Technical details and long-term outcomes of P.A.D.U.A. for congenital urethral narrowing; a case series and review of the literature.

INTRODUCTION: The P.A.D.U.A. technique is a method of addressing congenital urethral narrowing. It involves passive dilation with a series of progressively larger indwelling catheters. Utilization is limited by scant literature, particularly regarding technical details and long-term durability. Tools for achieving safe and reliable urinary drainage are critical in these patients, who require careful stewardship of their kidney and bladder function. OBJECTIVE: To describe long-term urethral patency and urinary function following P.A.D.U.A., and to provide sufficient technical detail to reproduce the technique. STUDY DESIGN: Patients with congenital urethral narrowing managed with P.A.D.U.A. were identified and chart review was performed. Details of catheter exchange sequences were compiled and described. The primary outcome was the attainment of adequate urethral caliber by successful completion of P.A.D.U.A., and the secondary outcome was voiding per urethra at most recent follow-up. RESULTS: P.A.D.U.A. achieved adequate urethral caliber in 9/11 (82%) of patients. This included seven patients with Prune Belly Syndrome, one with isolated urethral atresia, and one with a cloacal anomaly. P.A.D.U.A. failed to achieve urethral patency in one patient with urethral duplication, who was unable to progress through the catheter sequence, and one patient with Prune Belly Syndrome, who completed P.A.D.U.A. but developed recurrent narrowing one week later. There were no delayed failures of urethral patency. Patients who achieved patency underwent a median of seven catheter placements over 92 days. Median (range) initial and final catheter sizes were 3.5F (1.9-8F) and 14F (8-16F). While 82% achieved patency, only 3/11 (27%) were voiding spontaneously per native urethra at most recent follow-up. DISCUSSION: This series of patients undergoing P.A.D.U.A. for primary treatment of congenital urethral narrowing is the largest to date and provides granular technical details. It aligns with prior reports suggesting that P.A.D.U.A. achieves urethral patency in most patients with Prune Belly Syndrome or isolated urethral atresia, but has limited application in the hypoplastic duplicated urethra. Despite high rates of urethral patency in this select population, many patients will not achieve and maintain spontaneous voiding without catheterization. This is likely due to ongoing deterioration of bladder function caused by the prenatal developmental insult, paralleling the phenomenon seen in posterior urethral valves. CONCLUSION: P.A.D.U.A. is an effective and durable technique for achieving urethral patency. However, due to complicating factors such as the underlying bladder pathology present in many patients, urethral patency achieved with P.A.D.U.A. does not guarantee long-term safe and reliable spontaneous emptying per urethra.

Distribution of a photographic atlas did not reduce postoperative care utilization after pediatric circumcision or the indispensability of the pediatric urology clinic nurse.

BACKGROUND: Surgery in children is increasingly ambulatory, and caregiver responsibilities for postoperative care can produce anxiety. Prior studies have suggested the distribution of a photographic atlas can mitigate caregiver anxiety and reduce clinic phone calls and in-person presentations after pediatric penile surgery. OBJECTIVE: A pilot study of the ability of a photographic atlas, distributed to caregivers, was aimed to be conducted to reduce postoperative resource utilization. STUDY DESIGN: Patients undergoing circumcision or revision circumcision were randomized to standard postoperative instructions vs. standard instructions with a photographic atlas representing appropriate penile appearance at successive time points. Electronic records were reviewed for phone calls or in-person presentations to the clinic or emergency department (ED) within 1 month of surgery. RESULTS: Fourteen patients (44%) received the atlas, and 18 (56%) did not. Patients who received the atlas did not differ significantly from patients who did not receive it in their rate of clinic phone calls (36% vs 39%, p = 0.85), calls per patient (0.5 vs. 0.7, p = 0.78), ED visits (7% vs. 11%, p = 0.70), calls and visits combined (44% vs. 43%, p = 0.93), or the proportion of calls and emergency room presentations related to concerns about the penile appearance (22% vs. 36%, p = 0.66). Overall, 19 postoperative phone calls were received from 12 patients, and 4 visits to the ED were made by 3 patients. Reasons for calls to the clinic were diverse, and 9 distinct categories of concern were identified apart from wound appearance. DISCUSSION: The impressive diversity of caregiver concerns prompting postoperative communication may partly underlie the failure of the atlas to reduce resource utilization in this study. Most postoperative calls or visits were unrelated to concern about the penile appearance, which limits the degree to which this or any visual guide to wound healing can reduce the need for postoperative attention. CONCLUSION: Receipt of the atlas did not significantly reduce postoperative contacts or affect the proportion of contacts represented by concerns about penile appearance. Resources must remain directed toward individualized attention to caregiver concerns, delivered by experienced urologic support staffs, who remain the mainstay of postoperative support.

