ObjectivesTo quantitatively describe the nature, severity, and duration of symptoms and functional impairment during recovery from transurethral resection of bladder tumors.Materials and MethodsAll patients scheduled for transurethral resection were approached for enrollment in a text-message based ecological momentary symptom assessment platform. Nine patients reported outcomes were measured 7 days before surgery and on postoperative days 1, 2, 3, 5, 7, 10, and 14 using a 5-point Likert scale. Self-reported degree of hematuria was collected using a visual scale. Clinical data was collected via retrospective chart review.ResultsA total of 159 patients were analyzed. Postoperative symptoms were overall mild, with the largest differences from baseline to postoperative day 1 seen in dysuria (median 0/5 vs. 3/5) and ability to work (median 5/5 vs. 4/5). Recovery was generally rapid, with 76% of patients reporting ≥4/5 agreement with the statement “I feel recovered from surgery” by postoperative day 2, although 15% of patients reported persistently lower levels of agreement on postoperative day 10 or 14. Patients undergoing larger resections (≥2cm) did take longer to return to baseline in multiple symptom domains, but the difference of medians vs. those undergoing smaller resections was less than 1 day across all domains. Multivariable analysis suggested that receiving perioperative intravesical chemotherapy was associated with longer time to recovery. 84% of patients reported clear yellow urine by postoperative day 3.ConclusionIn this population, hematuria and negative effects on quality of life resulting from transurethral resection of bladder tumors were generally mild and short-lived, although a small number of patients experienced longer recoveries.

Introduction An accurate and non-invasive histologic assessment of renal masses remains elusive, as approximately 15% of resected renal masses prove benign upon resection. Oncocytomas and hybrid oncocytoma/chromophobe tumors (HOCTs) are the most commonly-resected oncologically low-risk masses and are not reliably distinguished from malignant lesions with standard cross-sectional imaging. Histologically, these tumors are notable for densely-packed mitochondria. Technetium-99m-sestamibi single-photon emission CT/ x-ray CT is a nuclear imaging modality that utilizes a mitochondria-targeting tracer. Early series using 99mTc-sestamibi SPECT/CT showed promise in differentiating renal cell carcinoma (RCC) from oncocytomas and HOCTs, but recently published data from our institution found that oncocytomas still accounted for 20% of lesions with low 99mTc-sestamibi tracer uptake, as qualitatively interpreted by a senior nuclear radiologist. Here, we asses performance of 99mTc-sestamibi scans utilizing quantitative assessment thresholds, hypothesizing that this may improve test characteristics over qualitative assessments. Methods Patients undergoing 99mTc-sestamibi SPECT/CT for evaluation of renal masses between February 2020 and December 2021 were included in our analysis. A mass was labeled as “hot” by the radiologist if its 99mTc-sestamibi uptake was qualitatively equivalent or higher than that of the ipsilateral renal parenchyma; otherwise it was labeled as “cold”. Using nuclear medicine image processing software, TBRs were calculated by comparing signal counts of the masses to those of the normal ipsilateral renal parenchyma using manually generated regions of interest. Quantitative “hot”/”cold” determinations for each mass were then re-evaluated using previously published TBR cutoffs of 0.46 and 0.6. Masses for which TBRs could not be calculated were assumed to have unchanged classifications on quantitative analysis. Qualitative and quantitative 99mTc-sestamibi SPECT/CT findings were then correlated to histology for masses that underwent pathologic confirmation via biopsy or surgical excision. Results 78 patients underwent 99mTc-sestamibi SPECT/CT for 98 renal masses. 52 masses had diagnostic pathology available from biopsy or surgical excision. Of these, 7 were “hot” (1 RCC, 6 oncocytomas) and 45 were “cold” (34 RCC, 2 non-RCC malignancies, 9 oncocytomas). The negative predictive value of qualitatively-interpreted “cold” 99mTc-sestamibi scans for ruling out oncocytoma was 80%. 1/52 (1.9%) malignant masses were interpreted as “hot” and;likely benign. When a TBR cutoff of 0.46 was applied, 17/45 “cold” masses were reclassified as “hot” (13 RCC, 1 non-RCC malignancy, 6 oncocytomas). For a TBR cutoff of 0.6, 6/45 “cold” masses were reclassified as “hot” (1 RCC, 1 non-RCC malignancy, 4 oncocytomas) while 1 “hot” RCC was reclassified as “cold” (Figure 1).; TBR cutoffs of 0.46 and 0.6 improved the NPV;of 99mTc-sestamibi SPECT/CT to 89% and 88% but increased the rate of “hot” malignant tumors to 23.1% and 3.8%, respectively. Conclusions When assessing histology of renal masses, applying previously-published quantitative TBR cutoffs to 99mTc-sestamibi SPECT/CT provides <10% improvement in the negative predictive value for ruling out oncocytomas compared to previously published qualitative interpretations of these scans. Conversely, the use of these thresholds in place of qualitative assessments tends to categorize more RCCs as "hot," thereby erroneously mimicking oncocytomas. Further work is needed to determine whether 99mTc-sestamibi SPECT/CT has a role in routine clinical practice.

