PIK3/Akt/mTOR pathway alterations in metastatic castration-sensitive prostate cancer.

BACKGROUND: Alterations in the PIK3/Akt/mTOR pathway are commonly seen in metastatic castration-sensitive prostate cancer (mCSPC), however their role in outcomes is unknown. We aim to evaluate the prognostic significance as well as the genetic landscape of PIK3/Akt/mTOR pathway alteration in mCSPC. METHODS: Fourhundred and seventy-two patients with mCSPC were included who underwent next generation sequencing. PIK3/Akt/mTor pathway alterations were defined as mutations in Akt1, mTOR, PIK3CA, PIK3CB, PIK3R1, PTEN, TSC1, and TSC2. Endpoints of interests were radiographic progression-free survival (rPFS), time to development of castration resistant prostate cancer (tdCRPC), and overall survival (OS). Kaplan-Meier analysis was performed and Cox regression hazard ratios (HR) were calculated. RESULTS: One hundred and fifty-two (31.9%) patients harbored a PIK3/Akt/mTOR pathway alteration. Median rPFS and tdCRPC were 23.7 and 21.0 months in PIK3/Akt/mTOR altered compared to 32.8 (p = 0.08) and 32.1 months (p = 0.002) in wildtype tumors. On multivariable analysis PIK3/Akt/mTOR pathway alterations were associated with tdCRPC (HR 1.43, 95% CI, 1.05-1.94, p = 0.02), but not rPFS [Hazard ratio (HR) 1.20, 95% confidence interval (CI), 0.90-1.60, p = 0.21]. PIK3/Akt/mTOR pathway alterations were more likely to be associated with concurrent mutations in TP53 (40% vs. 28%, p = 0.01) and TMPRSS2-ERG (37% vs. 26%, p = 0.02) than tumors without PIK3/Akt/mTOR pathway alterations. Concurrent mutations were typically associated with shorter median times to rPFS and tdCRPC. DAVID analysis showed p53 signaling and angiogenesis pathways were enriched in PIK3/Akt/mTOR pathway altered tumors while beta-catenin binding and altered BRCA pathway were enriched in PIK3/Akt/mTOR pathway wildtype tumors. CONCLUSIONS: PIK3/Akt/mTOR pathway alterations were common in mCSPC and associated with poorer prognosis. The genetic landscape of PIK3/Akt/mTOR pathway altered tumors differed from wildtype tumors. Additional studies are needed to better understand and target the PIK3/Akt/mTOR pathway in mCSPC.

Efficacy and Safety of Mitomycin Gel (UGN-101) as an Adjuvant Therapy After Complete Endoscopic Management of Upper Tract Urothelial Carcinoma.

PURPOSE: We describe a novel application of the reverse thermal polymer gel of mitomycin C (UGN-101) as adjuvant therapy after complete endoscopic ablation of upper tract urothelial carcinoma. MATERIALS AND METHODS: We retrospectively reviewed patients treated with UGN-101 from 15 high-volume centers. Adjuvant therapy was defined as treatment administered following visually complete endoscopic ablation. Response at primary endoscopic evaluation was defined as no visual tumor or negative biopsy. Ipsilateral disease-free and progression-free survival were estimated by the Kaplan-Meier method. Ureteral stenosis and other adverse events were abstracted from the medical records. Ureteral stenosis was defined as a condition requiring ureteral stent or nephrostomy, or that would typically warrant stent or nephrostomy. RESULTS: Adjuvant UGN-101 after complete endoscopic ablation was used in 52 of 115 (45%) renal units in the oncologic analysis. At first endoscopic evaluation, 36/52 (69%) were without visible disease. At 6.8 months' median follow-up, the ipsilateral disease-free rate was 63%. Recurrence after adjuvant UGN-101 therapy was more likely in multifocal tumors compared to unifocal (HR 3.3, 95% CI 1.07-9.91). Compared with UGN-101 treatment for chemoablation of measurable disease, there were significantly fewer disease detections with adjuvant therapy (P < .001). Ureteral stenosis after UGN-101 was diagnosed in 10 patients (19%) undergoing adjuvant therapy compared to 17 (29%) undergoing chemoablative therapy (P = .28). CONCLUSIONS: In patients being considered for UGN-101, maximal endoscopic ablation prior to UGN-101 treatment may result in fewer patients with disease at first endoscopy and possibly fewer adverse events than primary chemoablative therapy. Longer follow-up is needed to determine if UGN-101 after complete endoscopic ablation will lead to durable disease-free interval.

Impact of smoking on urologic cancers: a snapshot of current evidence.

PURPOSE: The purpose of this paper is to present evidence regarding the associations between smoking and the following urologic cancers: prostate, bladder, renal, and upper tract urothelial cancer (UTUC). METHODS: This is a narrative review. PubMed was queried for evidence-based analyses and trials regarding the associations between smoking and prostate, bladder, renal, and UTUC tumors from inception to September 1, 2022. Emphasis was placed on articles referenced in national guidelines and protocols. RESULTS: Prostate-multiple studies associate smoking with higher Gleason score, higher tumor stage, and extracapsular invasion. Though smoking has not yet been linked to tumorigenesis, there is evidence that it plays a role in biochemical recurrence and cancer-specific mortality. Bladder-smoking is strongly associated with bladder cancer, likely due to DNA damage from the release of carcinogenic compounds. Additionally, smoking has been linked to increased cancer-specific mortality and higher risk of tumor recurrence. Renal-smoking tobacco has been associated with tumorigenesis, higher tumor grade and stage, poorer mortality rates, and a greater risk of tumor recurrence. UTUC-tumorigenesis has been associated with smoking tobacco. Additionally, more advanced disease, higher stage, lymph node metastases, poorer survival outcomes, and tumor recurrence have been linked to smoking. CONCLUSION: Smoking has been shown to significantly affect most urologic cancers and has been associated with more aggressive disease, poorer outcomes, and tumor recurrence. The role of smoking cessation is still unclear, but appears to provide some protective effect. Urologists have an opportunity to engage in primary prevention by encouraging cessation practices.

