INTRODUCTION:Herein, we provide a review of the indications, practical considerations, and interpretation of urodynamics (UDS) with or without fluoroscopy, as well as cystourethroscopy, for women with suspected bladder outlet obstruction (BOO). METHODS AND RESULTS:A narrative review was performed focusing on the current primary literature and society guidelines around advanced diagnostic modalities for female BOO patients. UDS studies help diagnose BOO by identifying high-pressure low-flow voiding patterns and/or the characteristic radiographic appearance of the bladder neck and urethra during micturition. Cystourethroscopy aids in evaluating structural aberrations of the bladder outlet, and in surgical planning. CONCLUSIONS:UDS studies and cystourethroscopy are useful adjuncts in carefully-selected female patients with suspected BOO.

OBJECTIVE:To analyze the factors and costs associated with 30-day readmissions for patients undergoing radical nephrectomy. MATERIALS AND METHODS:We used the 2014 Nationwide Readmission Database to identify adults who underwent radical nephrectomy for renal cancer, stratified by surgical approach. We determined patient factors associated with readmission rates, diagnoses, and costs using multivariate logistic regression. RESULTS:Among 19,523 individuals, the 30-day readmission rate was 7.7% (n = 1,506). On multivariate regression, odds of readmission were significantly increased with age ≥75 in those who underwent open nephrectomy (OR: 1.35; 95%CI: 1.03-1.78). Subjects with a Charlson comorbidity score ≥3 had significantly higher rates of readmission regardless of surgical approach (Open RN - OR: 1.85; 95%CI: 1.33-2.56; Lap RN - OR: 1.99; 95%CI 1.10-3.59; Robotic RN - OR: 2.18; 95%CI: 1.23-3.86). Common reasons for readmission were gastrointestinal, cardiovascular, urinary tract infections, and wound complications across all surgical approaches. The mean cost per readmission was as high as 126% ($20,357) of the mean index admission cost. CONCLUSION:One in 13 adults undergoing radical nephrectomy is readmitted within 30 days of discharge. Associated readmission cost is up to 1.26 times the cost of index admission. Our findings may inform efforts aiming to reduce hospital readmissions and curtail healthcare costs.

OBJECTIVE:To describe the risk of multiple recurrences in intermediate-risk non-muscle invasive bladder cancer (IR-NMIBC) and their impact on progression. Prognostic studies of IR-NMIBC have focused on initial recurrences, yet little is known about subsequent recurrences and their impact on progression. MATERIALS AND METHODS:IR-NMIBC patients from the Be-Well Study, a prospective cohort study of NMIBC patients diagnosed from 2015 to 2019 at Kaiser Permanente Northern California, were identified. The frequency of first, second, and third intravesical recurrences of urothelial carcinoma were characterized using conditional Kaplan-Meier analyses and random-effects shared-frailty models. The association of multiple recurrences with progression was examined. RESULTS:In 291 patients with IR-NMIBC (median follow-up 38 months), the 5-year risk of initial recurrence was 54.4%. After initial recurrence (n = 137), 60.1% of patients had a second recurrence by 2 years. After second recurrence (n = 70), 51.5% of patients had a third recurrence by 3 years. In multivariable analysis, female sex (Hazard Ratio 1.51, P< .01), increasing tumor size (HR 1.14, P< .01) and number of prior recurrences (HR 1.24, P< .01) were associated with multiple recurrences; whereas maintenance BCG (HR 0.66, P = .03) was associated with reduced recurrences. The 5-year risk of progression varied significantly (P< .01) by number of recurrences: 9.5%, 21.9%, and 37.9% for patients with 1, 2, and 3+ recurrences, respectively. CONCLUSIONS:Multiple recurrences are common in IR-NMIBC and are associated with progression. Female sex, larger tumors, number of prior recurrences, and lack of maintenance BCG were associated with multiple recurrences. Multiple recurrences may prove useful as a clinical trial endpoint for IR-NMIBC.