Objective To determine whether a simple point‐of‐care measurement system estimating renal parenchymal volume using tools ubiquitously available could be used to replace nuclear medicine renal scintigraphy (NMRS) in current clinical practice to predict estimated glomerular filtration rate (eGFR) after nephrectomy by estimating preoperative split renal function. Patients and Methods We performed a retrospective review of patients who underwent abdominal cross‐sectional imaging (computed tomography/magnetic resonance imaging) and mercaptoacetyltriglycine (MAG3) NMRS prior to total nephrectomy at a single institution. We developed the real‐time estimation of nephron activity with a linear measurement system (RENAL‐MS) method of estimating postoperative renal function via the following technique: renal parenchymal volume of the removed kidney relative to the remaining kidney was estimated as the product of renal length and the average of six renal parenchymal thickness measurements. The utility of this value was compared to the utility of the split renal function measured by MAG3 for prediction of eGFR and new onset Stage 3 chronic kidney disease (CKD) at ≥90 days after nephrectomy using uni‐ and multivariate linear and logistic regression. Results A total of 57 patients met the study criteria. The median (interquartile range [IQR]) age was 69 (61–80) years. The median (IQR) pre‐ and postoperative eGFR was 74 (IQR 58–90) and 46 (35–62) mL/min/1.73 m 2 , respectively. [Correction added on 29 December 2023, after first online publication: The data numbers in the preceding sentence have been corrected.] Correlations between actual and predicted postoperative eGFR were similar whether the RENAL‐MS or NMRS methods were used, with correlation using RENAL‐MS being slightly numerically but not statistically superior ( R = 0.82 and 0.76; P = 0.138). Receiver operating characteristic curve analysis using logistic regression estimates incorporating age, sex, and preoperative creatinine to predict postoperative Stage 3 CKD were similar between RENAL‐MS and NMRS (area under the curve 0.93 vs. 0.97). [Correction added on 29 December 2023, after first online publication: The data numbers in the preceding sentence have been corrected.] Conclusion A point‐of‐care tool to estimate renal parenchymal volume (RENAL‐MS) performed equally as well as NMRS to predict postoperative eGFR and de novo Stage 3 CKD after nephrectomy in our population, suggesting NMRS may not be necessary in this setting.

Prostate cancer screening is a controversial topic in the general population and is even more contested among liver transplant candidates. Not only should transplant programs be concerned about the risk of false positive screening results but also the competing risks of death and the diagnostic and therapeutic effects of true prostate cancer, which often does not cause significant morbidity or mortality in organ transplant recipients. Our letter highlights a best-practices approach to prostate cancer screening in transplant candidates using available research and consensus guidelines.