Prognostic importance of lymphovascular invasion in urothelial carcinoma of the renal pelvis.

BACKGROUND: The current study was conducted to assess the impact of lymphovascular invasion on the survival of patients with urothelial carcinoma of the renal pelvis. METHODS: Patients with urothelial carcinoma of the renal pelvis who underwent radical nephroureterectomy from 2010 through 2015 were identified in the National Cancer Data Base. Patients were characterized according to demographic and clinical factors, including pathologic tumor stage and lymphovascular invasion. Associations with overall survival were assessed through proportional hazards regression analysis. RESULTS: A total of 4177 patients were identified; 1576 had lymphovascular invasion. Patients with T3 disease and lymphovascular invasion had 5-year survival that was significantly worse than that of patients with T3 disease without lymphovascular invasion (34.7% vs 52.6; P < .001 by the log-rank test), and approached that of patients with T4 disease without lymphovascular invasion (34.7% vs 26.5%; P = .002). On multivariate analysis controlling for age, comorbidities, grade, lymph node status, surgical margin status, race, sex, and chemotherapy administration, patients with T3 disease and lymphovascular invasion also were found to have significantly worse survival compared with patients with T3 disease without lymphovascular invasion (hazard ratio, 1.7; 95% confidence interval, 1.4-1.91). CONCLUSIONS: Lymphovascular invasion status is a key prognostic marker that can stratify the risk of patients with pT3 upper tract urothelial carcinoma further. Patients with this pathologic feature should be carefully considered for clinical trials exploring existing and novel therapies. Cancer 2018;124:2507-14. © 2018 American Cancer Society.

Partial Cystectomy for Primary Bladder Tumors in Contemporary Patients with Diverse Tumor Locations.

INTRODUCTION: Partial cystectomy use has historically been limited by stringent selection criteria. We compared outcomes following partial cystectomy at our institution with those in other contemporary series. Also, we specifically characterized outcomes in patients with tumors in bladder locations traditionally considered unamenable to partial cystectomy. METHODS: Patients who underwent partial cystectomy for primary bladder cancer from 1990 to 2012 were identified from our database. Clinical and pathological data were reviewed. Survival analyses were performed using Kaplan-Meier methods. Cox regression was done to identify factors associated with survival and recurrence. RESULTS: A total of 55 patients were included in analysis. Five-year overall, disease specific and recurrence-free survival was 70.3%, 77.0% and 39.4%, respectively. When controlling for clinical and pathological covariates, lymphovascular invasion predicted decreased recurrence-free survival (HR 10.6, p = 0.025). Perioperative morbidity and mortality rates were 4% and 5%, respectively. In 8 patients (15%) trigone tumors required ureteral reimplantation. Two of the 8 patients (25%) experienced complications, including hydronephrosis and bladder neck contracture, which were treated conservatively. Cancer recurred in 2 of the 8 patients (25%) and both were treated successfully. None of the 8 patients died of bladder cancer. CONCLUSIONS: Patients treated with partial cystectomy for primary bladder cancer had satisfactory cancer control and favorable perioperative morbidity consistent with other contemporary reports. Patients with tumors in the bladder trigone, historically considered poor candidates for partial cystectomy, also had good oncologic outcomes without significant complications related to reimplantation. Our data further support partial cystectomy in select patients with bladder cancer.

Active Surveillance for Small Renal Masses: A Review of the Aims and Preliminary Results of the DISSRM Registry.

Active surveillance is an increasingly accepted treatment modality for select patients with small renal masses. The DISSRM (delayed intervention and surveillance for small renal masses) registry is a multi-institutional, prospectively collected data repository which includes patients who select active surveillance for their small renal masses, as well as others who select immediate intervention. Preliminary results from the registry suggest oncological equivalence of active surveillance and surgical modalities in the intermediate term. Additionally, the registry provides the first published data regarding trends in renal function among patients undergoing active surveillance. On average, these patients experience a decline in renal function, and their renal functional outcomes are superior to those of patients undergoing radical nephrectomy, but do not significantly differ from those of patients undergoing partial nephrectomy.