OBJECTIVE:To describe the incidence, clinical and demographic factors, and treatment patterns associated with discordant elevated alpha-fetoprotein (AFP) findings in patients with pure seminomatous histology. METHODS:We queried the National Cancer Database to identify patients with testicular germ cell tumors (GCT) diagnosed in 2011-2015. Patients were grouped based on histologic diagnosis and pre-operative serum AFP level. RESULTS:Of 18,616 patients diagnosed with testicular GCT, 53% (N = 9,849) had pure seminomatous histology, of whom 8.3% (N = 821) had an elevated serum AFP pre-operatively. Non-white patients with seminoma were more likely to have a pre-op elevated AFP (OR 1.42; 95% CI: 1.10-1.83); patients treated at higher volume centers were less likely to have a pre-op elevated AFP (0.66, 95% CI: 0.53-0.83). Patients with seminoma with elevated AFP received adjuvant radiation more frequently than those with NSGCT (Stage I: 15% vs 0.2%, P <.01; Stage II: 21.9% vs 0.1%, P <.01) and less frequently underwent retroperitoneal lymph node dissection (RPLND) (Stage 1: 1.9% vs 11.1% P <.01; Stage II: 8.8% vs 17.4%, P <.01). CONCLUSION:The detection of elevated serum alpha-fetoprotein (AFP) in patients with pure seminomatous testicular germ cell tumors (GCT) is a discordant finding that implies the presence of occult non-seminomatous GCT (NSGCT) elements. 8% of patients with pure seminomatous GCTs had diagnostically discordant elevated pre-operative AFP levels. Despite recommendations to manage these patients as NSGCT, patients with seminoma and elevated AFP were managed in a fashion comparable to those with seminoma and normal AFP levels.

You have accessJournal of UrologyHealth Services Research: Value of Care: Cost and Outcomes Measures II (PD25)1 Sep 2021PD25-10 COST-UTILITY ANALYSIS IN UROLOGY Katherine Fero, Vidit Sharma, Patrick Lec, Christopher Saigal, and Karim Chamie Katherine FeroKatherine Fero More articles by this author , Vidit SharmaVidit Sharma More articles by this author , Patrick LecPatrick Lec More articles by this author , Christopher SaigalChristopher Saigal More articles by this author , and Karim ChamieKarim Chamie More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002018.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Cost-effectiveness analysis (CEA) defines value in healthcare by quantifying the benefit of an intervention for a given dollar expense. Cost-utility analysis (CUA) is a type of CEA that quantifies an intervention’s health benefits in terms of quality-adjusted life years (QALY’s). Understanding the CUA supporting an intervention is valuable in defining its best use. Here we characterize the state of cost-utility research in urology by evaluating the quality of published studies and reporting adherence to methodological guidelines. METHODS: We performed an analysis of all CUAs in the Cost-Effectiveness Analysis Registry (CEAR) published between 1976 and 2019. Studies on topics related to urology were screened by diagnosis code and then by title review. Studies were assigned to a urologic subspecialty by abstract review. Intervention studied, perspective, and quality score (1-7) are reported per CEAR abstraction processes. Associations between study characteristics and quality scores were evaluated using the Pearson product moment correlation coefficient. Mean quality scores between subspecialties were compared with ANOVA. RESULTS: 9080 articles were screened; 254 (2.8%) were pertinent to urology and were included in this analysis. There was an increase in studies published over the study period with a peak in 2013 (Figure 1a). Figure 1b shows the distribution of studies published by subspecialty. There were more CUA of pharmaceuticals than surgeries (38% vs 26%). Few modeled a reference case from the societal perspective (15%), most were from a payer perspective (62.6%). There was no change in proportion of studies reporting reference case from a societal perspective after the publication of guidelines recommending its use (p=0.38). A more recent publication year was associated with a higher study quality score (correlation co-efficient 0.18; p=0.004). No differences in quality were found by subspecialty (p=0.2), or between urology and non-urology CUA (mean score 4.7 vs 4.7). CONCLUSIONS: CUAs in urology make up a small fraction of published CEA research. More numerous and higher quality analyses have been published in recent years. Surgical interventions are understudied in urology and should be an area of focus for future analysis. Attention should be paid to methodological rigor, including use of recommended reference case perspective, when CEAs are considered for publication. Source of Funding: KEF Supported by H&H Lee Surgical Scholars (UCLA) © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e435-e436 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Katherine Fero More articles by this author Vidit Sharma More articles by this author Patrick Lec More articles by this author Christopher Saigal More articles by this author Karim Chamie More articles by this author Expand All Advertisement Loading ...

resistance. Furthermore, protein expression pro fi les of selected proteins of the akt/mTOR signaling pathway demonstrated an upregulation of pAKT, p4EBP1 and pmTOR in both resistant cell lines compared to therapy-naïve cells. Therapeutic potential of this pathway was further corroborated by ef fi cacy testing of everolimus. CONCLUSIONS: Resistance patterns and mechanisms were identi fi ed, emphasizing the involvement of the AKT/mTOR signaling pathway and paving the way for development of novel treatment strategies in PeCa. Targeting this pathway might prolong ef fi cacy of therapeutic regimens or induce a re-sensitization of treatment-resistant PeCa cells.

