Goal: The goal of this study is to determine factors associated with performance of duodenal biopsy during upper endoscopy. Background: Celiac disease (CD) prevalence approaches 1% in the United States and Europe, yet CD remains underdiagnosed, in part because of low rates of duodenal biopsy during upper endoscopy. We aimed to identify patient and provider factors associated with performance of duodenal biopsy during upper endoscopy. Study: In our hospital-based endoscopy suite, we identified all patients not previously diagnosed with CD who underwent upper endoscopy during a 5-year period for one of the following indications: abdominal pain/dyspepsia, gastroesophageal reflux (GERD), anemia/iron deficiency, diarrhea, and weight loss. We employed univariate and multivariate analysis to determine the association between clinical factors and the performance of duodenal biopsy. Results: Of 8572 patients included in the study, 4863 (57%) underwent duodenal biopsy. Of those who underwent duodenal biopsy, 24 (0.49%) were found to have CD. On multivariate analysis, age, gender, indication, gross endoscopic appearance, physician affiliation with a celiac disease center, and absence of a participating trainee were all significantly associated with the performance of duodenal biopsy. There was wide variability among providers, with duodenal biopsy rates ranging from 27% to 91% during these procedures. Conclusions: A duodenal biopsy is more likely to be performed in younger patients, females, and for key indications such as weight loss, diarrhea, and anemia. Providers varied widely in the performance of duodenal biopsy. Further study is warranted to better understand the decision to perform duodenal biopsy and to determine the optimal scenarios for its performance.

in several gastrointestinal disorders, resulting in altered gut fermentation patterns, which we (and others) have been able to recognise by analysis of volatile organic compounds (VOC) in urine, breath and faeces.The altered structure of the small intestinal mucosa, increased gut permeability and altered metabolism of gluten peptides, we hypothesised, would also change the microbiome, hence recognisable by its unique "fermentome" pattern, making it distinguishable from IBS. Aim: To determine if CD results in an altered VOC pattern in the urine, detectable by Field Asymmetric Ion Mobility Spectrometry (FAIMS), and distinguishable from the pattern in IBS.Methods: 47 patients were recruited, 27 with CD and 20 with diarrhea-predominant IBS (D-IBS).Urine was collected and 10 ml aliquots were stored frozen in universal containers.For assay, the containers were first heated to 40 ± 0.1oC.The headspace (the air above the sample) was then pumped from the containers and analysed by FAIMS (Owlstone, UK) .Linear discriminant analysis (LDA) was used for statistical evaluation.Results: LDA showed that FAIMS distinguishes the VOC pattern in CD vs D-IBS with a sensitivity and specificity of 85% respectively -see Figure .Conclusion: This pilot study suggests that FAIMS offers a novel non-invasive approach to identify those likely to have CD, and distinguishes from D-IBS.Further analysis using GCMS (Gas Chromatography and Mass Spectrometry) is underway to identify any chemical modulation.FAIMS also offers the potential to non-invasively track CD when on a gluten-free diet, to monitor adherence and observe changes.

BACKGROUND. Various definitions of biochemical failure (BF) have been used to predict cancer recurrence following prostate cryoablation. However to date, none of these definitions have been validated for this use. We have reviewed several definitions of BF to determine their accuracy in predicting biopsy-proven local recurrence following prostate cryoablation.METHODS. The Columbia University Urologic Oncology Database was queried for patients who underwent prostate cryoablation between 1994 and 2010, and who subsequently underwent surveillance biopsy due to clinical suspicion of prostate cancer recurrence. Serial postoperative prostate-specific antigen (PSA) results were used to determine BF according to various definitions of BF. Biopsy results were used to determine local recurrence. Sensitivity, specificity, positive and negative predictive value, and receiver operating characteristic (ROC) curve area were calculated for each of the BF definitions.RESULTS. A total of 110 patients met inclusion criteria for the study. These patients were treated with primary full-gland (n = 38), primary focal (n = 24), or salvage cryoablation (n 48). On surveillance biopsy, 66 patients (60%) were found to have locally recurrent prostate cancer. The most accurate BF definition overall was PSA nadir plus 2 ng/ml (Phoenix definition), with sensitivity, specificity, and ROC curve area of 68%, 59%, and 0.64, respectively.CONCLUSIONS. Overall, the Phoenix definition best predicted local cancer recurrence following prostate cryoablation. These preliminary data may be useful for researchers evaluating the short-term efficacy of cryoablation, and for urologists assessing their patients for potential cancer recurrence. Prostate 72: 1802-1808, 2012. (C) 2012 Wiley Periodicals, Inc.