You have accessJournal of UrologyCME1 Apr 2023MP39-16 COST-EFFECTIVENESS ANALYSIS OF UNIVERSAL CT STAGING VERSUS SELECTIVE CT STAGING STRATEGIES FOR PATIENTS WITH cT1a RENAL MASSES Diana Magee, Kevin Ginsburg, Jared Schober, Laura Bukavina, Spencer Bell, Elizabeth Handorf, Alexander Kutikov, Robert Uzzo, and Andres Correa Diana MageeDiana Magee More articles by this author , Kevin GinsburgKevin Ginsburg More articles by this author , Jared SchoberJared Schober More articles by this author , Laura BukavinaLaura Bukavina More articles by this author , Spencer BellSpencer Bell More articles by this author , Elizabeth HandorfElizabeth Handorf More articles by this author , Alexander KutikovAlexander Kutikov More articles by this author , Robert UzzoRobert Uzzo More articles by this author , and Andres CorreaAndres Correa More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003277.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The incidence of metastasis in patients with cT1a masses is an exceedingly rare event. However, guidelines recommend some form of thoracic imaging for patients with newly diagnosed renal masses. Screening for thoracic metastasis can be accomplished with either a chest x-ray (CXR) or CT of the thorax (CTT) and guidelines are agnostic to type of imaging modality utilized. Therefore, we designed a study evaluating the cost-effectiveness of CXR followed by selective CTT compared with that of universal CTT staging. METHODS: Using TreeAgePro 2019 software, we developed a clinical decision tree to estimate the thoracic metastasis detection rate and cost of a selective CTT strategy compared to universal CTT at the time of initial staging in patients with cT1a renal masses. Patients who had a positive CXR subsequently had a CTT to confirm the positive result. In the universal CTT arm all patients were staged with a CTT. Model probabilities were derived from published literature. Direct costs were obtained from the Medicare procedure database. Our primary outcomes were proportion of true cancers detected, accuracy of and the incremental cost effectiveness ratio (ICER) which evaluates the incremental cost per additional true positive (TP) metastasis identified. RESULTS: The universal CTT strategy resulted in a greater proportion of true cancers detected (TP/baseline prevalence of pulmonary metastases) (93.9%) when compared to CXR (66.7%). However, when the imaging tests were assessed by accuracy (true positive + true negative), the selective CTT staging strategy was found to be more accurate at 93.2% compared to 76.7% for the universal CTT staging strategy. This is balanced by a proportion of false positive (23.2%) in the universal CTT arm compared with 6.6% in the CXR based screening arm. To identify an additional metastasis diagnosed by a universal CTT that would be missed by a CXR based screening strategy would cost $59,931 . Our results are robust to sensitivity analyses evaluating the baseline prevalence of metastasis, but the ICER does vary considerably when the sensitivity of CT imaging was varied. CONCLUSIONS: Our study demonstrates that while a greater proportion of true positive tests are obtained using a universal CT staging strategy this is at the expense of a greater false positive rate. Given the low pretest probability of chest metastasis in patients with cT1a renal masses, there is considerable additional cost associated with screening this population with CTT to identify the few masses that would be missed with CXR based screening protocols. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e542 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Diana Magee More articles by this author Kevin Ginsburg More articles by this author Jared Schober More articles by this author Laura Bukavina More articles by this author Spencer Bell More articles by this author Elizabeth Handorf More articles by this author Alexander Kutikov More articles by this author Robert Uzzo More articles by this author Andres Correa More articles by this author Expand All Advertisement PDF downloadLoading ...

Accurate prediction of new baseline GFR (NBGFR) after radical nephrectomy (RN) can inform clinical management and patient counseling whenever RN is a strong consideration. Preoperative global GFR, split renal function (SRF), and renal functional compensation (RFC) are fundamentally important for the accurate prediction of NBGFR post-RN. While SRF has traditionally been obtained from nuclear renal scans (NRS), differential parenchymal volume analysis (PVA) via software analysis may be more accurate. A simplified approach to estimate parenchymal volumes and SRF based on length/width/height measurements (LWH) has also been proposed. We compare the accuracies of these three methods for determining SRF, and, by extension, predicting NBGFR after RN. All 235 renal cancer patients managed with RN (2006–2021) with available preoperative CT/MRI and NRS, and relevant functional data were analyzed. PVA was performed on CT/MRI using semi-automated software, and LWH measurements were obtained from CT/MRI images. RFC was presumed to be 25%, and thus: Predicted NBGFR = 1.25 × Global GFRPre-RN × SRFContralateral. Predictive accuracies were assessed by mean squared error (MSE) and correlation coefficients (r). The r values for the LWH/NRS/software-derived PVA approaches were 0.72/0.71/0.86, respectively (p < 0.05). The PVA-based approach also had the most favorable MSE, which were 120/126/65, respectively (p < 0.05). Our data show that software-derived PVA provides more accurate and precise SRF estimations and predictions of NBGFR post-RN than NRS/LWH methods. Furthermore, the LWH approach is equivalent to NRS, precluding the need for NRS in most patients.