BACKGROUND:Monitoring surgical recovery has traditionally been confined to metrics measurable within the hospital and clinic setting. However, commercially available mobile sensors are now capable of extending measurements into a patient's home. As these sensors were developed for nonmedical applications, their clinical role has yet to be established. The aim of this systematic review is to evaluate the relationship between data generated by mobile sensors and postoperative outcomes.OBJECTIVE:The objective of this study is to describe the current use of mobile sensors in the perioperative setting and the correlation between their data and clinical outcomes.METHODS:A systematic search of EMBASE, MEDLINE, and Cochrane Library from inception until April 2019 was performed to identify studies of surgical patients monitored with mobile sensors. Sensors were considered if they collected patient metrics such as step count, temperature, or heart rate. Studies were included if patients underwent major surgery (≥1 inpatient postoperative day), patients were monitored using mobile sensors in the perioperative period, and the study reported postoperative outcomes (ie, complications and hospital readmission). For studies including step count, a pooled analysis of the step count per postoperative day was calculated for the complication and noncomplication cohorts using mean and a random-effects linear model. The Grading of Recommendations, Assessment, Development, and Evaluation tool was used to assess study quality.RESULTS:From 2209 abstracts, we identified 11 studies for review. Reviewed studies consisted of either prospective observational cohorts (n=10) or randomized controlled trials (n=1). Activity monitors were the most widely used sensors (n=10), with an additional study measuring temperature, respiratory rate, and heart rate (n=1). Low step count was associated with worse postoperative outcomes. A median step count of around 1000 steps per postoperative day was associated with adverse surgical outcomes. Within the studies, there was heterogeneity between the type of surgery and type of reported postoperative outcome.CONCLUSIONS:Despite significant heterogeneity in the type of surgery and sensors, low step count was associated with worse postoperative outcomes across surgical specialties. Further studies and standardization are needed to assess the role of mobile sensors in postoperative care, but a threshold of approximately 1000 steps per postoperative day warrants further investigation.

Objectives: To investigate treatment patterns of partial cystectomy (PC), neoadjuvant chemotherapy (NAC), lymph node dissection (LND), and treatment delays, and the associations with overall survival (OS) among patients with muscle-invasive bladder cancer. Patients and Methods: We identified patients with cT2-4cN0cM0 urothelial carcinoma of the bladder in the National Cancer Database who underwent PC from 2007 through 2015. We performed descriptive statistics and assessed temporal trends using the Cochrane-Armitage test. Our outcomes of interest were NAC, LND, and treatment delay defined as >= 8 or >= 12 weeks for patients who underwent NAC or upfront surgery, respectively. We used logistic regression and multivariable Cox proportional hazards models to evaluate predictors and associations with OS, respectively. Results: A total of 9,199 patients met inclusion criteria. Over the study period, PC utilization decreased from 9% to 7% (P = 0.06). Compared with patients who underwent radical cystectomy, patients treated with PC less frequently received NAC (7% vs. 17%, P < 0.01) and LND (57% vs. 91%, P < 0.01), but were less likely to experience treatment delays (25% vs. 31%, P < 0.01). Only 4.1% (27/655) of patients treated with PC received the combination of NAC, LND, and no treatment delay. In a Cox model, adequacy of LND was associated with improved OS (<10 nodes: HR 0.62, 95% CI 0.48-0.81 and >= 10 nodes: HR 0.48, 95% CI 0.32-0.72). Conclusion: PC is uncommon and associated with poorer utilization of NAC and LND, but fewer treatment delays. The adequacy of LND was associated with improved OS while NAC and treatment delay were not. (C) 2021 Elsevier Inc. All rights reserved.

