Critical care therapy and in-hospital mortality after radical nephroureterectomy for nonmetastatic upper urinary tract carcinoma.

BACKGROUND: Use of critical care therapies (CCT), that include invasive mechanical ventilation (IMV), total parenteral nutrition (TPN) and other modalities are unknown after radical nephroureterectomy (RNU) for upper urinary tract carcinoma (UUTC). Their relationship with in-hospital mortality is also unknown. METHODS: Within the National Inpatient Sample (2008-2019), we identified non-metastatic UUTC patients treated with RNU. Multivariable logistic regression models were used. RESULTS: Of 8,995 patients, 375 (4.2%) received CCT and 82 (0.9%) experienced in-hospital mortality. Of CCT modalities, 215 (2.4%) received IMV and 139 (1.5%) TPN. Temporal CCT, IMV, and TPN trends very closely followed in-hospital mortality trends. Relative to historical UUTC patients (2008-2013), contemporary (2014-2019) patients exhibited lower CCT (Δ = 2.2%, P value < 0.0001), lower IMV (Δ = 1.4%, P < 0.0001), lower TPN (Δ = 2.2%, P < 0.0001), and lower in-hospital mortality (Δ = 0.4%, P = 0.03) rates. Of in-hospital mortalities, 52 out of 82 received CCT but 30 of 82 did not. Median age (> 72 years; odds ratio [OR] 1.4; P = 0.002) and Charlson comorbidity index ≥ 3 (OR 4.1; P < 0.001) and ≥ 1-2 (OR 1.7; P = 0.001) independently predicted overall higher CCT, IMV, TPN, and in-hospital mortality. CONCLUSION: After RNU, CCT rates parallels in-hospital mortality rates. CCT represents a 5 to 6-fold multiple of in-hospital mortality rate. In RNU patients, CCT rates are higher in older and sicker individuals. Lower CCT rates that are paralleled by lower in-hospital mortality may be interpreted as an indicator of improved quality of care. Ideally all in-hospital mortalities should be predated by CCT exposure.

Perioperative Complications and In-Hospital Mortality in Paraplegic Radical Cystectomy Patients.

OBJECTIVE: The aim of this study was to test for the association between paraplegia and perioperative complications as well as in-hospital mortality after radical cystectomy (RC) for non-metastatic bladder cancer. METHODS: Perioperative complications and in-hospital mortality were tabulated in RC patients with or without paraplegia in the National Inpatient Sample (2000-2019). RESULTS: Of 25,527 RC patients, 185 (0.7%) were paraplegic. Paraplegic RC patients were younger (≤70 years of age; 75 vs. 53%), more frequently female (28 vs. 19%), and more frequently harbored Charlson Comorbidity Index ≥3 (56 vs. 18%). Of paraplegic vs. non-paraplegic RC patients, 141 versus 15,112 (76 vs. 60%) experienced overall complications, 38 versus 2794 (21 vs. 11%) pulmonary complications, 36 versus 3525 (19 vs. 14%) genitourinary complications, 33 versus 3087 (18 vs. 12%) intraoperative complications, 21 versus 1035 (11 vs. 4%) infections, and 17 versus 1343 (9 vs. 5%) wound complications, while 62 versus 6267 (34 vs. 25%) received blood transfusions, 47 versus 3044 (25 vs. 12%) received critical care therapy (CCT), and intrahospital mortality was recorded in 13 versus 456 (7.0 vs. 1.8%) patients. In multivariable logistic regression models, paraplegic status independently predicted higher overall CCT use (odds ratio [OR] 2.1, p < 0.001) as well as fourfold higher in-hospital mortality (p < 0.001), higher infection rate (OR 2.5, p < 0.001), higher blood transfusion rate (OR 1.45, p = 0.009), and higher intraoperative (OR 1.56, p = 0.02), wound (OR 1.89, p = 0.01), and pulmonary (OR 1.72, p = 0.004) complication rates. CONCLUSION: Paraplegic patients contemplating RC should be counseled about fourfold higher risk of in-hospital mortality and higher rates of other untoward effects.

Life Expectancy in High-Grade Incidental Prostate Cancer Patients Versus Population-Based Controls According to Treatment Type.

