decrease in PSA levels ≥20 ng/mL was noted among black men (DID, −3.11%; 95% CI, −5.25% to 0.96%; P = .005).ConclusionsIn Medicaid expansion states, there was an associated decrease in the proportion of young men presenting with PSA ≥20 ng/mL at the time of PCa diagnosis. These results suggest that Medicaid expansion improved access to PCa screening. Longer term data should assess oncologic outcomes.

We assessed whether Medicaid expansion has led to more timely treatment of metastatic renal cell carcinoma (mRCC). We compared the time to treatment before and after expansion between the states that had and had not expanded Medicaid for patients with mRCC within the National Cancer Database. Medicaid expansion was not associated with more timely treatment for patients with mRCC. Introduction: The absence of health insurance coverage has been associated with worse outcomes for patients with metastatic renal cell carcinoma (mRCC). Medicaid expansion in the United States was an important provision of the Affordable Care Act, which increased the number of low-income individuals eligible for Medicaid starting in January 2014 in several states. The effect of Medicaid expansion on access to healthcare for patients with mRCC is unknown. Materials and Methods: We performed a retrospective cohort study of 6844 patients aged < 65 years with mRCC at diagnosis within the National Cancer Database. We compared the time to treatment and the rates of no insurance before (2012-2013) and after (2015-2016) expansion between patients living in states that had and had not expanded Medicaid using difference-in-difference (DID) analyses. DIDs were calculated using linear regression analysis with adjustment for sociodemographic covariates. Results: The rate of no insurance did not change in the expansion states compared with the nonexpansion states (DID, -0.55%; 95% confidence interval, -3.32% to 2.21%; P = .7). The percentage of patients receiving treatment within 60 days of diagnosis had increased in the expansion states from 43% to 49% and in the nonexpansion states from 42% to 46% after expansion. No change was found in treatment within 60 days of diagnosis among all patients (DID, 2.81%; 95% confidence interval, -2.61% to 8.22%; P = .3). Conclusions: Medicaid expansion was not associated with improved healthcare access for patients with mRCC as reflected by timely treatment. Future work should assess the association between Medicaid expansion and oncologic outcomes. (C) 2020 Elsevier Inc. All rights reserved.

You have accessJournal of UrologyProstate Cancer: Epidemiology & Natural History II (MP64)1 Apr 2020MP64-18 RISK OF PROSTATE CANCER IN MEN WITH CHRONIC INFLAMMATORY CONDITIONS Anuj Desai*, Jacob A. Burns, Jason Cohen, Lauren Cooley, Adam Weiner, Conor Driscoll, Amanda Vo, Oliver Ko, Channa Amarasekera, Irene Helenowski, Hui Zhang, Jim C. Hu, John S. Witte, William J. Catalona, Edward M. Schaeffer, and Shilajit Kundu Anuj Desai*Anuj Desai* More articles by this author , Jacob A. BurnsJacob A. Burns More articles by this author , Jason CohenJason Cohen More articles by this author , Lauren CooleyLauren Cooley More articles by this author , Adam WeinerAdam Weiner More articles by this author , Conor DriscollConor Driscoll More articles by this author , Amanda VoAmanda Vo More articles by this author , Oliver KoOliver Ko More articles by this author , Channa AmarasekeraChanna Amarasekera More articles by this author , Irene HelenowskiIrene Helenowski More articles by this author , Hui ZhangHui Zhang More articles by this author , Jim C. HuJim C. Hu More articles by this author , John S. WitteJohn S. Witte More articles by this author , William J. CatalonaWilliam J. Catalona More articles by this author , Edward M. SchaefferEdward M. Schaeffer More articles by this author , and Shilajit KunduShilajit Kundu More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000939.018AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The role of chronic inflammation and possible immunomodulatory effects of chronic immunosuppression in men with chronic inflammatory conditions (CIDs) is not clearly understood. Recent data has implicated inflammatory bowel disease (IBD) as a risk factor for clinically-significant prostate cancer (PC). Our objective was to compare the incident rates of PC in men with or without CID. METHODS: We performed a matched-cohort review at a single tertiary academic medical center