You have accessJournal of UrologyBladder Cancer: Non-invasive I (PD09)1 Sep 2021PD09-08 ADVERSE EVENTS AFTER TRANSURETHRAL RESECTION OF INTERMEDIATE-RISK NON-MUSCLE INVASIVE BLADDER CANCER Vidit Sharma, David S Aaronson, Katherine E Fero, Patrick M Lec, Karim Chamie, Valerie S Lee, Charles Quesenberry, Julie R Munneke, Mark Schoenberg, Lawrence H Kushi, Li Tang, and Marilyn L Kwan Vidit SharmaVidit Sharma More articles by this author , David S AaronsonDavid S Aaronson More articles by this author , Katherine E FeroKatherine E Fero More articles by this author , Patrick M LecPatrick M Lec More articles by this author , Karim ChamieKarim Chamie More articles by this author , Valerie S LeeValerie S Lee More articles by this author , Charles QuesenberryCharles Quesenberry More articles by this author , Julie R MunnekeJulie R Munneke More articles by this author , Mark SchoenbergMark Schoenberg More articles by this author , Lawrence H KushiLawrence H Kushi More articles by this author , Li TangLi Tang More articles by this author , and Marilyn L KwanMarilyn L Kwan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001977.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The transurethral resection of bladder tumor (TURBT) is a common urologic procedure with a reported complication rate of about 5% according to administrative data. However, such data sources may underestimate the frequency of “adverse events” that are not easily classified using administrative codes and do not usually account for co-occurring adverse events. Here, we analyze TURBT-associated adverse events from a prospective cohort of intermediate risk non-muscle invasive bladder cancer (IR-NMIBC) patients, a subgroup with highly variable prognosis. METHODS: The Be-Well Study, a prospective cohort of NMIBC patients treated at Kaiser Permanente Northern California from 2015-2019, was queried for patients meeting criteria for IR-NMIBC. Adverse events were identified using a combination of electronic medical record review, ICD-10-CM codes, CPT codes, and pharmacy prescription data. Adverse events were examined individually and according to Clavien-Dindo Classification at a primary endpoint of 90 days and with secondary endpoints beyond 90 days . RESULTS: In a prospective cohort of 291 IR-NMIBC patients, 103 (35.4%) experienced at least one adverse event (Figure 1) within 90 days of initial TURBT, with the most common events being: urinary tract infection (n=74, 25.4%), lower urinary tract symptoms requiring a new anticholinergic prescription at least 8 days after TURBT (n=21, 7.2%), and urinary retention requiring catheter replacement (n=19, 6.5%). Patients who had at least one adverse event had a 38.8% risk of a second adverse event. Notably, 71.4% (15/21) of patients who received an anticholinergic within 90 days of TURBT re-filled their prescription at least once after 90 days beyond TURBT. The incidence of Clavien-Dindo Grade III or higher events was 1.7% (n=5). ICD-10-CM codes alone had a sensitivity of 57.8% for detecting adverse events. CONCLUSIONS: About one-third of patients undergoing TURBT will experience an adverse event within 90 days, and about one-third of them will experience a second adverse event, suggesting that the existing literature may underestimate the impact of this procedure. These data can provide more accurate expectations to assist patient counseling prior to TURBT and identify opportunities to reduce adverse events. Source of Funding: Vidit Sharma is supported by the VA HSRD fellowship © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e122-e122 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Vidit Sharma More articles by this author David S Aaronson More articles by this author Katherine E Fero More articles by this author Patrick M Lec More articles by this author Karim Chamie More articles by this author Valerie S Lee More articles by this author Charles Quesenberry More articles by this author Julie R Munneke More articles by this author Mark Schoenberg More articles by this author Lawrence H Kushi More articles by this author Li Tang More articles by this author Marilyn L Kwan More articles by this author Expand All Advertisement PDF downloadLoading ...