Renal cell carcinoma: risks and benefits of nephron-sparing surgery for T1 tumors.

Renal cell carcinoma is the most common cancer of the kidneys that is primarily treated with surgery, including removal of part or all the involved kidney depending on size and tumor, complexity, and patient characteristics. Partial nephrectomy historically was restricted to cases of solitary kidney or bilateral tumors. It was then started for masses smaller than 4 cm and currently is even studied and justified in tumors smaller than 7 cm if surgically feasible. Although partial nephrectomy preserves kidney tissue and, therefore, delays or prevents the new onset of CKD and ESRD, radical nephrectomy is still overused even for the small tumors. Studies have shown that although this practice is driven by an easier complete removal of the kidney especially in the era of minimally invasive surgery, partial nephrectomy is successful in curing cancer and achieving excellent cancer-specific survival in addition to its benefits on cardiovascular health. Nowadays interest in preserving healthy kidney tissue is increasing to the level of studying the impact of larger volume removed around the kidney and the histopathology of that non-neoplastic tissue to predict kidney function behavior postoperatively.

Active Surveillance is Superior to Radical Nephrectomy and Equivalent to Partial Nephrectomy for Preserving Renal Function in Patients with Small Renal Masses: Results from the DISSRM Registry.

PURPOSE: We compared renal function outcomes among patients in the surveillance and intervention arms of the DISSRM registry. MATERIALS AND METHODS: Patients were grouped into chronic kidney disease stages by estimated glomerular filtration rate range. Cases were considered up staged if a more advanced chronic kidney disease stage was entered during followup. Chronic kidney disease up staging-free survival was compared among groups using Kaplan-Meier analysis and paired comparisons log rank tests. Multivariate Cox regression identified independent predictors of chronic kidney disease up staging-free survival. RESULTS: A total of 162 patients met the study inclusion criteria, with 68 in the surveillance arm, 65 undergoing partial nephrectomy, 15 undergoing radical nephrectomy and 14 undergoing cryoablation. Median tumor size was 2.2 cm. Mean estimated glomerular filtration rate change was significantly larger for radical nephrectomy vs surveillance (-9.2 vs -0.5 ml/minute/1.73 m(2)) and for radical vs partial nephrectomy (-9.2 vs -1.9 ml/minute/1.73 m(2)) (p=0.001). No other groups differed significantly. On Kaplan-Meier analysis patients undergoing radical nephrectomy had significantly worse chronic kidney disease up staging-free survival vs those treated with partial nephrectomy (p=0.029), surveillance (p=0.007) and cryoablation (p=0.019). No other groups differed significantly. On multivariate analysis radical nephrectomy independently predicted poor chronic kidney disease up staging-free survival (odds ratio vs surveillance 30.6, p=0.001). Neither partial nephrectomy (p=0.985) nor cryoablation (p=0.976) predicted poor chronic kidney disease up staging-free survival relative to surveillance. CONCLUSIONS: Patients in the surveillance arm had superior estimated glomerular filtration rate preservation compared to those in the radical nephrectomy but not the partial nephrectomy arm. In certain patients with small renal masses surveillance and partial nephrectomy may offer comparable renal functional outcomes. This could be partly attributable to a modest estimated glomerular filtration rate decrease associated with surveillance itself. A thorough understanding of the renal functional impacts of treatment modalities is critical in the management of small renal masses.

Delay from biopsy to radical prostatectomy influences the rate of adverse pathologic outcomes.