OBJECTIVE: To quantify the differences in 5-year overall survival (OS) between high-grade (Gleason sum 8-10) incidental prostate cancer (IPCa) patients and age-matched male population-based controls, according to treatment type: no active versus active treatment. MATERIALS AND METHODS: We relied on the Surveillance, Epidemiology, and End Results (SEER) database (2004-2015) to identify not actively treated and actively treated high-grade IPCa patients. For each case, we simulated an age-matched male control (Monte Carlo simulation), relying on Social Security Administration Life Tables (2004-2020) with 5 years of follow-up. Additionally, we relied on Kaplan-Meier plots to display OS for each treatment type. Multivariable Cox regression models were fitted to predict overall mortality (OM). RESULTS: Of 564 high-grade IPCa patients, 345 (61%) were not actively treated versus 219 (39%) were actively treated, either with radical prostatectomy or radiotherapy. Median OS was 3 years for not actively treated high-grade IPCa patients, with OS difference at 5 years follow-up of 27% relative to their age-matched male population-based controls (37% vs. 64%). Median OS was 8 years for actively treated high-grade IPCa patients, with OS difference at 5 years follow-up of 6% relative to their age-matched male population-based controls (68% vs. 74%). In the multivariable Cox regression model, active treatment independently predicted lower OM (hazard ratio = 0.6; 95% confidence interval = 0.4-0.8; p < 0.001). CONCLUSION: Relative to Life Tables' derived age-matched male controls, not actively treated high-grade IPCa patients exhibit drastically worse OS than their actively treated counterparts. These observations may encourage clinicians to consider active treatment in newly diagnosed high-grade IPCa patients.

Prenatal identification of invasive placentation using ultrasound in women with placenta previa and prior cesarean delivery.

OBJECTIVE: To evaluate the performance of ultrasound for antenatal identification of invasive placentation in women with placenta previa in the setting of prior cesarean delivery. STUDY DESIGN: This was a multicenter, retrospective, cohort study. Singleton pregnancies at risk of placenta accreta because of persistent placenta previa in the setting of prior cesarean delivery who delivered at four centers, from January 2010 to May 2020, were included in the study. For this study, pregnancies with diagnosis of accreta, increta, or percreta were considered under the umbrella term of placenta accreta. All women with placenta previa identified in the second trimester had a follow-up ultrasound at 32-34 weeks. Only those with prior cesarean delivery were considered at risk of placenta accreta. Women were considered with suspected accreta in case of suspected prenatal ultrasound. Women with suspected placenta accreta had delivery planned via cesarean hysterectomy at 34+0 - 35+6 weeks, without any attempt to remove the placenta. The primary endpoint of the study was the performance of ultrasound for antenatal identification of invasive placentation. The following ultrasound signs were evaluated: placenta lacunae; loss of clear space; increased vascularity between myometrium and placenta; intracervical lake; rail sign; uterovesical hypervascularity; increased vascularity in the inferior part of the lower uterine segment potentially extending into the parametrial region; and disruption of bladder-myometrial interface. RESULTS: 180 singleton pregnancies with placenta previa in the setting of prior cesarean delivery were identified. Of them, 155 (86.1%) had antenatal suspected placenta accreta based on ultrasound, having at least one sign of invasive placentation. Of the 155 suspected cases, 99 had confirmed placenta accreta at the time of delivery. Among the 99 cases of confirmed placenta accreta, all of them had at least one sign of invasive placentation at ultrasound. Among the 81 cases with placenta previa, prior cesarean delivery, without placenta accreta, 25/81 (30.9%) had ultrasound scan negative for sign of invasive placentation, and 56/81 (69.1%) had at least one sign of invasive placentation). In particular, 12/81 (14.8%) had placenta lacunae, 16/81 (19.8%) had loss of clear space, 20/81 (24.7%) had increased vascularity between myometrium and placenta, 9/81 (11.1%) had intracervical lake, 14/81 (17.3%) had rail sign, 14 (17.3%) had uterovesical hypervascularity, 5/81 (6.2%) had increased vascularity in the inferior part of the lower uterine segment potentially extending into the parametrial region, 8/81 (9.9%) had disruption of bladder-myometrial interface. In the group of women with confirmed placenta accreta, the most common sign recorded was the disruption of bladder-myometrial interface, being recorded in 88/99 women. Disruption of bladder-myometrial interface had the highest sensitivity in detection placenta accreta. Women with disruption of bladder-myometrial interface at ultrasound had 73-fold increase in the risk of placenta accreta compared to those who did not. CONCLUSION: Prenatal ultrasound has an excellent diagnostic accuracy in identifying invasive placentation in women with placenta previa and prior cesarean delivery.