Background Upper tract urothelial carcinoma (UTUC) is a heterogeneous disease that presents a clinical management challenge for the urologic surgeon. We assessed treatment patterns, costs, and survival outcomes among patients with nonmetastatic UTUC. Methods We identified 4114 patients diagnosed with nonmetastatic UTUC from 2004 to 2013 in the Survival Epidemiology, and End Results-Medicare population-based database. Patients were stratified into low- or high-risk disease groups. Median total costs from 30 days prior to diagnosis through 365 days after diagnosis were compared between groups. Overall and cancer-specific survival were evaluated using Cox proportional hazards regression. All statistical tests were 2-sided. Results After risk stratification, 1027 (24.9%) and 3087 (75.0%) patients were classified into low- vs high-risk UTUC groups. Most patients underwent at least 1 surgical intervention (95.1%); 68.4% underwent at least 1 endoscopic intervention. Patients diagnosed with high- vs low-risk UTUC were more likely to undergo nephroureterectomy (83.6% vs 72.0%; P < .001); few patients with low-risk disease were exclusively managed endoscopically (16.9%). At 365 days after diagnosis, costs of care for high- vs low-risk UTUC were statistically significantly higher ($108 520 vs $91 233; median difference $16 704, 95% confidence interval [CI] = $11 619 to $21 778; P < .001). Those with high-risk UTUC had worse cancer-specific and overall survival compared with patients with low-risk UTUC (cancer-specific survival hazard ratio [HR] = 4.14, 95% CI = 3.19 to 5.37; overall survival HR = 1.78, 95% CI = 1.62 to 1.96). Conclusions UTUC continues to be managed primarily with nephroureterectomy, regardless of risk stratification, and patients with high-risk UTUC have worse overall and cancer-specific survival. Substantial costs are associated with management of low- and high-risk UTUC, with the latter being more costly up to 1 year from diagnosis.

You have accessJournal of UrologyHealth Services Research: Value of Care: Cost and Outcomes Measures II (PD25)1 Sep 2021PD25-03 THE INCIDENCE AND PREDICTORS OF FINANCIAL TOXICITY IN A PROSPECTIVE COHORT OF PATIENTS WITH NON-MUSCLE INVASIVE BLADDER CANCER Vidit Sharma, Katherine E Fero, Patrick M Lec, Valerie S Lee, Isaac J Ergas, Janise M Roh, Karim Chamie, Mark Schoenberg, David S Aaronson, Devon K Check, Reina Haque, Lawrence H Kushi, Li Tang, and Marilyn L Kwan Vidit SharmaVidit Sharma More articles by this author , Katherine E FeroKatherine E Fero More articles by this author , Patrick M LecPatrick M Lec More articles by this author , Valerie S LeeValerie S Lee More articles by this author , Isaac J ErgasIsaac J Ergas More articles by this author , Janise M RohJanise M Roh More articles by this author , Karim ChamieKarim Chamie More articles by this author , Mark SchoenbergMark Schoenberg More articles by this author , David S AaronsonDavid S Aaronson More articles by this author , Devon K CheckDevon K Check More articles by this author , Reina HaqueReina Haque More articles by this author , Lawrence H KushiLawrence H Kushi More articles by this author , Li TangLi Tang More articles by this author , and Marilyn L KwanMarilyn L Kwan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002018.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Even though non-muscle invasive bladder cancer (NMIBC) has high costs care, the patient-level impact of this cost (“financial toxicity”) has been understudied. We describe predictors and quality-of-life (QOL) implications of financial toxicity in a prospective cohort of NMIBC survivors. METHODS: The Bladder Cancer Epidemiology, Wellness, and Lifestyle Study is a prospective cohort of newly diagnosed NMIBC patients at Kaiser Permanente Northern and Southern California. Financial toxicity was assessed using the COST-FACIT questionnaire (scale 0 to 44, with lower score having more financial toxicity) at 2-years post-diagnosis. QOL was assessed using the PROMIS global health questionnaire’s physical and mental health domains at 2-years post-diagnosis. Demographic and oncologic associations with financial toxicity were examined using descriptive statistics and multivariable generalized linear regression models. RESULTS: In a cohort of 412 participants, the mean (SD) COST and PROMIS physical and mental health QOL scores at 2-years post-diagnosis were: 36.6 (7.3), 16.2 (2.3), 15.4 (2.7), respectively. The correlation between the COST and PROMIS physical and mental health scores was r=0.36 (p<0.01) and r=0.38 (p<0.01), respectively, suggesting a modest association between financial toxicity and QOL. Between 4–16% of participants reported some financial strain from NMIBC on specific COST questions (Figure 1). At 2-years, 5% of patients described the financial burden of NMIBC as being significant, and 2% of patients experienced financial distress from treating their cancer. On regression analysis, younger age (coefficient -0.12, p<0.01) and NMIBC progression (coefficient -2.9, p=0.04) were associated with increased financial toxicity (reduced COST score). Gender or race/ethnicity were not significantly associated with financial toxicity. CONCLUSIONS: In a vertically integrated health system, financial toxicity from NMIBC was less prevalent than reported in prior studies in conventional health systems. However, younger age and NMIBC progression were associated with increased financial toxicity, suggesting a need to identify mitigation strategies for such patients. Source of Funding: Vidit Sharma is supported by the VA HSRD fellowship © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e432-e432 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Vidit Sharma More articles by this author Katherine E Fero More articles by this author Patrick M Lec More articles by this author Valerie S Lee More articles by this author Isaac J Ergas More articles by this author Janise M Roh More articles by this author Karim Chamie More articles by this author Mark Schoenberg More articles by this author David S Aaronson More articles by this author Devon K Check More articles by this author Reina Haque More articles by this author Lawrence H Kushi More articles by this author Li Tang More articles by this author Marilyn L Kwan More articles by this author Expand All Advertisement Loading ...