BACKGROUND: We sought to determine maximum wait times between biopsy diagnosis and surgery for localized prostate cancer, beyond which the rate of adverse pathologic outcomes is increased. METHODS: We retrospectively reviewed 4,610 patients undergoing radical prostatectomy between 1990 and 2011. Patients were stratified by biopsy Gleason score and PSA value. For each stratification, χ2 analysis was used to determine the smallest 15-day multiple of surgical delay (e.g., 15, 30, 45…180 days) for which adverse pathologic outcomes were significantly more likely after the time interval than before. Adverse outcomes were defined as positive surgical margins, upgrading from biopsy, upstaging, seminal vesicle invasion, or positive lymph nodes. RESULTS: Two thousand two hundred twelve patients met inclusion criteria. Median delay was 64 days (mean 76, SD 47). One thousand six hundred seventy-five (75.7%), 537 (24.3%), and 60 (2.7%) patients had delays of <=90, >90, and >180 days, respectively. Twenty-six percent were upgraded on final pathology and 23% were upstaged. The positive surgical margin rate was 24.2% and the positive lymph node rate was 1.1%. Significant increases in the proportion of adverse pathological outcomes were found beyond 75 days in the overall cohort (P = 0.03), 150 days for patients with Gleason <=6, and PSA 0-10 (P = 0.038), 60 days for patients with Gleason 7 and PSA >20 (P = 0.032), and 30 days for patients with Gleason 8-10 and PSA 11-20 (0.041). CONCLUSION: In low-risk disease, there is a considerable but not unlimited surgical delay which will not adversely impact the rate of adverse pathologic features found. In higher risk disease, this time period is considerably shorter.

The natural history of renal functional decline in patients undergoing surveillance in the DISSRM registry.

OBJECTIVE: To describe the natural history of renal function in patients on active surveillance (AS) for small renal masses (SRM) in the Delayed Intervention and Surveillance for Small Renal Masses Registry. METHODS: Delayed Intervention and Surveillance for Small Renal Masses is a prospective, multi-institutional registry of patients with SRM (≤ 4 cm) who choose intervention or AS. Of these, 64 patients on AS had longitudinal serum creatinine (sCr) values and underwent analysis of estimated glomerular filtration rate (eGFR). eGFR was calculated using the Modification of Diet in Renal Disease formula. The Kidney Disease Outcomes Quality Initiative chronic kidney disease (CKD) classification was used to categorize patients' eGFR values. RESULTS: Median age was 74 (range: 34-88) years at onset of AS. Overall, 9% (6/64) of patients had CKD at baseline. Median initial tumor size was 2.1cm (range: 0.8-4.0). Median Charlson comorbidity index score was 4 (range: 0-8). Median baseline sCr was 1.0mg/dl (range: 0.4-2.1) and median baseline eGFR was 70.25 (range: 24.07-165.52). After a median follow-up of 17 (range: 2-46) months, 64% of patients experienced a decrease in eGFR, with average yearly decrease in eGFR of 1.82 ml/min/1.73 m(2) (P = 0.092) and average yearly increase in sCr of 0.046 (P = 0.012). A total of 15 (24%) patients experienced an upstaging in classification of CKD. DISCUSSION: Nearly two-thirds of patients on AS experienced a decrease in eGFR and nearly one-fourth had upstaging of CKD classification. The annual eGFR decline experienced by patients on AS minimally exceeded the annual decline of 1.49 ± 0.3 ml/min/1.73 m(2) that an individual who was 70 to 79 years of age can expect from aging alone. Further follow-up is necessary to assess this in a more definitive manner, but this trend should be considered when evaluating AS as an alternative to interventional therapies for SRM.

Utilization and Perioperative Outcomes of Partial Cystectomy for Urothelial Carcinoma of the Bladder: Lessons from the ACS NSQIP Database.

INTRODUCTION: We identified predictors of partial cystectomy in the ACS NSQIP® database of more than 400 hospitals across North America. We also reviewed perioperative outcomes. METHODS: We reviewed the records of patients with an ICD-9 diagnosis of urothelial carcinoma of the bladder who were treated with partial or radical cystectomy from 2007 to 2012. The proportion of patients who underwent partial vs radical cystectomy and the proportion who received neoadjuvant chemotherapy were compared across time. We reviewed 30-day morbidity and mortality, and determined risk factors. Logistic regression was used to identify factors predictive of undergoing partial vs radical cystectomy. RESULTS: A total of 2,393 patients met study inclusion criteria. The ratio of partial to radical cystectomy was low and stable at 0% to 7% (p = 0.36). While patients undergoing radical cystectomy were more likely to receive neoadjuvant chemotherapy in later years (p <0.001), neoadjuvant chemotherapy use before partial cystectomy was consistently low with time (p = 0.68). The 30-day morbidity rate after partial and radical cystectomy was 23.3% and 58.1% (p = 0.001), and the 30-day mortality rate was 1.6% and 2.1%, respectively (p = 0.66). On multivariate regression factors independently associated with partial vs radical cystectomy were cerebrovascular accident history (OR 4.4, p = 0.005), current nonsmoking (OR 0.43, p = 0.032) and lack of trainee participation in the operation (OR 0.28, p <0.001). CONCLUSIONS: The ratio of the number of partial to radical cystectomies performed was stable. Cerebrovascular accident history, nonsmoker status and lack of trainee participation were associated with partial cystectomy. Patients treated with radical cystectomy but not those who underwent partial cystectomy were more likely to receive neoadjuvant chemotherapy in later years. Large detailed registries such as ACS NSQIP have important potential use for evaluating trends in urological practice.