between 1996 and 2018. We identified male patients who had at least a single screening prostate-specific-antigen (PSA) measurement at our institution. Men with CIDs (cases=14,706) were randomly matched by age and race to men without CID (controls=47,588). Kaplan-Meier and multivariable Cox proportional hazard models, adjusted for age and race, evaluated the relationship between CIDs and the incidence of any PC. Subgroup analyses were conducted on groups of CIDs by their most commonly affected organ system. RESULTS: Progression-free-survival from PC diagnosis was 92.9% versus 90.9% for men with any CID compared to controls [HR 0.66 (95% CI 0.62-0.71), p < 0.0001]. On subgroup analysis, IBD-associated gastrointestinal conditions [HR 2.2 (95% CI 1.9 to 2.7), p<0.0001] and CIDs commonly affecting multiple organ sites [HR 1.9 (95% CI 1.6-2.2), p<0.0001] were significantly associated with increased risk of PC. In contrast, endocrinologic [HR 0.69 (95% CI 0.49-0.97), p=0.04], neurologic [HR 0.39 (95% CI 0.22-0.71), p=0.002], and non-IBD related gastrointestinal [HR 0.07 (95% CI 0.02-0.29), p=0.0002] inflammatory conditions were associated with reduced risk of any PC diagnosis. CONCLUSIONS: Men with CID have lower rates of any PC diagnosis overall and vary with the organ system affected. However, PC risk was significantly greater in men with IBD-associated gastrointestinal conditions. Source of Funding: Department of Urology, Feinberg School of Medicine at Northwestern University © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e970-e970 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Anuj Desai* More articles by this author Jacob A. Burns More articles by this author Jason Cohen More articles by this author Lauren Cooley More articles by this author Adam Weiner More articles by this author Conor Driscoll More articles by this author Amanda Vo More articles by this author Oliver Ko More articles by this author Channa Amarasekera More articles by this author Irene Helenowski More articles by this author Hui Zhang More articles by this author Jim C. Hu More articles by this author John S. Witte More articles by this author William J. Catalona More articles by this author Edward M. Schaeffer More articles by this author Shilajit Kundu More articles by this author Expand All Advertisement PDF downloadLoading ...

INTRODUCTION AND OBJECTIVE: Patients with bladder cancer who have insurance coverage experience improved outcomes. Medicaid expansion under the Affordable Care Act aimed to increase insurance coverage and improve access to care. The association between Medicaid expansion and insurance coverage and time to treatment for those with bladder cancer has not been investigated. METHODS: A large, US-based cancer registry was utilized to evaluate the association between Medicaid expansion and rates of insurance, stage of cancer at diagnosis, and time to treatment for those diagnosed with bladder cancer. We compared these outcomes in patients aged 18-64 in non-expansion states (n = 16,602) to those in expansion states (n = 15,921) before (years 2012-2013) and after (years 2015-2016) Medicaid expansion by calculating adjusted difference-in-differences (DIDs) using multivariable linear regression. RESULTS: Overall percentage of those without insurance coverage did not change following expansion on multivariable regression (-0.65%, 95% confidence interval [CI] -1.71 to 0.41, p = 0.2). Similarly, the percentage of patients with bladder cancer presenting with Stage ≥ II disease (0.02%, 95% CI -1.91 to 1.95%, p = 0.9) or metastatic disease (-0.07%, 95% CI -1.14 to 1.00%, p = 0.9) did not change. Treatment with cystectomy or systemic therapy >60 days after diagnosis of Stage ≥ II disease also did not change (1.48%, 95% CI -3.29 to 6.25%, p = 0.5). On subgroup analysis of a cohort of patients living in regions of low income, no changes were seen for rates of no insurance coverage, Stage ≥ II disease, metastatic disease, or time to treatment (all p > 0.1) CONCLUSIONS: Medicaid expansion did not result in changes in insurance coverage, stage at diagnosis, or time to treatment for patients with newly-diagnosed bladder cancer residing in expansion states relative to non-expansion states. Longer-term follow-up should investigate why insurance coverage following Medicaid expansion did not increase for bladder cancer.Source of Funding: none