Objectives: To investigate the difference in renal function outcomes for patients with oncocytomas undergoing active surveillance (AS) vs. partial nephrectomy (PN). Methods: We reviewed our institutional database for patients with biopsy/surgically confirmed oncocytoma from 2000-2020. The primary outcome was to assess for differences in renal function outcomes in patients undergoing AS vs. PN. We fit two generalized estimating equation (GEE) with an interaction term between follow up time and management strategy to predict 1) mean eGFR for patients managed with AS and PN and 2) the probability of progression to CKD stage III or greater. Results: We identified 114 eligible patients, of which 32 were managed with AS. Median follow-up was 21 months vs. 44 months for PN vs. AS patients. AS patients tended to be older (median: 72 years vs. 65 years, P<0.001) and have lower baseline renal function (median: eGFR: 71 mL/min/1.73m(2) vs. 82 mL/min/1.73m(2), P<0.001) compared with PN patients. Renal mass size from baseline imaging was similar between patients undergoing PN vs. AS (2.8 cm vs. 2.9 cm, P=0.634). For patients undergoing PN vs. AS, there was not a significant difference in predicted longitudinal eGFR (-0.079, 95% CI -0.18-0.023, P=0.129) or predicted probability of progression to CKD stage III or greater (OR: 0.61, 95% CI: 0.16-2.33, P=0.47). Conclusions: In our institutional dataset, patients undergoing AS or PN with an oncocytoma had similar long-term renal function outcomes. Given similar renal function outcomes in patients undergoing AS and PN, surgery should remain reserved for select patients with oncocytomas. (c) 2022 Published by Elsevier Inc.

Introduction The surgical treatment of men with lower urinary tract symptoms (LUTS) and significantly enlarged symptomatic prostates on active surveillance (AS) for low-risk prostate cancer (PCa) is not well defined. We report our single-institution initial experience with holmium laser enucleation of the prostate (HoLEP) for LUTS in men with low-risk PCa being managed with AS. Materials and Methods Men on AS who underwent HoLEP between 2013 and 2019 were identified. Data regarding preoperative cancer workup, prostate-specific antigen (PSA), perioperative outcomes, and voiding parameters were analyzed. Postoperative surveillance for PCa including PSA nadir, prostate magnetic resonance imaging, prostate biopsy (PBx), and PSA at last follow-up were evaluated. Results Twenty men met the inclusion criteria. Preoperative mean max flow 7.9 ml/s, median postvoid residual 101 cc, and mean transrectal ultrasound prostate size 99 cc. Patients had a median adjusted preoperative PSA of 8.5 (interquartile range [IQR]: 4.8-13.2) ng/ml. Mean resected tissue weight was 65.5 g with improved postoperative flow rate and significantly decreased residual. A total of 5/20 men had PCa in the specimen (all Gleason Grade Group 1). The median postoperative PSA nadir was 1.2 (IQR: 0.5-1.8) ng/ml at median of 5 months. At the last follow-up (median 18.5 months, IQR: 10.5-37.8), the median postoperative PSA was 1.4 (IQR: 0.63-2.48) ng/ml. Nine men underwent postoperative multiparametric magnetic resonance imaging (mpMRI) with the identification of a new prostate imaging reporting and data system 5 lesion in one patient who underwent negative fusion biopsy. Five men underwent post-HoLEP PBx with progression in two patients, who both successfully underwent radical prostatectomy. Conclusions Men on AS for low-risk PCa can safely undergo HoLEP with significantly improved voiding parameters. Postoperative monitoring with PSA, mpMRI, and PBx can detect disease progression requiring definitive treatment. Further research is needed to optimize surveillance strategies and long-term cancer-specific outcomes.