You have accessJournal of UrologyProstate Cancer: Localized1 Apr 20111003 PROSTATE CRYOABLATION BEFORE AND AFTER SOLID ORGAN TRANSPLANTATION Philippa Cheetham, Scott Stevenson, Zahid Saeed, Max Pitman, Elton Llukani, and Aaron Katz Philippa CheethamPhilippa Cheetham New York, NY More articles by this author , Scott StevensonScott Stevenson New York, NY More articles by this author , Zahid SaeedZahid Saeed New York, NY More articles by this author , Max PitmanMax Pitman New York, NY More articles by this author , Elton LlukaniElton Llukani New York, NY More articles by this author , and Aaron KatzAaron Katz New York, NY More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1036AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Prostate cancer (PCa) is being diagnosed with increasing frequency due to routine PSA screening. To date, reported experiences with transplantation in men with a history of prostate cancer are limited to a few small studies. There are no prior studies reporting experiences with transplantation in men with PCa who have been treated with cryotherapy. The objective of this study was to report on outcomes for patients who had undergone prostate cryotherapy at our institution, either before or after solid organ transplantation. This study represents the first in the medical literature of transplant patients with PCa who have undergone prostate cryotherapy. METHODS A retrospective patient chart and Institutional Review Board (IRB) approved cryoablation database review of 900 consecutive cases of prostate cryoablation conducted between 1994 and 2010 at a single academic institution was performed. Those who had undergone a solid organ transplant before or after cryoablation were identifed. Data on relevant pre-, intra- and post treatment information was retrospectively reviewed. Data was collected on time interval from PCa diagnosis and prostate cryotherapy to transplantation or vice versa, immunosuppressive medication, biochemical and clinical recurrence rates and mortality (categorized as prostate cancer specific, transplant-related or unrelated mortality). RESULTS Seven patients who were or had been on the transplant register who had prostate cryotherapy for PCa were identified: 4 cardiac and 3 renal transplant recipients. Mean age at PCa diagnosis was 64.2 (50–78) years. Median preoperative PSA 9.2 (5.2–20.2) ng/ml. Mean Gleason score 7 (6–8). 4 were transplanted before undergoing prostate cryotherapy (3 cardiac, 1 renal). 3 were transplanted after having had prostate cryotherapy (1 cardiac, 2 renal). There were no PCa or transplant-related deaths. The only death was in a cardiac transplant recipient who died of lung adenocarcinoma 9 years after prostate cryotherapy, with an undetectable PSA at the time of death. CONCLUSIONS In conclusion, prostate cryotherapy is feasible as a minimally invasive treatment option for PCa in solid organ transplant recipients. Prostate cryotherapy is also a good PCa treatment option men awaiting transplantation, who require PCa treatment in order to meet the criteria for remaining on the transplant register. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e404 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Philippa Cheetham New York, NY More articles by this author Scott Stevenson New York, NY More articles by this author Zahid Saeed New York, NY More articles by this author Max Pitman New York, NY More articles by this author Elton Llukani New York, NY More articles by this author Aaron Katz New York, NY More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Purpose: We used a large, population based registry to assess whether a difference in overall and cardiovascular survival may exist between radical nephrectomy and partial nephrectomy for renal cell carcinoma 2 cm or less.Materials and Methods: From the SEER (Surveillance, Epidemiology and End Results) registry we identified 4,216 patients with histologically confirmed renal cell carcinoma 2 cm or less who were treated with partial or radical nephrectomy. Patient and tumor characteristics were compared between the 2 