Predictive factors of hemoglobin drop after robot-assisted radical prostatectomy: a single center prospective study.

Robotic surgery provides precise control, allowing for optimal dissection and cutting of tissues while minimizing bleeding. However, a significant drop in hemoglobin (Hb) after robot-assisted radical prostatectomy (RARP) is often recorded. The current study aimed to examine the postoperative Hb drop and its predictive factors in prostate cancer (PCa) patients who underwent RARP. From our tertiary care center's prospectively maintained database, all PCa patients who underwent RARP from January 2022 to January 2023 were identified. For each patient, baseline, anesthesiologic, and surgical characteristics, as well as blood samples before and after surgery, were collected. Multivariable linear and logistic regression models were fitted to investigate potential predictive factors of linear Hb drop or Hb drop ≥ 2 g/dl between preoperative and postoperative day (POD) one, after RARP. Overall, 110 RARP patients were enrolled. Considering the Hb, the median preoperative and POD1 values were 14.6 and 12.7 g/dl respectively (∆ = 1.9, p < 0.001); between POD2 and POD3, no statistically significant difference was recorded (12.4 vs 12.5 g/dl, ∆ = 0.1, p = 0.1). After multivariable analyses, age, BMI, prostate volume, nerve-sparing approach, anesthesia time, intraoperative fluids, intraoperative blood loss, and intraoperative diuresis did not show a statistically significant predictive value (all p > 0.05). The current prospective study showed a statistically significant Hb drop until POD1. After that, a quick stabilization of the Hb value was recorded. This reduction was not correlated with pre- and intraoperative variables. These observations might play an important role in postoperative inpatient RARP management, in both large and low-volume centers.

The prostate-gland asymmetry affects the 3- and 12-month continence recovery after RARP in patients with small prostate glands: a single center study.

To test the impact of the prostate-gland asymmetry on continence rates, namely 3- and 12-month continence recovery, in prostate cancer (PCa) patients who underwent robot-assisted radical prostatectomy (RARP). Within our institutional database, RARP patients with complete preoperative MRI features and 12 months follow-up were enrolled (2021-2023). The population has been stratified according to the presence or absence of prostate-gland asymmetry (defined as the presence of median lobe or side lobe dominance). Multivariable logistic regression models (LRMs) predicting the continence rate at 3 and 12 months after RARP were fitted in the overall population. Subsequently, the LRMs were repeated in two subgroup analyses based on prostate size (≤ 40 vs > 40 ml). Overall, 248 consecutive RARP patients were included in the analyses. The rate of continence at 3 and 12 months was 69 and 72%, respectively. After multivariable LRM the bladder neck sparing approach (OR 3.15, 95% CI 1.68-6.09, p value < 0.001) and BMI (OR 0.90, 95% CI 0.82-0.97, p = 0.006) were independent predictors of recovery continence at 3 months. The prostate-gland asymmetry independently predicted lower continence rates at 3 (OR 0.33, 95% CI 0.13-0.83, p = 0.02) and 12 months (OR 0.31, 95% CI 0.10-0.90, p = 0.03) in patients with prostate size ≤ 40 ml. The presence of prostate lobe asymmetry negatively affected the recovery of 3- and 12-months continence in prostate glands ≤ 40 mL. These observations should be considered in the preoperative planning and counseling of RARP patients.

Urological Challenges during Pregnancy: Current Status and Future Perspective on Ureteric Stent Encrustation.

The management of ureter hydronephrosis and urolithiasis during pregnancy has been changed by the adoption of ureteric stents. Despite their broad use for several other conditions, from emergency to elective settings, their complications cannot be ignored. Being most prevalent during pregnancy, urinary tract infections and stent encrustations are particularly common and can affect either fetal growth or maternal-fetal homeostasis, leading to obstetric complications. The main concern associated with ureteric stents is the indwelling time, which could represent the potential trigger of those complications. However, to ensure the optimal management of a ureteric stent during pregnancy, factors such as the grading of encrustations and the presence, size, and location of stones should be evaluated in pre-operative planning. As a consequence, a multimodal approach, including obstetrics, gynecologists, urologists, and nurses, is essential to ensure a complication-free procedure and successful ureteric stent removal. Finally, future research should focus on utilizing biodegradable and biocompatible materials to reduce and even eliminate the complications related to forgotten stents in order to reduce the financial burden associated with stent replacement and the management of stent-encrustation-related complications.