PURPOSE:We evaluated oncologic risks in a large cohort of patients with radiographic cystic renal masses who underwent active surveillance or intervention. MATERIALS AND METHODS:A single-institutional database of 4,340 kidney lesions managed with either active surveillance or intervention between 2000-2020 was queried for radiographically cystic renal masses. Association of radiographic tumor characteristics and high-grade pathology was evaluated. RESULTS:We identified 387 radiographically confirmed cystic lesions in 367 patients. Of these, 247 were resected (n=240) or ablated (n=7; n=247, 203 immediate vs 44 delayed intervention). Pathologically, 23% (n=56) demonstrated high-grade pathology. Cystic features were explicitly described by pathology in only 18% (n=33) of all lesions and in 7% (n=4) of high-grade lesions. Of the intervention cohort, African American race, male gender, and Bosniak score were associated with high-grade pathology (P < .05). On active surveillance (n=184), Bosniak IV lesions demonstrated faster growth rates than IIF and III lesions (2.7 vs 0.6 and 0.5 mm/y, P ≤ .001); however, growth rates were not associated with high-grade pathology (P = .5). No difference in cancer-specific survival was identified when comparing intervention vs active surveillance at 5 years (99% vs 100%, P = .2). No difference in recurrence was observed between immediate intervention vs delayed intervention (P > .9). CONCLUSIONS:A disconnect between "cystic" designation on imaging and pathology exists for renal lesions. Over 80% of radiographic Bosniak cystic lesions are not described as "cystic" on pathology reports. More than 1 in 5 resected cystic renal lesions demonstrated high-grade disease. Despite this finding, judiciously managed active surveillance ± delayed intervention is a safe and effective management option for most radiographic cystic renal masses.

While multiple mechanisms have been hypothesized to explain the therapeutic effect of lymph node (LN) yield in patients with urothelial cell carcinoma (UCC) undergoing radical cystectomy (RC), the effect of stage migration, commonly known as the Will Rogers effect, is often discounted. We reviewed the National Cancer Database for patients with UCC undergoing RC with pathologically node -negative (pN0) disease from 2004 to 2016. We tested for an adjusted association between LN yield and overall survival using multivariable Cox proportional -hazard models. Median survival was estimated using the Kaplan-Meier method. We identified 19 939 patients with pN0 UCC treated with RC. After adjustment, patients in the highest quantile for LN yield (=26 LNs) had a 34% lower risk of death in comparison to patients in the lowest quantile (=5 LNs). As we increased the threshold for LN yield for dichotomization from >5 to >15 to >25 LNs, median sur-vival increased from 83 to 95 to 103 mo. The pN0 group with higher LN yield appeared to live longer in this analysis owing to the mathematical artifact of how patients are indexed. Resection of a greater number of negative LNs will lead to higher fidelity for pN0 cohorts being evaluated, as the likelihood of contamina-tion by pN+ cases that were missed will be lower. Patient summary: A strategy to dissect a high number of lymph nodes in patients undergoing removal of their bladder for bladder cancer can be associated with side effects, and the benefit in terms of cancer control or survival remains uncertain. Urologists and their patients should engage in shared decision-making and consider the risks and benefits of more extensive lymph node dissection during surgery.

PURPOSE:Technetium-99m-sestamibi single-photon emission CT/x-ray CT is an emerging clinical tool to differentiate oncocytic tumors from renal cell carcinomas. We report data from a large institutional cohort of patients who underwent technetium-99m-sestamibi scans during evaluation of renal masses. MATERIALS AND METHODS:Patients who underwent technetium-99m-sestamibi single-photon emission CT/x-ray CT between February 2020 and December 2021 were included in the analysis. Scans were defined as "hot" for oncocytic tumor when technetium-99m-sestamibi uptake was qualitatively equivalent or higher between the mass of interest and normal renal parenchyma, suggesting oncocytoma, hybrid oncocytic/chromophobe tumor, or chromophobe renal cell carcinoma. Demographic, pathological, and management strategy data were compared between "hot" and "cold" scans. For individuals who underwent diagnostic biopsy or extirpative procedures, the concordance between radiological findings and pathology was indexed. RESULTS:A total of 71 patients (with 88 masses) underwent technetium-99m-sestamibi imaging with 60 (84.5%) patients having at least 1 "cold" mass on imaging and 11 (15.5%) patients exhibiting only "hot" masses. Pathology was available for 7 "hot" masses, with 1 biopsy specimen (14.3%) being discordant (clear cell renal cell carcinoma). Five patients with "cold" masses underwent biopsy. Out of 5 biopsied masses, 4 (80%) were discordant oncocytomas. Of the extirpated specimens, 35/40 (87.5%) harbored renal cell carcinoma and 5/40 (12.5%) yielded discordant oncocytomas. In sum, 20% of pathologically sampled masses that were "cold" on technetium-99m-sestamibi imaging still harbored oncocytoma/hybrid oncocytic/chromophobe tumor/chromophobe renal cell carcinoma. CONCLUSIONS:Further work is needed to define utility of technetium-99m-sestamibi in real-world clinical practice. Our data suggest this imaging strategy is not yet ready to replace biopsy.