patient groups. Multivariate logistic regression was done to predict the odds of undergoing radical nephrectomy. Cardiovascular survival and overall survival were compared between the 2 cohorts, adjusting for patient and tumor characteristics.Results: Overall 2,301 patients (55%) underwent partial nephrectomy. Partial nephrectomy use steadily increased during the study period from 27% of all cases in 1998 to 66% in 2007. Patients who underwent partial nephrectomy were an average of 2.5 years younger than those treated with radical nephrectomy (56.4 vs 58.9 years, p < 0.001). They were more likely to be white and from the western or northeastern United States. Older age was the only independent predictor of radical nephrectomy (OR 1.02, 95% CI 1.01-1.03). When controlling for patient characteristics and surgery year, radical nephrectomy was associated with worse overall mortality (HR 2.24, 95% CI 1.75-2.84) and cardiovascular mortality (HR 2.53, 95% CI 1.51-4.23).Conclusions: Radical nephrectomy is associated with worse overall and cardiovascular survival compared to partial nephrectomy in patients with localized renal cell carcinoma 2 cm or less. These findings justify the widespread application of nephron sparing techniques to treat localized kidney cancer.

OBJECTIVE To examine socioeconomic and clinical factors that may predict a longer interval between prostate biopsy and radical prostatectomy (RP).METHODS The Columbia University Urologic Oncology Database was queried for patients who underwent RP from 1990-2010. Time to surgery (TTS) was defined as the period between the most recent positive prostate biopsy and date of surgery. Clinical factors examined included: age, D'Amico risk group, year of surgery, body mass index, and comorbidities. Socioeconomic factors included race/ethnicity, relationship status, income, and distance to treatment center. The relationship between clinical/socioeconomic factors and TTS was evaluated using univariate and multivariate regression models.RESULTS Two-thousand five-hundred seventy-three patients were included in the analysis. Median TTS was 48 days (IQR 35-70, range 43-1103), and 71% of patients underwent RP within 60 days after the most recent positive biopsy. On multivariate analysis, living further from the medical center was associated with shorter TTS (P = .01), whereas more recent year of surgery (P = .01), comorbid cardiovascular disease (P = .007), African-American (P = .005) or Hispanic race (P = .005), divorced relationship status (P = .01), and lower income (P = .003) were all associated with longer TTS.CONCLUSION Patients often experience widely variable intervals between the diagnosis and treatment of localized prostate cancer. Longer intervals before surgery may point to disparities in access to prostate cancer care, and not increased decision-making time by the patient. UROLOGY 80: 1027-1032, 2012. (C) 2012 Published by Elsevier Inc.

You have accessJournal of UrologyHistory of Urology Forum1 Apr 20111037 REGINALD HARRISON: PIONEERING UROLOGIC DISCOVERIES IN LATE 19TH CENTURY ENGLAND Max S. Pitman, Elton Llukani, Philippa J. Cheetham, and Aaron E. Katz Max S. PitmanMax S. Pitman New York, NY More articles by this author , Elton LlukaniElton Llukani New York, NY More articles by this author , Philippa J. CheethamPhilippa J. Cheetham New York, NY More articles by this author , and Aaron E. KatzAaron E. Katz New York, NY More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1073AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES A little-known figure in the modern urologic community, Mr. Reginald Harrison made enormous scholarly contributions to urology, particularly in the fields of bladder stones and prostate disease. METHODS Review of historical materials, including original articles, texts, and speeches by Mr. Harrison. RESULTS Reginald Harrison was born in Stafford, England, on August 24, 1837. He became a member of the Royal College of Surgeons in 1866, and practiced in Liverpool until 1889, when he joined the faculty at St. Peter's Hospital for Stone and Other Urinary Disease