You have accessJournal of UrologyProstate Cancer: Basic Research & Pathophysiology III (PD59)1 Apr 2020PD59-06 INFLAMMATORY-BOWEL-DISEASE IS ASSOCIATED TUMOR-INFILTRATING CD8 AND CD20 LYMPHOCYTES IN PROSTATE CANCER Anuj Desai*, Jason Cohen, Ketan Jain-Poster, Michael H. Shin, Lauren Cooley, Minh Pham, Conor Driscoll, Adam Weiner, Amanda Vo, Oliver Ko, Sarki A Abdulkadir, Jenny Ross, Tamara L Lotan, Jennifer D. Wu, and Shilajit Kundu Anuj Desai*Anuj Desai* More articles by this author , Jason CohenJason Cohen More articles by this author , Ketan Jain-PosterKetan Jain-Poster More articles by this author , Michael H. ShinMichael H. Shin More articles by this author , Lauren CooleyLauren Cooley More articles by this author , Minh PhamMinh Pham More articles by this author , Conor DriscollConor Driscoll More articles by this author , Adam WeinerAdam Weiner More articles by this author , Amanda VoAmanda Vo More articles by this author , Oliver KoOliver Ko More articles by this author , Sarki A AbdulkadirSarki A Abdulkadir More articles by this author , Jenny RossJenny Ross More articles by this author , Tamara L LotanTamara L Lotan More articles by this author , Jennifer D. WuJennifer D. Wu More articles by this author , and Shilajit KunduShilajit Kundu More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000969.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Recent data has implicated inflammatory bowel disease (IBD) as a risk factor for clinically-significant prostate cancer (PC). One key driver of IBD-associated malignant transformation could be systemic chronic inflammation or immunomodulation from immunosuppressive medications. However, how IBD may influence the local tissue microenvironment of the prostate and induce prostate tumorigenesis is unknown. Our objective is to determine whether prostate cancer tissue in men with IBD has differences in the inflammatory infiltrate and associated downstream signaling cascade compared to those without IBD. METHODS: We obtained radical prostatectomy specimens on 10 patients with IBD and 22 controls at our institution. Clinical parameters were obtained by chart review. Immunohistochemical (IHC) analysis was performed for inflammatory markers (CD4, CD8, CD20 lymphocytes) and androgen receptor (AR). Stained sections were reviewed and scored by a blinded independent genitourinary pathologist for the site-specific (benign glands, tumor infiltrating, stroma, and peri-prostatic regions) positivity of each IHC marker. Multivariable linear regression adjusting for age, race, prostate-specific-antigen (PSA) level, and pathologic gleason grade was performed to determine the relationship between IBD and each IHC marker. RESULTS: There was no significant difference in median age [61 (53-71) vs. 63 (53-73) yrs, p=0.65], the proportion of black patients [1/10 (10%) vs. 5/22 (23%), p=0.71], and PSA level [5.4 (2.3-9.4) vs. 5.8 (1.4-15.4), ng/mL, p=0.67] between IBD and non-IBD patients in our cohort. Positivity of inflammatory markers and AR was not different in benign glands, stroma, and peri-prostatic regions (p>0.05). However, IBD was associated with tumor infiltrating CD20 [OR 1.57 (1.15-2.14), p = 0.009] and CD8 [OR 1.61(1.71-2.21) p= 0.008] lymphocytes. CONCLUSIONS: PC in men with IBD has a unique tumor microenvironment and is enriched with tumor-infiltrating CD8 and CD20 lymphocytes. These findings may suggest that high numbers of intratumoral lymphocytes suppress anti-tumor activity, thereby promoting tumor development in men with IBD. However, further investigation is needed to determine the mechanistic and prognostic significance of these findings. Source of Funding: SPORE in Prostate Cancer © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1207-e1207 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Anuj Desai* More articles by this author Jason Cohen More articles by this author Ketan Jain-Poster More articles by this author Michael H. Shin More articles by this author Lauren Cooley More articles by this author Minh Pham More articles by this author Conor Driscoll More articles by this author Adam Weiner More articles by this author Amanda Vo More articles by this author Oliver Ko More articles by this author Sarki A Abdulkadir More articles by this author Jenny Ross More articles by this author Tamara L Lotan More articles by this author Jennifer D. Wu More articles by this author Shilajit Kundu More articles by this author Expand All Advertisement PDF downloadLoading ...