IMPORTANCE:Bladder cancer is a common malignancy in women and is the fourth most common malignancy in men. Bladder cancer ranges from unaggressive and usually noninvasive tumors that recur and commit patients to long-term invasive surveillance, to aggressive and invasive tumors with high disease-specific mortality.OBSERVATIONS:Advanced age, male sex, and cigarette smoking contribute to the development of bladder cancer. Bladder tumors can present with gross or microscopic hematuria, which is evaluated with cystoscopy and upper tract imaging depending on the degree of hematuria and risk of malignancy. Non-muscle-invasive tumors are treated with endoscopic resection and adjuvant intravesical therapy, depending on the risk classification. Enhanced cystoscopy includes technology used to improve the detection of tumors and can reduce the risk of recurrence. Patients with high-risk non-muscle invasive tumors that do not respond to adjuvant therapy with the standard-of-care immunotherapy, bacille Calmette-Guérin (BCG), constitute a challenging patient population to manage and many alternative therapies are being studied. For patients with muscle-invasive disease, more aggressive therapy with radical cystectomy and urinary diversion or trimodal therapy with maximal endoscopic resection, radiosensitizing chemotherapy, and radiation is warranted to curb the risk of metastasis and disease-specific mortality. Treatment of patients with advanced disease is undergoing rapid changes as immunotherapy with checkpoint inhibitors, targeted therapies, and antibody-drug conjugates have become options for certain patients with various stages of disease.CONCLUSIONS AND RELEVANCE:Improved understanding of the molecular biology and genetics of bladder cancer has evolved the way localized and advanced disease is diagnosed and treated. While intravesical BCG has remained the mainstay of therapy for intermediate and high-risk non-muscle-invasive bladder cancer, the therapeutic options for muscle-invasive and advanced disease has expanded to include immunotherapy with checkpoint inhibition, targeted therapies, and antibody-drug conjugates.

Background: Palliative care has an established role in improving the quality of life in patients with advanced cancer, but little is known regarding its delivery among patients with urologic malignancies. Objective: To determine trends in the utilization of palliative interventions among patients with advanced bladder, prostate, and kidney cancer. Design, Setting, and Participants: We performed a retrospective cohort study of patients from years 2004 to 2013 in the National Cancer Database diagnosed with stage IV bladder (n = 17,997), prostate (n = 23,322), and kidney (n = 34,697) cancer, after excluding those with missing disease stage, treatment, and outcomes data. Outcome Measurements and Statistical Analysis: Descriptive statistics and logistic regression were performed to evaluate utilization of palliative care intervention. Utilization was analyzed by cancer type and by overall survival strata (< 6, 6-24, and > 24 months). Kaplan-Meier and Cox proportional hazards models analyzed overall survival. Results and Limitations: Palliative interventions were utilized in 12.5% (2,257/17,997), 14.7% (3,442/23,322), and 19.9% (6,935/34,697) of advanced bladder, prostate, and kidney cancer patients, respectively. Older age and longer survival were associated with lower odds of palliative intervention utilization in each malignancy, as was minority race in kidney and bladder cancer patients. Palliative radiation was used most commonly, and utilization of any palliative intervention was associated with poorer overall survival. Limitations largely stem from imperfect data abstraction, and the analysis of interventions' incomplete reflection of palliative care. Conclusions: Palliative interventions were seldom used among patients with advanced urologic malignancies. Palliative interventions were less frequently used in older patients and minority races. Further study is warranted to define the role of palliative interventions in advanced urologic malignancies and guide their utilization. (C) 2020 Elsevier Inc. All rights reserved.