Contemporary survival in metastatic bladder cancer patients: A population-based study.

The overall survival (OS) improvement after the advent of several novel systemic therapies, designed for treatment of metastatic urothelial carcinoma of the urinary bladder (mUCUB), is not conclusively studied in either contemporary UCUB patients and/or non-UCUB patients. Within the Surveillance, Epidemiology, and End Results database, contemporary (2017-2020) and historical (2000-2016) systemic therapy-exposed metastatic UCUB and, subsequently, non-UCUB patients were identified. Separate Kaplan-Meier and multivariable Cox regression (CRM) analyses first addressed OS in mUCUB and, subsequently, in metastatic non-UCUB (mn-UCUB). Of 3443 systemic therapy-exposed patients, 2725 (79%) harbored mUCUB versus 709 (21%) harbored mn-UCUB. Of 2725 mUCUB patients, 582 (21%) were contemporary (2017-2020) versus 2143 (79%) were historical (2000-2016). In mUCUB, median OS was 11 months in contemporary versus 8 months in historical patients (Δ = 3 months; p < .0001). After multivariable CRM, contemporary membership status (2017-2020) independently predicted lower overall mortality (OM; hazard ratio [HR] = 0.68, 95% confidence interval [CI] = 0.60-0.76; p < .001). Of 709 mn-UCUB patients, 167 (24%) were contemporary (2017-2020) and 542 (76%) were historical (2000-2016). In mn-UCUB, median OS was 8 months in contemporary versus 7 months in historical patients (Δ = 1 month; p = .034). After multivariable CRM, contemporary membership status (2017-2020) was associated with HR of 0.81 (95% CI = 0.66-1.01; p = .06). In conclusion, contemporary systemic therapy-exposed metastatic patients exhibited better OS in UCUB. However, the magnitude of survival benefit was threefold higher in mUCUB and approximated the survival benefits recorded in prospective randomized trials of novel systemic therapies.

Survival of stage III non-seminoma testis cancer patients versus simulated controls, according to race/ethnicity.

BACKGROUND: It is unknown whether 5-year overall survival (OS) differs and to what extent between the American Joint Committee on Cancer stage III non-seminoma testicular germ cell tumor (NS-TGCT) patients and simulated age-matched male population-based controls, according to race/ethnicity groups. METHODS: We identified newly diagnosed (2004-2014) stage III NS-TGCT patients within the Surveillance Epidemiology and End Results database 2004-2019. For each case, we simulated an age-matched male control (Monte Carlo simulation), relying on Social Security Administration (SSA) Life Tables with 5 years of follow-up. We compared OS rates between stage III NS-TGCT patients and simulated age-matched male population-based controls, according to race/ethnicity groups (Caucasian, Hispanic, Asian/Pacific Islander and African American). Both, cancer-specific mortality (CSM) and other-cause mortality (OCM) were computed. RESULTS: Of 2054 stage III NS-TGCT patients, 60% were Caucasians versus 33% Hispanics versus 4% Asians/Pacific Islanders versus 3% African Americans. The 5-year OS difference between stage III NS-TGCT patients versus simulated age-matched male population-based controls was highest in Asians/Pacific Islanders (64 vs. 99%, Δ = 35%), followed by African Americans (66 vs. 97%, Δ = 31%), Hispanics (72 vs. 99%, Δ = 27%), and Caucasians (76 vs. 98%, Δ = 22%). The 5-year CSM rate was highest in Asians/Pacific Islanders (32%), followed by African Americans (26%), Hispanics (25%), and Caucasians (20%). The 5-year OCM rate was highest in African Americans (8%), followed by Caucasians (4%), Asians/Pacific Islanders (4%), and Hispanics (2%). CONCLUSION: Relative to SSA Life Tables, the highest 5-year OS disadvantage applied to stage III NS-TGCT Asian/Pacific Islander race/ethnicity group, followed by African American, Hispanic and Caucasian, in that order.

Adjuvant Systemic Therapy Improved Survival After Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma.