in London. He originally trained in general surgery but early in his career turned his attention to urologic disorders, soon becoming a pre-eminent expert in the field. He authored a well-known textbook, “Surgical Disorders of the Urinary Organs,” which went through four editions, as well as a number of original papers in the prominent surgical journals of England and America. In 1881, he reported on “A Case of Lithotomy where a Tumour of the Prostate Was Successfully Enucleated,” thus becoming one of the first physicians ever to describe the surgical excision of a prostate tumor. He would continue to advance his technique over the next 20 years, eventually publishing his results, “Cancer of the Prostate and the Selection of Cases for Suprapubic Prostatectomy,” in the British Medical Journal in 1903. Perhaps his greatest contribution to the study of prostate cancer, Harrison was among the first to recognize the high frequency of prostate cancer among patients with apparently benign prostatic enlargement. In the famous Bradshaw Lecture to the Royal College of Surgeons in 1896, he remarked, “I have long thought that slowly progressive carcinoma of the prostate is far more common than is generally believed to be the case.” He further noted that “to the naked eye [there is] but little to distinguish the specimen from ordinary hypertrophy.” This distinction marked a pivotal step toward understanding the natural history of prostate cancer, and helped pave the way for the great advances in diagnosis and treatment of the 20th Century. Mr. Harrison received a number of prestigious awards and appointments throughout his career, including Hunterian Professor of Pathology and Surgery at the Royal College of Surgeons, Honorary Fellow of the American Surgical Association, and President of the Medical Society of London. CONCLUSIONS The late 19th Century was a time of fruitful discovery throughout the medical sciences. Harrison was among the most influential surgeons of the time, and his great contributions to urology remain significant into the modern era. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e417 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Max S. Pitman New York, NY More articles by this author Elton Llukani New York, NY More articles by this author Philippa J. Cheetham New York, NY More articles by this author Aaron E. Katz New York, NY More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PURPOSE:Vitamin D has a well-known role in calcium metabolism and bone health. It may also help prevent a number of chronic diseases, including cardiovascular disease, diabetes and malignancies such as breast, colorectal and prostate cancer. To our knowledge the prevalence of vitamin D deficiency has never been reported in the general urological population. We evaluated the vitamin D status of this population at a large academic center.MATERIALS AND METHODS:We retrospectively reviewed the records of 3,763 male and female patients from a urology database at a single academic institution. Patients were identified whose levels of serum 25-hydroxyvitamin D were measured for the first time between 1997 and 2010. We determined the prevalence of normal--greater than 30, insufficient--20 to 29 and deficient--less than 20 ng/ml 25-hydroxyvitamin D. Logistic regression analysis was performed to identify risk factors for vitamin D deficiency.RESULTS:Overall 2,559 patients (68%) had suboptimal 25-hydroxyvitamin D (less than 30 ng/ml), of whom 1,331 (52%) were frankly deficient (less than 20 ng/ml) in the vitamin. Vitamin D deficiency was more common in patients younger than age 50 years (44.5%), black (53.2%) and Hispanic (41.6%) patients (p <0.001), and patients without an existing urological malignancy (35.4%, p <0.001). On multivariate analysis race, age, season and cancer diagnosis were independent predictors of vitamin D status.CONCLUSIONS:Vitamin D deficiency is extremely common in urological patients at a major urban medical center. Urologists should consider recommending appropriate supplementation during the initial assessment of all patients.