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Quality of Life and Shared Decision Making II (MP12)1 Apr 2020General & Epidemiological Trends & Socioeconomics: Practice Patterns, Quality of Life and Shared Decision Making II (MP12) View All Author Informationhttps://doi.org/10.1097/JU.0000000000000832AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Expand All Advertisement PDF downloadLoading ...

Postoperative ileus (POI) and constipation are common secondary effects of opioids and carry significant clinical and economic impacts. μ-Opioid receptors mediate opioid analgesia in the central nervous system (CNS) and gastrointestinal-related effects in the periphery. Peripherally acting μ-opioid receptor antagonists (PAMORAs) block the peripheral effects of opioids in the gastrointestinal tract, while maintaining opioid analgesia in the CNS. While most are not approved for POI or postoperative opioid-induced constipation (OIC), PAMORAs have a potential role in these settings via their selective effects on the μ-opioid receptor. This review will discuss recent clinical trials evaluating the safety and efficacy of PAMORAs, with a focus on alvimopan (Entereg®) and methylnaltrexone (Relistor®) in patients with POI or postoperative OIC. We will characterize potential factors that may have impacted the efficacy observed in phase 3 trials and discuss future directions for the management and treatment of POI.

Background: High-risk ureteral tumors represent an understudied subset of upper tract urothelial carcinoma, whose surgical management can range from a radical nephroureterectomy (NU) to segmental ureterectomy (SU). Objectives: To evaluate contemporary trends in the management of high-risk ureteral tumors, the utilization of lymphadenectomy and peri-operative chemotherapy, and their impact on overall survival (OS). Design, setting, and participants: We performed a retrospective cohort study of patients in the National Cancer Database from years 2006 to 2013 with clinically localized high-risk ureteral tumors treated with NU or SU. Outcome measurements and statistical analysis: Chi-squared tests were utilized to assess differences in clinicodemographic features and peri-operative treatment delivery between SU and NU cohorts. Cochran-Armitage tests and linear regressions were performed to evaluate temporal trends in treatment utilization. Multivariable logistic regression models were employed to assess predictors of treatment delivery. Multivariable Cox proportional hazards models evaluated associations with OS. Results: Of the 1,962 patients included, NU was more commonly performed than SU (72.4%, 1,421/1,962 vs. 27.6%, 541/1,962). Only 22.7% (446/1,962) of the population underwent lymphadenectomy, and 24.8% (271/1,092) of those with advanced pathology (>= pT2 or pN +) received adjuvant chemotherapy. Lymphadenectomy was associated with improved OS in NU patients when more than 3 nodes were removed (hazard ratio [HR] 0.58, 95% confidence interval [CI] 0.39-0.89). Receipt of adjuvant chemotherapy for advanced pathology had no impact OS in both the NU (HR 1.10, 95% CI 0.84-1.44) and SU (HR 0.94, 95% CI 0.61-1.46) cohorts. Performance of SU was not associated with poorer OS on multivariable analysis (HR 1.02, 95% CI 0.89-1.21, P = 0.83). Conclusion: Our study suggests that SU may be an appropriate alternative to NU for the management of high-risk ureteral tumors. Further, lymphadenectomy may play an important role at the time of NU, and adjuvant chemotherapy is infrequently utilized in patients with advanced pathology. (C) 2020 Elsevier Inc. All rights reserved.