Impact of the 2012 United States Preventive Services Task Force statement on prostate-specific antigen screening: analysis of urologic and primary care practices.

OBJECTIVE: To identify the effect of the 2012 United States Preventive Services Task Force (USPSTF) prostate-specific antigen (PSA) recommendation statement on primary care referral patterns and urologists' decision making. METHODS: Men referred to our institution for newly elevated PSA level from June 2011 to June 2013 were identified. Patients with a prior history of prostate cancer or biopsy were excluded. Clinical and management parameters were compared between those presenting in the year before vs the year after the USPSTF statement. Factors predictive of receiving a prostate biopsy were identified using multivariate regression analysis. RESULTS: A total of 201 men were identified in the pre-USPSTF period and 212 men, thereafter. The groups were comparable in age, race, prostate cancer family history, PSA values, and digital rectal examination findings. At the initial evaluation, patients presenting after the statement were more likely to undergo PCA3 testing (27% vs 11%; P <.01) and repeat PSA testing (82% vs 72%; P = .02) and less likely to undergo immediate biopsy (16% vs 24%; P = .03). The proportion of patients ultimately receiving a biopsy was equivalent. The groups were similar in the percentage of positive biopsies, Gleason distribution, and D'Amico risk. African American race and family history were predictors for receiving a biopsy in the post-USPSTF group but not in the pre-USPSTF group. CONCLUSION: The 2012 USPSTF recommendation statement has not affected the number or clinical characteristics of patients referred to a tertiary center for elevated PSA level. After recommendation, urologists ordered significantly more PCA3 and repeat PSA tests and recommended fewer biopsies at the initial visit. The fraction of patients ultimately receiving a biopsy remained the same.

Mixed low- and high-grade non-muscle-invasive bladder cancer: a histological subtype with favorable outcome.

OBJECTIVE: To determine whether heterogeneity of tumor grade affects the response to Bacillus Calmette-Guérin (BCG) treatment for patients with non-muscle-invasive bladder cancer (NMIBC). METHODS: Patients with Ta or T1 NMBIC receiving a 6-week induction course of intravesical BCG therapy after transurethral resection were divided according to the tumor grade. Clinical and pathological variables were compared. Advanced intervention-free survival (AIFS), defined as duration of freedom from advanced intervention (including non-BCG intravesical agents or cystectomy) or metastasis, was plotted using Kaplan-Meier methods. The effect of grade on survival duration was assessed by multivariate Cox proportional hazards modeling. RESULTS: One hundred and fifty-three patients were identified: 17 with mixed low- and high-grade (MG) and 136 with pure high-grade (PHG) NMIBC. Demographic and additional pathologic variables were comparable between groups (p > 0.05). Five-year AIFS was 88.2% for MG patients, compared to 48.5% for PHG patients (p = 0.030 by log-rank test). On multivariate analysis, PHG was an independent risk factor for worse AIFS (HR 4.4, 95% CI 1.1-18.4, p = 0.040). Among patients failing to respond to primary BCG induction, who underwent a secondary induction of BCG with interferon, MG patients had better response than PHG patients (100 vs. 26.3%, p = 0.035). CONCLUSIONS: Mixed low- and high-grade NMIBC exhibits a significantly better response profile to intravesical BCG therapy compared to PHG NMIBC. The implications of these results are that less aggressive treatment strategies for this unique cancer entity may be needed and that there is a benefit to the reporting of tumor heterogeneity in transurethral resection of bladder tumor specimens.