UNLABELLED:Study Type - Therapy (case series). Level of Evidence 4. What's known on the subject? and What does the study add? For patients electing surgical treatment, the question of the effect of surgical delay on clinical outcomes in prostate cancer is controversial. In this study we examined the effect of delay from diagnosis to surgery on outcomes in men with localized prostate cancer and found no association between time to surgery and risk of biochemical recurrence, even for patients with longer delays and high-risk disease. Men with localized prostate cancer can be reassured that reasonable delays in treatment will not influence disease outcomes.OBJECTIVE:• To examine the effect of time from last positive biopsy to surgery on clinical outcomes in men with localized prostate cancer undergoing radical prostatectomy (RP).PATIENTS AND METHODS:• We conducted a retrospective review of 2739 men who underwent RP between 1990 and 2009 at our institution. • Clinical and pathological features were compared between men undergoing RP ≤ 60, 61-90 and >90 days from the time of prostate biopsy. • A Cox proportional hazards model was used to analyse the association between clinical features and surgical delay with biochemical progression. Biochemical recurrence (BCR)-free rates were assessed using the Kaplan-Meier method.RESULTS:• Of the 1568 men meeting the inclusion criteria, 1098 (70%), 303 (19.3%) and 167 (10.7%) had a delay of ≤ 60, 61-90 and >90 days, respectively, between biopsy and RP. A delay of >60 days was not associated with adverse pathological findings at surgery. • The 5-year survival rate was similar among the three groups (78-85%, P= 0.11). • In a multivariate Cox model, men with higher PSA levels, clinical stages, Gleason sums, and those of African-American race were all at higher risk for developing BCR. • A delay to surgery of >60 days was not associated with worse biochemical outcomes in a univariate and multivariate model.CONCLUSIONS:• A delay of >60 days is not associated with adverse pathological outcomes in men with localized prostate cancer, nor does it correlate with worse BCR-free survival. • Patients can be assured that delaying treatment while considering therapeutic options will not adversely affect their outcomes.

You have accessJournal of UrologyKidney Cancer: Localized1 Apr 20111668 THE OVERUSE OF NEPHRON-WASTING RADICAL NEPHRECTOMY IN THE ELDERLY: AN ANALYSIS OF TRENDS IN THE UNITED STATES POPULATION FROM 1998–2007 Max Kates, Gina Badalato, Max Pitman, Arindam RoyChoudhury, and James McKiernan Max KatesMax Kates New York, NY More articles by this author , Gina BadalatoGina Badalato New York, NY More articles by this author , Max PitmanMax Pitman New York, NY More articles by this author , Arindam RoyChoudhuryArindam RoyChoudhury New York, NY More articles by this author , and James McKiernanJames McKiernan New York, NY More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1801AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Over the past 10 years, partial nephrectomy has become the standard of care for small renal masses. Elderly patients, often with multiple comorbid conditions, are likely to benefit from nephron-sparing surgery, yet surgeons may be hesitant to perform a more complex, lengthy procedure in this older cohort. We analyzed the utilization of radical nephrectomy (RN) and partial nephrectomy (PN) over a 10 year period in patients ≥75 years old compared to their younger counterparts. METHODS Using the Surveillance, Epidemiology, and End Results (SEER) registry, we identified 18,045 cases of localized Renal Cell Carcinoma (RCC) ≤4cm diagnosed between 1998 and 2007. Baseline differences in demographic and tumor characteristics were compared between the two age cohorts (<75 vs. ≥75), and rates of RN were determined, stratified by tumor size. A multivariate logistic regression model was then fitted to predict the odds of receiving a radical nephrectomy for clinical T1a disease. RESULTS Overall 2,733 (15%) patients were ≥75 years old. On univariate analysis, elderly patients were more likely to be Caucasian, female, and have slightly larger tumors (2.9cm vs 2.7cm, p<0.001 for all). The use of radical nephrectomy in all patients decreased over the study period (79% in 1998 to 49% in 2007). Overall, 66% of patients ≥75 yrs underwent RN for their disease, compared to 59% of patients <75 yrs (p<0.001). The disparity in use of RN between the two age groups was most pronounced for patients with the smallest tumors, such that 51% of patients ≥75 yrs with tumors ≤2 cm underwent RN, compared to 41% in the younger cohort (see figure). In a multivariate logistic model controlling for gender, race, tumor size, Fuhrman grade, and year of diagnosis, age≥75 independently predicted the use of radical nephrectomy (OR: 1.18; 95% CI: 1.08–1.29). A 1 year increase in age was associated with a 1% increase in risk of undergoing RN (OR:1.01; 95% CI: 1.01–1.01). CONCLUSIONS Elderly patients with clinically localized small renal masses receive RN more often than younger patients. Further studies should address the medical implications of the selective use of radical surgery within the geriatric population. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e670 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Max Kates New York, NY More articles by this author Gina Badalato New York, NY More articles by this author Max Pitman New York, NY More articles by this author Arindam RoyChoudhury New York, NY More articles by this author James McKiernan New York, NY More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