BACKGROUND: Bladder cancer patients who are insured experience improved outcomes. Medicaid expansion aimed to increase insurance coverage and improve access to care. However, the association between Medicaid expansion and stage at diagnosis or time to treatment for those with advanced bladder cancer is unknown. OBJECTIVE: We sought to determine to association of Medicaid expansion with stage at diagnosis, and time to treatment for patients with muscle-invasive bladder cancer. METHODS: A US-based cancer registry was utilized to evaluate the association between Medicaid expansion and cancer stage at diagnosis, insurance rates, and time to treatment (>60 days from diagnosis) for those diagnosed with bladder cancer. We compared outcomes in non-Medicare-aged patients in non-expansion states ( n = 16,602) and expansion states ( n = 15,921) before (years 2012-2013) and after (years 2015-2016) Medicaid expansion with adjusted difference-in-differences (DIDs) using multivariable linear regression. RESULTS: The DIDs of percentage of bladder cancer patients with Stage≥II disease (0.02%; 95% confidence interval [CI] –1.91 to 1.95%, p = 0.9), without insurance (–0.65%; 95% CI –1.71 to 0.41), and with metastatic disease at diagnosis (–0.07%; 95% CI –1.14 to 1.00, both p > 0.10) did not change following insurance expansion despite an increase in Medicaid coverage (6.03%; 95% CI 4.79 to 7.29, p < 0.01). Any treatment with either cystectomy, radiation or systemic therapy > 60 days after diagnosis of stage≥II disease did not change (DID 1.48%; 95% CI –3.29 to 6.25%, p = 0.50). On subgroup analysis of patients living in low-income regions, the rates of stage≥II disease, no insurance, metastatic disease, and time to treatment did not significantly change. CONCLUSION: Medicaid expansion was not associated with changes in advanced cancer stage at diagnosis or time to treatment in newly diagnosed bladder cancer patients.

Female voiding dysfunction and incontinence are common in the general population, and symptoms have been shown to have a significant negative impact on health-related quality of life. This article highlights the epidemiology, evaluation, diagnosis, pharmacologic therapies, and surgical treatment for overactive bladder, stress urinary incontinence, and urogenital fistulas.

Objective: Diagnosis of obesity using traditional body mass index (BMI) using length may not be a reliable indicator of body composition in spina bifida (SB). We examine traditional and surrogate measures of adiposity in adults with SB, correlated with activity, metabolic disease, attitudes towards exercise and quality of life. Design: Adult subjects with SB underwent obesity classification using BMI by length and arm span, abdominal girth and percent trunk fat (TF) on dual energy X-ray absorptiometry (DXA). Quality of life measures, activity level and metabolic laboratory values were also reviewed. Results: Among eighteen subjects (6 male, 12 female), median age was 26.5 (range 19-37) years, with level of lesion 16.7% <= L2, 61.1% L3-4, and 22.2% >= L5, respectively. Median weight was 71.8 (IQR 62.4, 85.8) kg, similar between sexes (P = 0.66). With median length of 152.0 (IQR 141.8, 163.3) cm, median conventional BMI was 29.4 m/kg(2), with 7 (43.8%) subjects with BMI >30. Median BMI by arm span was 30.2 m/kg(2), abdominal girth of 105.5 cm, and TF 45.7%. More subjects were classified as obese using alternate measures, with 9 (56.3%) by arm span, 14 (82.4%) by abdominal girth and 15 (83.3%) by TF (P = 0.008). Reclassification of obesity from conventional BMI was significant when using TF (P = 0.03). No difference in quality of life measures, activity level and metabolic abnormalities was demonstrated between obese and non-obese subjects. Conclusions: Conventional determination of obesity using BMI by length is an insensitive marker in adults with SB. Adults with SB are more often classified as obese using TF by DXA.