BACKGROUND: The purpose of this study was to test for survival differences according to adjuvant chemotherapy (AC) status in radical nephroureterectomy (RNU) patients with pT2-T4 and/or N1-2 upper tract urothelial carcinoma (UTUC). PATIENTS AND METHODS: Within the Surveillance, Epidemiology, and End Results database (SEER, 2007-2020), patients with UTUC treated with AC versus RNU alone were identified. Kaplan-Meier plots and multivariable Cox regression models addressed cancer-specific mortality (CSM). RESULTS: Of 1995 patients with UTUC, 804 (40%) underwent AC versus 1191 (60%) RNU alone. AC rates increased from 36.1 to 57.0% over time in the overall cohort [estimated annual percentage changes (EAPC) ± 4.5%, p < 0.001]. The increase was from 28.8 to 50.0% in TanyN0 patients (EAPC ± 7.8%, p < 0.001) versus 50.0-70.9% in TanyN1-2 patients (EAPC ± 2.3%, p = 0.002). Within 698 patients harboring TanyN1-2 stage, median CSM was 31 months after AC versus 16 months in RNU alone (Δ = 15 months, p < 0.0001) and AC independently predicted lower CSM [hazard ratio (HR) 0.64; p < 0.001]. Similarly, within subgroup analyses according to stage, relative to RNU alone, AC independently predicted lower CSM in T2N1-2 (HR 0.49; p = 0.04), in T3N1-2 (HR 0.72; p = 0.015), and in T4N1-2 (HR 0.49, p < 0.001) patients. Conversely, in all TanyN0 as well as in all stage-specific subgroup analyses addressing N0 patients, AC did not affect CSM rates (all p > 0.05). CONCLUSIONS: In RNU patients, AC use is associated with significantly lower CSM in lymph-node-positive (N1-2) patients but not in lymph-node-negative patients (N0). The distinction between N1-2 and N0 regarding the effect of AC on CSM applied across all T stages from T2 to T4, inclusively.

The role of lipidic balance on erectile dysfunction in prostate cancer patients undergoing robotic surgery.

OBJECTIVE: New indices of dyslipidemia, such as the Atherogenic Index of Plasma (AIP) or Castelli Risk Index I and II (CR-I/II), have been tested to predict erectile dysfunction (ED). The aim of this study was to assess the role of these lipidic scores in predicting severe ED and erectile function (EF) worsening in patients who underwent robot-assisted radical prostatectomy (RARP). METHODS: Data from 1249 prostate cancer patients who underwent RARP at our single tertiary academic referral center from September 2021 to April 2023 were reviewed. RARP patients with a complete lipid panel were included in the final analysis. Two independent multivariable logistic regression models (LRMs) were fitted to identify predictors of ED severity and worsening in RARP patients. RESULTS: Among the 357 RARP patients, the median age was 70 (interquartile range [IQR]: 65-74), and the median BMI was 28.4 (IQR: 26-30.4). According to the preoperative IIEF5, 115 (32.2%), 86 (24.5%), 26 (7.3%), and 40 (11.2%) were mild, mild-moderate, moderate, and severe ED patients, respectively. After multivariable LRMs predicting severe ED, only the nerve-sparing (NS) approach (odds ratio [OR]: 0.09) as well as the preoperative IIEF5 score (OR: 0.32) were independent predictors (p < 0.001). After LRMs predicting EF worsening, only preoperative IIEF5 was an independent predictor (OR: 1.42, p < 0.001). CONCLUSION: The power of novel lipidic scores in predicting severe ED and EF worsening in RARP patients was low, and they should not be routinely applied as a screening method in this patient subgroup. Only preoperative IIEF5 and nerve-sparing approaches are relevant in EF prediction after RARP.

Survival of Metastatic Urothelial Carcinoma of Urinary Bladder According to Number and Location of Visceral Metastases.

OBJECTIVE: To test the association between number as well as locations of organ-specific metastatic sites and overall survival (OS) in systhemic-therapy exposed metastatic urothelial carcinoma of urinary bladder (mUCUB) patients. METHODS: Within Surveillance, Epidemiology and End Results database (2010-2020), all systhemic therapy-exposed mUCUB patients were identified. Kaplan-Meier and multivariable Cox regression (CRM) models first addressed OS in patients according to number of metastatic organ-locations: solitary versus 2 versus 3 or more. Subsequently, separate analyses stratified according to location type were completed in patients with solitary metastatic organ-location as well as in patients with 2 metastatic organ-locations. RESULTS: Of 1,310 mUCUB, 1,069 (82%) harbored solitary metastatic organ-location versus 193 (15%) harbored 2 separate metastatic organ-locations versus 48 (3%) harbored 3 or more metastatic organ-locations. Median OS decreased with increasing number of metastatic organ-locations (solitary vs. 2 vs. 3 or more, P < .0001). In multivariable CRM, relative to solitary metastatic organ-location, 2 (HR: 1.57, 95 Confidence interval [CI], 1.33-1.85) as well as 3 or more (HR: 1.69, 95% CI, 1.23-2.31) metastatic organ-locations independently predicted higher overall mortality (OM) (P = .001). In patients with solitary metastatic organ-location, brain metastases independently predicted higher OM (HR 1.67; 95% CI, 1.05-2.67; P = .03) than other locations. In patients with 2 metastatic organ-locations, no differences in OM were recorded according to organ type location. CONCLUSION: In systemic therapy exposed mUCUB, number of metastatic organ-locations (solitary vs. 2 vs. 3 or more), independently predicted increasingly worse prognosis. In patients with solitary metastatic organ-location, brain purported worse prognosis than others.