To assess the impact of N-methylnaltrexone, a peripherally acting mu-opioid receptor antagonist, on the post-operative recovery of patients undergoing robotic-assisted radical cystectomy for bladder cancer. We retrospectively reviewed patients undergoing robotic-assisted radical cystectomy by a single surgeon (KC) prior to (control group) and after (treatment group) the routine use of N-methylnaltrexone. Kaplan–Meier curves and the log-rank test were used to quantify time to flatus, bowel movement, and discharge. Daily mean opioid use, daily pain assessment rating, and episodes of severe pain (7–10/10) were compared. Gastrointestinal-related complications, including ileus, emesis, and/or need for post-op nasogastric tube placement, and 30-day readmissions were also compared between groups. Charge capture data were compared between groups to analyze cost impact. 29 patients each in the control and treatment group met inclusion criteria. Patients receiving N-methylnaltrexone had reduced length of stay compared with no N-methylnaltrexone (median 4 vs. 7 days, p < 0.01). Time to flatus and bowel movement, however, were similar. In a multivariable analysis controlling for possible confounders, however, the improvement in length of stay associated with N-methylnaltrexone use did not reach statistical significance (p = 0.11). Episodes of severe pain and composite gastrointestinal-related complications were reduced in the N-methylnaltrexone group (44.8% vs. 10.3%, p < 0.01). The reduction in length of stay was associated with approximately $10,500 in cost savings per patient. In this study, N-methylnaltrexone was associated with reduced length of stay, fewer episodes of severe pain, and reduced costs. These results provide the impetus for further study.

INTRODUCTION:Renal mass biopsy (RMB) may not be indicated when the results are unlikely to impact management, such as in young and/or healthy patients and in elderly and/or frail patients. We analyzed the utility of RMB in three patient cohorts stratified by age-adjusted Charlson comorbidity index score (ACCI).MATERIALS AND METHODS:We identified patients with cT1a renal tumors in the National Cancer Database from 2004-2014. We combined age and Charlson-Deyo scores to identify young and/or healthy patients ('healthy-ACCI'), elderly and/or frail patients ('frail-ACCI'), and a reference cohort. We performed multivariable logistic regression to identify predictors of RMB and treatment. We evaluated the impact of RMB on management by analyzing the proportion of high-grade disease on final pathology as a surrogate for risk stratification.RESULTS:We identified 36,720 healthy-ACCI, 2,516 frail-ACCI, and 18,989 reference-ACCI patients. Healthy-ACCI patients were less likely to undergo RMB (7.5% versus 10.8%; p < 0.001) while frail-ACCI patients underwent RMB at similar rates (11.8% versus 10.8%; p = 0.14) compared with reference-ACCI patients. On multivariable logistic regression, in both healthy-ACCI and frail-ACCI patients, RMB was associated with decreased odds of surgical treatment, and increased odds of ablation and surveillance (all p < 0.01). In the frail-ACCI patients, higher grade disease at surgery was identified in the RMB cohort (32.9% versus 23.5%, p = 0.05).CONCLUSIONS:RMB is performed less frequently in healthy-ACCI patients compared with the reference cohort. RMB is associated with decreased odds of surgical treatment and increased odds of surveillance and ablation in all cohorts. In frail-ACCI patients who underwent surgery, RMB may provide additional risk stratification as these patients had lower rates of low-grade disease.

INTRODUCTION:Radical cystectomy (RC) is the standard of care for refractory high-risk non-muscle invasive bladder cancer (NMIBC). We aim to identify predictors of adequate lymph node dissection (LND) in a cohort of NMIBC patients undergoing RC, as well as its impact on clinical outcomes. METHODS:The National Cancer Database was queried for patients who underwent RC for urothelial cell carcinoma for clinical stage Tis/a/1 N0M0 disease between 2004 and 2013. Patients were stratified by LND: none, inadequate (<10) or adequate (≥10 nodes). Factors associated with LND were analyzed. Inverse-probability weighted propensity score matching was used to assess the impact of adequate LND on overall survival. RESULTS:The final cohort of 3,226 patients had a median follow-up of 39.0 months, had a mean age of 65.3 years, was 70% male, and was 81% Caucasian. Overall, 16.6% received no LND, 28.5% inadequate LND, and 55.0% adequate LND. Treatment at an academic facility, Charlson-Deyo Comorbidity score of 1, and later year of treatment were significantly associated with adequate LND. Overall survival was significantly higher with adequate LND compared to a matched-cohort of inadequate LND patients (68.7% vs. 60.6% at 5 years, P < 0.01). CONCLUSIONS:Nearly half of NMIBC patients undergoing RC do not receive an adequate LND, despite an association with increased overall survival. Treatment at an academic facility was associated with increased likelihood of adequate LND. Initiatives to improve adequate LND in this population may be warranted.