OBJECTIVE To analyze the use of radical nephrectomy (RN) and partial nephrectomy during a 10-year period in patients aged >= 75 years compared with their younger counterparts.METHODS Using the Surveillance, Epidemiology, and End Results registry, we identified 18 045 cases of localized renal cell carcinoma of <= 4 cm diagnosed from 1998 to 2007. The baseline differences in demographic and tumor characteristics were compared between the 2 age cohorts (<75 vs >= 75 years), and the rates of RN were determined, stratified by tumor size. A multivariate logistic regression analysis was conducted to predict the odds of undergoing radical nephrectomy for clinical Stage T1a disease.RESULTS Overall, 2733 patients (15%) were aged >= 75 years. The use of radical nephrectomy for clinical Stage T1a renal cell carcinoma decreased during the study period for all patients (79% in 1998 to 49% in 2007). Overall, 66% of patients aged >= 75 years underwent RN for their disease compared with 59% of patients aged <75 years (P < .001). For patients with tumors of <= 2 cm, 51% of those aged >= 75 years underwent RN compared with 41% of the younger cohort. In a multivariate logistic regression model, age >= 75 years independently predicted the use of radical nephrectomy (odds ratio 1.18, 95% confidence interval 1.08-1.29). A 1-year increase in age was associated with a 1% increase in the risk of undergoing RN (odds ratio 1.01, 95% confidence interval 1.01-1.01).CONCLUSION Elderly patients with clinically localized small renal masses are treated with RN more frequently than younger patients. Additional studies should address the medical implications of the increased use of radical surgery within the geriatric population. UROLOGY 78: 555-560, 2011. (C) 2011 Elsevier Inc.

OBJECTIVE To analyze the use of radical nephrectomy (RN) and partial nephrectomy during a 10-year period in patients aged 75 years compared with their younger counterparts. METHODS Using the Surveillance, Epidemiology, and End Results registry, we identified 18 045 cases of localized renal cell carcinoma of 4 cm diagnosed from 1998 to 2007. The baseline differences in demographic and tumor characteristics were compared between the 2 age cohorts (75 vs 75 years), and the rates of RN were determined, stratified by tumor size. A multivariate logistic regression analysis was conducted to predict the odds of undergoing radical nephrectomy for clinical Stage T1a disease. RESULTS Overall, 2733 patients (15%) were aged 75 years. The use of radical nephrectomy for clinical Stage T1a renal cell carcinoma decreased during the study period for all patients (79% in 1998 to 49% in 2007). Overall, 66% of patients aged 75 years underwent RN for their disease compared with 59% of patients aged 75 years (P .001). For patients with tumors of 2 cm, 51% of those aged 75 years underwent RN compared with 41% of the younger cohort. In a multivariate logistic regression model, age 75 years independently predicted the use of radical nephrectomy (odds ratio 1.18, 95% confidence interval 1.08-1.29). A 1-year increase in age was associated with a 1% increase in the risk of undergoing RN (odds ratio 1.01, 95% confidence interval 1.01-1.01). CONCLUSION Elderly patients with clinically localized small renal masses are treated with RN more frequently than younger patients. Additional studies should address the medical implications of the increased use of radical surgery within the geriatric population. UROLOGY 78: 555‐560, 2011. © 2011 Elsevier Inc.

Bladder cancer is a heterogeneous disease that offers a unique challenge for the patient and the physician as treatment paradigms are continually evolving. There are multiple factors that can influence how each individual is treated, including lymphovascular invasion, micropapillary histology, and p53 nuclear accumulation which have demonstrated a worse prognosis in patients with bladder cancer. They can influence the use of neoadjuvant and adjuvant chemotherapy, which in itself can affect the timing of extirpative surgery. This review will focus on the contemporary management and treatment of bladder cancer focusing on areas of clinical decision making.