Increasing volume of non-neoplastic parenchyma in partial nephrectomy specimens is associated with chronic kidney disease upstaging.

INTRODUCTION: We examined the effect of non-neoplastic parenchymal volumes (NNPVs) in partial nephrectomy (PN) surgical specimens on long-term postoperative renal function. PN for renal cortical neoplasms has demonstrated superior long-term renal function outcomes compared with radical nephrectomy. Minimizing the distance between the surgical margin and tumor will reduce the NNPV removed. The role of NNPV on postoperative outcomes has been preliminarily investigated, with varying results. Thus, we sought to determine the association between the NNPV removed and postoperative chronic kidney disease (CKD) staging. MATERIALS AND METHODS: Our institutional database was queried for patients who had undergone PN from 1990 to 2012. The demographic and pathologic data were collected. The ellipsoid formula was used to calculate the surgical specimen and tumor volumes, which were then subtracted from each other to determine the NNPV. The estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease formula. Binary logistic regression analysis was used to determine the predictors of postoperative CKD upstaging according to the eGFR. RESULTS: A total of 584 patients meeting the inclusion criteria had undergone PN. On binary logistic regression analysis, controlling for age, tumor volume, surgical modality, and preoperative CKD stage, an increasing NNPV in the surgical specimen was independently associated with postoperative CKD upstaging (odds ratio, 1.004; P = .007). CONCLUSION: An increasing NNPV removed during PN correlated with CKD upstaging using the eGFR; therefore, additional emphasis should be placed on healthy parenchymal preservation, with long-term follow-up to ensure adequate oncologic outcomes.

Who really benefits from nephron-sparing surgery?

OBJECTIVE: To analyze the influence of preoperative renal function on postoperative renal outcomes after radical nephrectomy (RN) and nephron-sparing surgery (NSS) for malignancy in patients stratified according to preoperative chronic kidney disease (CKD) stage and surgical extent (NSS vs RN). PATIENTS AND METHODS: Retrospective review of patients undergoing renal surgery for localized renal masses stratified by surgical extent and preoperative CKD stage based on glomerular filtration rate (GFR) level: stage I (>90 mL/min/1.73 m(2)), stage II (60-89 mL/min/1.73 m(2)), and stage III (30-59 mL/min/1.73 m(2)). Survival analysis for significant renal impairment was based on freedom from the development of new-onset GFR <30 or <45 mL/min/1.73 m(2). RESULTS: A total of 1306 patients were included in the analysis with preoperative CKD stage I (27.9%), II (52.1%), and III (20.1%); 41.3% and 58.7% underwent NSS and RN, respectively. NSS was associated with a lower annual rate of GFR decline in preoperative CKD stage-I (P = .028) and stage-II patients (P = .018), but not in CKD stage-III patients (P = .753). Overall, 5.0% and 15.0% developed new-onset GFR <30 mL/min/1.73 m(2) and <45 mL/min/1.73 m(2), respectively. There was no difference in the probability of developing significant renal impairment between NSS and RN in CKD stage-I or -III patients, whereas only in CKD stage-II patients was the surgical extent independently associated with development of significant renal impairment (RN: odds ratio, 9.0; P = .042 for GFR <30 mL/min/1.73 m(2) and odds ratio, 2.3; P = .003 for GFR <45 mL/min/1.73 m(2)). CONCLUSION: Compared with RN, NSS is associated with a lower rate of GFR decline for preoperative CKD stage-I and -II patients, but only CKD stage-II patients demonstrated a decreased risk of developing significant renal impairment.

The association between socioeconomic status, renal cancer presentation, and survival in the United States: a survival, epidemiology, and end results analysis.