You have accessJournal of UrologyCME1 May 2022MP24-08 REAL-TIME ESTIMATION OF NEPHRON ACTIVITY WITH A LINEAR MEASUREMENT SYSTEM (RENAL-MS) OBVIATES THE NEED FOR NUCLEAR MEDICINE SCANS TO PREDICT GLOMERULAR FILTRATION RATE AFTER NEPHRECTOMY Jared Schober, Matthew Loecher, David Strauss, Eric Cho, Alberto Castro Bigalli, Kevin Ginsburg, Alexander Kutikov, and Marshall Strother Jared SchoberJared Schober More articles by this author , Matthew LoecherMatthew Loecher More articles by this author , David StraussDavid Strauss More articles by this author , Eric ChoEric Cho More articles by this author , Alberto Castro BigalliAlberto Castro Bigalli More articles by this author , Kevin GinsburgKevin Ginsburg More articles by this author , Alexander KutikovAlexander Kutikov More articles by this author , and Marshall StrotherMarshall Strother More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002563.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Nuclear medicine renal scintigraphy (NMRS) is often used to predict glomerular filtration (eGFR) after nephrectomy. Recent data have shown that measurements of renal parenchymal volume using specialized software can be used to predict postoperative eGFR accurately, obviating the need for NMRS. We sought to determine whether a simplified measurement system using tools available in the basic image display software could be used to replace NMRS in current clinical practice. METHODS: We performed a retrospective review of institutional patients who underwent abdominal cross-sectional imaging (CT or MRI) and Mercaptoacetyltriglycine (MAG-3) renal scintigraphy prior to total nephrectomy. Patients with hydronephrosis, active or chronic infection, and missing creatinine were excluded. A formula incorporating renal length and the mean of 6 renal parenchymal thickness measurements was utilized to estimate differential kidney function and predict postoperative eGFR through a clinical point-of-care Real-time Estimation of Nephron Activity with a Linear Measurement System (RENAL-MS). The predictive ability of RENAL-MS for estimation of postoperative eGFR was compared to MAG-3 scintigraphy using linear regression. RESULTS: 66 patients met study criteria with a median age of 69 (IQR 61-80) years. The most common indications for nephrectomy were renal cell carcinoma (55%) and upper tract urothelial cancer (24%). Median solid renal tumor diameter was 5.0 (3.65-6.50) cm. Median preoperative and postoperative eGFR was 72 (53-87) mL/min/1.73^2 and 46 (35-62), respectively. Correlation between actual ≥90 day postoperative eGFR and predicted postoperative eGFR using RENAL-MS and MAG3 were nearly identical, with RENAL-MS being numerically superior (R=0.81 and 0.76; p<0.001 and <0.001, respectively) (Figure 1). CONCLUSIONS: Simple linear measurements of renal volume are equally accurate to split renal function measured on NMRS for prediction of eGFR after nephrectomy in our population. The use of NMRS in this clinical context may be safely abandoned for these patients. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e395 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jared Schober More articles by this author Matthew Loecher More articles by this author David Strauss More articles by this author Eric Cho More articles by this author Alberto Castro Bigalli More articles by this author Kevin Ginsburg More articles by this author Alexander Kutikov More articles by this author Marshall Strother More articles by this author Expand All Advertisement PDF DownloadLoading ...