Unmarried Status Effect on Stage at Presentation and Treatment Patterns in Non-Metastatic Upper Tract Urothelial Carcinoma Patients.

BACKGROUND: Unmarried status has been associated with higher proportions of locally advanced stage and lower treatment dose intensification rates in several urological and non-urological malignancies. However, no previous investigators focused on the association between unmarried status and advanced stage (T3-4N0-2) at presentation and lower nephroureterectomy (RNU) and systemic therapy (ST) rates in non-metastatic upper tract urothelial carcinoma (UTUC) patients. METHODS: Using the Surveillance, Epidemiology, and End Results (SEER) database 2000-2020, all non-metastatic UTUC patients were identified. Multivariable logistic regression models (LRMs) tested for differences in stage at presentation and treatment (RNU and ST) according to marital status (married vs unmarried), in a sex-specific fashion. RESULTS: Of all 8544 non-metastatic UTUC patients, 4748 (56%) were male vs 3190 (44%) were female. Of all 4748 male UTUC patients, 1191 (25%) were unmarried. Of all 3190 female UTUC patients, 1608 (50%) were unmarried. In multivariable LRMs predicting RNU, unmarried status was an independent predictor of lower RNU rates in male (Odds Ratio [OR]: 0.56; P < .001), but not in female (OR: 0.81; P = .1) non-metastatic UTUC patients. In multivariable LRMs predicting ST exposure, unmarried status was an independent predictor of lower ST rates in both male (OR:0.73; P = .03) and female (OR:0.64; P < .001) UTUC patients. In multivariable LRMs predicting locally advanced stage (T3-4N0-2), unmarried status was not associated with an increased risk of locally advanced stage at presentation in either male (OR: 0.95; P = .5) or female (OR: 0.99; P = .9) UTUC patients. CONCLUSIONS: Unmarried male UTUC patients appear at risk of less being able to access RNU, relative to their married counterparts. Moreover, unmarried UTUC patients appear to less benefit from ST, regardless of sex. Conversely, unmarried status was not associated with an increased risk of locally advanced stage at presentation in either male or female UTUC patients.

Survival benefit of nephroureterectomy in systemic therapy exposed metastatic upper tract urinary urothelial carcinoma patients.

BACKGROUND: It is unknown whether the stage of the primary may influence the survival (OS) of metastatic upper tract urothelial carcinoma (mUTUC) patients treated with nephroureterectomy (NU) and systemic therapy (ST). We tested this hypothesis within a large-scale North American cohort. METHODS: Within Surveillance Epidemiology and End Results database 2000-2020, all mUTUC patients treated with ST+NU or with ST alone were identified. Kaplan-Maier plots depicted OS. Multivariable Cox regression (MCR) models tested for differences between ST+NU and ST alone predicting overall mortality (OM). All analyses were performed in localized (T1-T2) and then repeated in locally advanced (T3-T4) patients. RESULTS: Of all 728 mUTUC patients, 187 (26%) harbored T1-T2 vs 541 (74%) harbored T3-T4. In T1-T2 patients, the median OS was 20 months in ST+NU vs 10 months in ST alone. Moreover, in MCR analyses that also relied on 3 months' landmark analyses, the combination of ST+NU independently predicted lower OM (HR 0.37, p < 0.001). Conversely, in T3-T4 patients, the median OS was 12 in ST+NU vs 10 months in ST alone. Moreover, in MCR analyses that also relied on 3 months' landmark analyses, the combination of ST+NU was not independently associated with lower OM (HR 0.85, p = 0.1). CONCLUSIONS: In mUTUC patients, treated with ST, NU drastically improved survival in T1-T2 patients, even after strict methodological adjustments (multivariable and landmark analyses). However, this survival benefit did not apply to patients with locally more advanced disease (T3-T4).