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Neurogenic Voiding Dysfunction II1 Apr 2018PD36-09 HIGH RATES OF ADMISSION AMONG ADULT NEUROGENIC BLADDER PATIENTS PRESENTING TO THE EMERGENCY ROOM Oluwarotimi Nettey, Alicia Roston, Emily Yura, Amanda Vo, and Stephanie Kielb Oluwarotimi NetteyOluwarotimi Nettey More articles by this author , Alicia RostonAlicia Roston More articles by this author , Emily YuraEmily Yura More articles by this author , Amanda VoAmanda Vo More articles by this author , and Stephanie KielbStephanie Kielb More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1732AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Studies show that NGB patients frequent the emergency room (ER) as an access point for medical care because they lack coordinated care for their complex, varied needs. Although a known NGB complication, chronic bacteriuria in these patients might bias ER testing. We assess rates of admission from the ER and hospital related interventions among adult NGB patients at a single urban academic tertiary center. METHODS A retrospective review of electronic health records of NGB patients presenting to Northwestern Memorial Hospital (NMH) Emergency Room from 2008-2015 was performed. Vitals, admission status, ER diagnostic testing and disposition for unique patient encounters were captured using descriptive statistics. Outcomes were stratified by NGB etiology including multiple sclerosis (MS), spinal cord injury (SCI), brain/spinal cord tumor, spina bifida (SB) and all other conditions. RESULTS 4,479 NGB patients made 6,998 unique ER encounters (range 1-30), representing an average of 1.6 ER visits per patient per year. Study included 1348 (19.3%) patients with MS, 677 SCI (9.7%), 598 (8.5%) tumor, 540 (7.7%) SB, and 3827 patients (54.7%) with heterogeneous other conditions. 82.6% of ER encounters resulted in inpatient admission, of which 20.2% were direct admits to the intensive care unit (p<0.001). 31.0% of NGB patients presenting to the ER met systemic inflammatory response (SIRS) criteria with 56.2% receiving antibiotics (p<0.001). NGB patients not meeting SIRS criteria received antibiotics 23.7% of the time (p<0.001). On subgroup analysis, SCI patients were sicker with higher frequency of fever (45.2%, p<0.001), leukocytosis (30%, p<0.001), and severe sepsis (4.7%, p<0.001). SCI patients were disproportionately admitted (94.7%), and administered computed tomography scans (20.8%), urine cultures (81.4%), and antibiotics (64.4%) compared to other NGB patient groups (all p<0.001). Although 51.5% of patients underwent urine culture, urinary tract infections (UTI) comprised the second most frequent discharge diagnosis (12%, p<0.001), after general symptoms (14.9%) and was associated with 30.2% of SCI and 24.7% SB patient encounters (p<0.001). CONCLUSIONS Neurogenic bladder patients have a high rate of inpatient admission resulting from an ER visit and receive an inordinate amount of ER testing and antibiotic administration. Our study highlights the discrepant vulnerability of SCI patients, and the need for improved long-term care coordination and ER provider training about asymptomatic bacteriuria in this population. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e729 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Oluwarotimi Nettey More articles by this author Alicia Roston More articles by this author Emily Yura More articles by this author Amanda Vo More articles by this author Stephanie Kielb More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Purpose: There is a perception in urology that female urologists encounter gender based role assignments and are often pigeonholed into caring for more female patients and female specific urological issues than their male colleagues. We assessed the influence of surgeon gender on patient gender demographics by exploring the surgical case logs of American urologists.Materials and Methods: Six-month case logs of certifying urologists from 2003 to 2012 were obtained from the ABU (American Board of Urology). We reviewed case logs based on CPT codes of common urological procedures, focusing on 6 index gender neutral and gender specific procedure groups, including treatment of nephrolithiasis, nephrectomy, resection of bladder tumors, treatment of stress urinary incontinence, elective sterilization and treatment of prostate cancer.Results: Among a cohort of 6,166 urologists 1,011,800 cases were logged. Female surgeons operated on a significantly higher percent of female patients than their male peers (54.4% vs 32.5%, p < 0.01). Female surgeons performed significantly more female specific procedures, such as slings, than their male counterparts (18 vs 10 per year, p < 0.001). Male urologists performed significantly more male specific procedures than their female colleagues, including 3 times as many vasectomies (32 vs 12 per year, p < 0.001) and more than twice as many prostatectomies (15 vs 6 per year, p < 0.001). These trends were consistent across all subspecialties and geographic regions (p < 0.01).Conclusions: Female surgeon gender has a significant influence on patient gender demographics among index urological procedures. As the number of women in urology grows, increasing attention to gender biases is necessary to understand how these disparities will shape the clinical landscape.