OBJECTIVE: To determine whether socioeconomic status (SES) predicts the size and local extent of tumors at presentation, and if this association leads to differences in survival. MATERIALS AND METHODS: The National Cancer Institute's Survival, Epidemiology, and End Results registry was queried for patients diagnosed with renal cancers between 2004 and 2010. Demographic, tumor, survival, and socioeconomic data were obtained. Cancers with T0 classification, nonrenal cell histology, or missing clinical or pathologic data were excluded. An SES measure was created from available metrics. Outcomes analyzed were tumor size, TNM classifications at diagnosis, tumor grade and histology subtype, and survival duration. RESULTS: A total of 40,212 cases were identified. On regression modeling, lower SES was an independent risk factor for tumor size ≥ 4 cm (P = .003) and for T classification ≥ T2 (P = .040) at presentation, but did not predict histology subtype, positive lymph nodes, or metastasis. Lower SES predicted high-grade disease on univariate analysis (P = .012) but lost significance in the multivariate model. Lower SES was also independently predictive of shortened cancer-specific survival on multivariate analysis after adjusting for available cofactors (lowest vs highest SES quartile; P = .001). CONCLUSION: This study suggests that low SES is correlated with poorer survival outcomes in renal cancer, and this may be related to a tendency toward larger and more locally advanced tumors at diagnosis. Additional investigation is needed to ascertain whether these effects could be mediated by relatively lower rates of incidental detection via abdominal imaging in disadvantaged populations.

Venous thromboembolism after major urologic oncology surgery: a focus on the incidence and timing of thromboembolic events after 27,455 operations.

OBJECTIVE: To investigate the incidence and timing of venous thromboembolism (VTE) and identify risk factors for venous thromboembolism among patients undergoing major surgery for urologic malignancies. VTE events are stratified by occurrence in the inpatient vs outpatient settings. MATERIALS AND METHODS: The National Surgical Quality Improvement Program database was queried using Current Procedural Terminology and International Statistical Classification of Diseases, Ninth Revision codes to identify patients undergoing major surgery for urologic malignancies between 2005 and 2012. The incidence of overall 30-day VTE, postdischarge VTE, and post-VTE death was calculated for each surgical procedure. Logistic regression analysis was used to identify risk factors for VTE, adjusting for covariates including age, race, gender, smoking status, medical comorbidities, performance of pelvic lymph node dissection, and operative time. RESULTS: The study identified 27,455 patients who underwent an operation for malignancy--radical nephrectomy, partial nephrectomy, nephroureterectomy, radical prostatectomy, or radical cystectomy. The incidence and timing of VTE varied substantially across the procedures of interest. Overall, VTE occurred after radical cystectomy in 113 of 2065 of patients (5.5%), whereas only 19 of 2624 (0.7%) and 12 of 1690, respectively, of patients undergoing minimally invasive radical or partial nephrectomy procedures suffered a VTE event within 30-days of surgery. Among patients suffering a VTE after radical prostatectomy, 147 of 178 of venous thromboembolic events (82.6%) occurred after hospital discharge. CONCLUSION: This study demonstrates the significant burden of VTE beyond the time of hospital discharge. Identification of high-risk patients should prompt consideration of extended-duration VTE prophylaxis in the outpatient setting.

Cost-effectiveness of neoadjuvant chemotherapy before radical cystectomy for muscle-invasive bladder cancer.

OBJECTIVES: To determine the costs of treatment and the duration of survival, adjusted for quality of life, for patients with muscle-invasive bladder cancer treated with immediate radical cystectomy (RC) or with neoadjuvant chemotherapy (NAC) with intent for subsequent RC. METHODS AND MATERIALS: A retrospective review of our institutional review board-approved database identified patients with muscle-invasive bladder cancer treated at our institution from 2004 to 2011. Patients were divided into those receiving RC alone and those receiving NAC before planned RC. Patients who refused RC following NAC were included in an intention-to-treat analysis. Survival duration was converted to quality-adjusted life years (QALYs), and costs of treatment per QALY were determined. RESULTS: A total of 119 patients (65.4%) received RC alone and 63 (34.6%) received NAC, 38 of whom proceeded to cystectomy as planned. Mean total costs were $42,890 and $52,429 for RC and NAC, respectively (P = 0.005). The 5-year overall survival was 31.7% and 42.5% for the RC-only group and the NAC group, respectively (P = 0.034). The 5-year overall survival measured in QALYs was 21.9% and 42.9% for the RC-only and the NAC groups, respectively (P = 0.021). The increased cost for NAC was $5,840 per additional life year gained (95% CI: $1,772-$9,909) and $6,187 per additional QALY gained (95% CI: $1,877-$10,498). CONCLUSIONS: The use of NAC is associated with a significant increase in quality-adjusted survival. The additional cost per QALY gained is approximately $6,000. The cost-utility analysis of NAC compares favorably with other cancer-specific therapies.