Validation of the Quality Analysis of Medical Artificial Intelligence (QAMAI) tool: a new tool to assess the quality of health information provided by AI platforms.

BACKGROUND: The widespread diffusion of Artificial Intelligence (AI) platforms is revolutionizing how health-related information is disseminated, thereby highlighting the need for tools to evaluate the quality of such information. This study aimed to propose and validate the Quality Assessment of Medical Artificial Intelligence (QAMAI), a tool specifically designed to assess the quality of health information provided by AI platforms. METHODS: The QAMAI tool has been developed by a panel of experts following guidelines for the development of new questionnaires. A total of 30 responses from ChatGPT4, addressing patient queries, theoretical questions, and clinical head and neck surgery scenarios were assessed by 27 reviewers from 25 academic centers worldwide. Construct validity, internal consistency, inter-rater and test-retest reliability were assessed to validate the tool. RESULTS: The validation was conducted on the basis of 792 assessments for the 30 responses given by ChatGPT4. The results of the exploratory factor analysis revealed a unidimensional structure of the QAMAI with a single factor comprising all the items that explained 51.1% of the variance with factor loadings ranging from 0.449 to 0.856. Overall internal consistency was high (Cronbach's alpha = 0.837). The Interclass Correlation Coefficient was 0.983 (95% CI 0.973-0.991; F (29,542) = 68.3; p < 0.001), indicating excellent reliability. Test-retest reliability analysis revealed a moderate-to-strong correlation with a Pearson's coefficient of 0.876 (95% CI 0.859-0.891; p < 0.001). CONCLUSIONS: The QAMAI tool demonstrated significant reliability and validity in assessing the quality of health information provided by AI platforms. Such a tool might become particularly important/useful for physicians as patients increasingly seek medical information on AI platforms.

Contemporary conditional cancer-specific survival rates in surgically treated nonmetastatic primary urethral carcinoma.

BACKGROUND: We examined the effect of disease-free interval (DFI) duration on cancer-specific mortality (CSM)-free survival, otherwise known as the effect of conditional survival, in radical urethrectomy nonmetastatic primary urethral carcinoma (PUC) patients. METHODS: Using the Surveillance, Epidemiology, and End Results (SEER) database 2000-2020, patient (age, sex, race/ethnicity, and marital status) and tumor (stage and histology) characteristics, as well as systemic therapy exposure status of nonmetastatic PUC patients were tabulated. Conditional survival estimates at 5-year were assessed based on DFI duration and according to stage at presentation (T1 -2N0 vs. T3-4N0-2). RESULTS: Of all 512 radical urethrectomy PUC patients, 278 (54%) harbored T1-2N0 stage versus 234 (46%) harbored T3-4N0-2 stage. In 512 PUC patients, 5-year CSM-free survival at initial diagnosis was 61.8%. Provided a DFI duration of 36 months, 5-year CSM-free survival was 85.6%. In 278 T1-2N0 PUC patients, 5-year CSM-free survival at initial diagnosis was 68.4%. Provided a DFI duration of 36 months, 5-year CSM-free survival was 86.9%. In 234 T3-4N0-2 PUC patients, 5-year CSM-free survival at initial diagnosis was 53.8%. Provided a DFI duration of 36 months, 5-year CSM-free survival was 83.6%. CONCLUSIONS: Although intuitively, clinicians and patients are well aware of the concept that increasing DFI duration improves survival probability, only a few clinicians can accurately estimate the magnitude of survival improvement, as was done within the current study. Such information is crucial to survivors, especially in those diagnosed with rare malignancies, where the survival estimation according to DFI duration is even more challenging.

Telemedicine and social media: A contemporary analysis of the most shared content by internet users.