Microabstract: In the National Cancer Database (NCDB), patients treated with minimally invasive adrenalectomy (MIA) for adrenocortical carcinoma (ACC) had similar oncological outcomes and cumulative treatment burden with less morbidity compared with open adrenalectomy (OA). Although OA remains the standard of care for adrenal lesions concerninge for malignancy, MIA in appropriately selected patients may offer equivalent oncological outcomes. Introduction/Background: We investigated the cumulative treatment burden, oncological effectiveness, and perioperative morbidity in patients undergoing MIA compared with (OA) for patients with ACC. Patients and Methods: We reviewed the NCDB for patients undergoing surgical resection (MIA vs. OA) for ACC from 2010 to 2017. Inverse probability of treatment weighted logistic regression, negative binomial, and Cox proportional hazards models were fit to assess for an association of surgical approach with cumulative treatment burden (any adjuvant therapy, radiation therapy [RT], and systemic therapy), oncological effectiveness (positive surgical margins [PSM], lymph node yield [LNY], and overall survival [OS]), and perioperative morbidity (length of stay [LOS] and readmission) as appropriate. Results: We identified 776 patients that underwent adrenalectomy for ACC, of which 307 underwent MIA. We noted patients with larger tumors (OR 0.82, 95% CI 0.78-0.86, P <.001) were less likely to have MIA prior to IPTW. We did not appreciate a significant association of MIA with cumulative treatment burden or the use of any adjuvant therapy (OR 0.85, 95% CI 0.60-1.21, P=.375), adjuvant RT (OR 0.94, 95% CI 0.59-1.50, P=.801), or adjuvant systemic therapy (OR 0.84, 95% CI 0.58-1.21, P=.352). Patients undergoing MIA had similar oncological effectiveness of surgery and OS when compared with patients which underwent OA. Patients that underwent MIA had a significantly shorter LOS (IRR: 0.74, 95% CI 0.62-0.88, P=.001) and lower odds of readmission (OR 0.46, 95% CI 0.23-0.91, P=.026). Conclusions: Although the standard of care for adrenal lesions suspicious for ACC remains OA, in appropriately selected patients, MIA may offer similar oncological effectiveness and cumulative treatment burden, with less morbidity, than OA. (c) 2022 Elsevier Inc. All rights reserved.

Kevin B. Ginsburg, Johnathan Drevik, Jared P. Schober, Alberto A. Castro Bigalli, Jeffrey L. Ellis*, Avery Braun, Kaynaat Syed, Philadelphia, PA; John Danella, Danville, PA; Serge Ginzburg, Philadelphia, PA; Laurence Belkoff, Bala Cynwyd, PA; Adam C. Reese, Philadelphia, PA; Jeffrey Tomaszewski, Camden, NJ; Edouard Trabulsi, Phiadelphia, PA; Eric A. Singer, New Brunswick, NJ; Bruce Jacobs, Pittsburgh, PA; Jay D. Raman, Hershey, PA; Thomas Guzzo, Robert G. Uzzo, Marc C. Smaldone, Andres F. Correa, Philadelphia, PA

Introduction:Our objective was to estimate the difference in outcomes for patients with clinical T stage 1 (cT1) and 2 (cT2) micropapillary (MPBC) and urothelial carcinoma (UCBC) bladder cancer treated with radical cystectomy (RC). Methods:We reviewed the National Cancer Database for patients with cT1/2N0M0 MPBC and UCBC treated with RC from 2004-2016. Patients were classified by cT stage and histology. Outcomes of interest included upstaging to advanced pathological stage (pT3/4), pathologically node positive disease (pN+), and overall survival (OS). The Kaplan-Meier method was used to estimate 5-year OS probability. Multivariable logistic regression models were fit to test for an association between cT stage and histology with outcomes. Results:We identified 23,871 patients, of whom 384 had MPBC and 23,487 had UCBC. More patients with cT1 and cT2 MPBC had advanced pathological stage and pN+ (cT1: 31% and 34%; cT2: 44% and 60%, respectively) compared with cT1 and cT2 UCBC (cT1: 18% and 14%; cT2: 27% and 24%, respectively). Compared with cT2 UCBC, patients with cT1 MPBC had similar odds of advanced pathological stage (OR: 0.96, 95% CI: 0.63-1.45, p=0.837) and increased odds of pN+ (OR: 1.62, 95% CI: 1.03-2.56, p=0.038). Five-year OS estimates for cT1 MPBC and UCBC were similar (58% and 60%, respectively) while cT2 MPBC had worse OS than cT2 UCBC (33% and 45%, respectively). Conclusions:In a cohort of patients undergoing RC, cT1/2 MPBC had worse outcomes than cT1/2 UCBC. Patients and surgeons should consider aggressive therapies for patients with cT1 MPBC due to the risk of inferior outcomes associated with cT2 MPBC disease.