OBJECTIVE: To evaluate the telemedicine information published on the most popular social media platforms, during the second year of the COVID-19 pandemic. METHODS: We queried the BuzzSumo tool to identify related telemedicine article links that were shared most on social media, from February 2021 to February 2022. The PEMAT-P was used for the quality assessment of the most shared links. RESULTS: 125 links were eligible for the analysis. Facebook was the most used social media platform for sharing articles (median engagement: 1000). Most of the articles were published by magazines (n = 82, 65.6%) and the main topic addressed was general information (n = 49, 39.2%). In the subgroup analyses of the 34 most shared articles, Facebook was the most used social media platform (median engagement:1950), most of the articles were published by magazines (n = 24, 70.6%), whereas the main topic addressed was the prescription of the abortion pill (n = 9, 26.5%). According to the PEMAT-P tool, the median understandability and actionability score was 63.8 and 20%, respectively. CONCLUSIONS: The interest in telemedicine has increased all over the world, as evidenced by the high engagement in social media articles, recorded during the last year. However, the access to digital health services is still limited, the information provided is often not verified by an official entity and unable to fill the digital divide exacerbated by COVID 19 pandemic crisis. Hence, health policy should be developed or modified to ensure a more egalitarian Internet access for all citizens. Official medical institutions should standardize telemedicine regulation and online content to reduce the widespread of misleading information.

Other-cause mortality in incidental prostate cancer.

BACKGROUND: In incidental prostate cancer (IPCa), elevated other-cause mortality (OCM) may obviate the need for active treatment. We tested OCM rates in IPCa according to treatment type and cancer grade and we hypothesized that OCM is significantly higher in not-actively-treated patients. METHODS: Within the Surveillance, Epidemiology, and End Results database (2004-2015), IPCa patients were identified. Smoothed cumulative incidence plots as well as multivariable competing risks regression models were fitted to address OCM after adjustment for cancer-specific mortality (CSM). RESULTS: Of 5121 IPCa patients, 3655 (71%) were not-actively-treated while 1466 (29%) were actively-treated. Incidental PCa not-actively-treated patients were older and exhibited higher proportion of Gleason sum (GS) 6 and clinical T1a stage. In smoothed cumulative incidence plots, 5-year OCM was 20% for not-actively-treated versus 8% for actively-treated patients. Conversely, 5-year CSM was 5% for not-actively-treated versus 4% for actively-treated patients. No active treatment was associated with 1.4-fold higher OCM, even after adjustment for age, cancer characteristics, and CSM. According to GS, OCM reached 16%, 27%, and 35% in GS 6, 7, and 8-10 not-actively-treated IPCa patients, respectively and exceeded CSM recorded for the same three groups (2%, 6%, and 28%, respectively). CONCLUSION: Our results quantified OCM rates, confirming that in not-actively-treated IPCa patients OCM is indeed significantly higher than in their actively-treated counterparts (HR: 1.4). These observations validate the use of no active treatment in IPCa patients, in whom OCM greatly surpasses CSM (20% vs. 5%).

Intraplaque injections of hyaluronic acid for the treatment of stable-phase Peyronie's disease: a retrospective single-center experience.

Peyronie's disease (PD) is a condition of penile connective tissue affecting up to 10% of men worldwide. In the complexity of its management, nonsurgical treatments, such as intraplaque injections, are gaining attention. The current literature shows data on the efficacy of intraplaque injections of hyaluronic acid (HA) mainly in acute-phase PD. However, data on injections of HA in stable-phase PD are lacking. Data for this retrospective study were derived from a prospectively maintained database of private patients presenting at a private medical practice affiliated to the University of Naples "Federico II" (Naples, Italy) with stable-phase PD between January 2020 and March 2023. Patients underwent a standard protocol of three injections, each administered at a two-week interval. During the intervals, patients performed vacuum device therapy, penile stretching, and modeling exercises. All patients compiled the Peyronie's Disease Questionnaire (PDQ) and Global Assessment of Peyronie's Disease (GAPD) at baseline and 2 weeks after the third injection. A penile Doppler ultrasound was performed 2 weeks after the last injection to record the final curvature. Overall, we recruited 62 patients with stable-phase PD and a mean (±standard deviation [s.d.]) curvature of 52.7° (±9.7°). After 6 weeks, eight (12.9%) patients did not experience any curvature improvement. The remaining 54 patients had a final mean (±s.d.) curvature of 40.3° (±9.1°) with P < 0.001, compared to that before treatment. We found improvement in all PDQ domains (all P ≤ 0.01), and 50 (80.6%) patients reported subjective improvement of the penile curvature according to the GAPD. In conclusion, we demonstrated that after three injections of HA administered according to the adopted protocol, patients with stable-phase PD could experience significant improvements in penile curvature, and physical and psychological consequences of the disease without significantly relevant side effects.