Metastasis-Directed Therapy for Oligometastatic Castration-Sensitive Prostate Cancer: An Alternative to ADT?

PURPOSE OF REVIEW: The standard treatment of patients with metastatic prostate cancer is systemic treatment with androgen-deprivation therapy (ADT). The spectrum-based model of metastatic disease includes the presence of an oligometastatic state, an intermediary between localized and widespread metastatic disease, in which radical local treatment might improve systemic control. Our purpose is to review the literature on metastasis-directed therapy in the treatment of oligometastatic prostate cancer. RECENT FINDINGS: Several prospective clinical trials have reported improvements in ADT-free survival and progression-free survival with metastasis-directed therapy of oligometastatic prostate cancer. Retrospective studies have found improvements in oncologic outcomes for patients with oligometastatic prostate cancer undergoing metastasis-directed therapy, and several recent prospective clinical trials have confirmed these results. Advancements in imaging as well as an understanding of the genomics of oligometastatic prostate cancer may allow for better patient selection for metastasis-directed therapy and the potential for cure in selected patients.

Quantifying Publication Rates and Time to Publication for American Urological Association Podium Presentations.

PURPOSE: The American Urological Association (AUA) Annual Meeting serves as the premier platform for presenting unpublished research in urology. Among selected abstracts, podium presentations represent the most impactful submissions. While podium presentations receive a large audience through conference attendance and social media posts, it is unclear how often they manifest as publications in peer-reviewed journals. MATERIALS AND METHODS: Podium presentations from the 2017 AUA Annual Meeting were reviewed. Abstracts were assessed for publication between January 1, 2015 and May 31, 2020 allowing for a 3-year window of publication and accounting for publications prior to the submission deadline. Abstract authors were individually searched with key terms being added sequentially until <30 results were generated in PubMed®. Abstracts were deemed published if at least 1 author and 1 conclusion matched a manuscript. Publication rate, time to publication, and 2019 journal impact factor were collected. Statistical analysis was performed by linear and logistic regression. RESULTS: Of 872 podium presentations, 453 (51.9%) were published within 3 years. Median time from submission to publication was 12.5 months (IQR: 7.5-20.5). The number of articles published at 1, 2 and 3 years from submission was 203, 368 and 430, respectively. The median journal impact factor of publications was 3.2 (IQR: 2.0-5.8). Oncology studies (OR=1.21 [95% CI: 0.91-1.60], p=0.186) had similar rates of publication compared to non-oncology studies. CONCLUSIONS: While AUA podium presentations disseminate valuable data, approximately half were not published in peer-reviewed journals within 3 years. Therefore, care must be taken when promoting findings or adopting new practices based on these presentations alone.

Association of Lymph Node Count and Survival after Primary Retroperitoneal Lymphadenectomy for Nonseminomatous Testicular Cancer.

PURPOSE: Retroperitoneal lymph node dissection (RPLND) for men with clinical stage (CS) I or II testicular nonseminomatous germ cell tumor (NSGCT) has both staging and therapeutic implications. We aimed to investigate the impact of lymph node count (LNC) on outcome after primary RPLND for men with CS I or II NSGCT using a nationally representative data set. MATERIALS AND METHODS: A retrospective analysis of men who received a primary RPLND for CS I or II NSGCT was performed using the National Cancer Database. The Kaplan-Meier method was used to determine overall survival (OS) according to LNC. Logistic regression analyses were used to identify factors associated with LNC >20 and factors predictive of lymph node-positive (pN+) disease after primary RPLND. RESULTS: Of 1,376 men who comprised our analytical cohort, 50.1% and 49.9% had 1-20 lymph nodes (LNs) and >20 LNs removed, respectively. Five-year OS rates were 96.4% and 99.1% for men with 1-20 and >20 LNs resected, respectively (p=0.004). A higher proportion of men with >20 LNs removed were treated at academic centers, had private insurance, presented with higher AJCC (American Joint Committee on Cancer) CS and were more likely to have pN+ disease, compared to those with 1-20 LNs removed. Factors significantly associated with pN+ disease after RPLND include higher AJCC CS and LNC (per 10-count increase). CONCLUSIONS: Higher LNC after primary RPLND significantly increases the likelihood of identifying pN+ disease and is associated with improved OS. Our data support the therapeutic implications of a thoroughly performed RPLND in the primary setting.

Long-term renal function in patients with chronic kidney disease following radical cystectomy and orthotopic neobladder.

OBJECTIVE: To evaluate long-term renal function in patients with chronic kidney disease (CKD) Stage IIIa who underwent radical cystectomy and orthotopic neobladder (RC/ONB) compared to matched controls. PATIENTS AND METHODS: Using our Institutional Review Board-approved institutional database, patients with a glomerular filtration rate (GFR) of 45-59.9 mL/min/1.73 m2 who underwent RC/ONB were identified. A control group of patients with a GFR of ≥60 mL/min/1.73 m2 was selected. Groups were matched based on age, baseline hypertension/diabetes mellitus, perioperative chemotherapy, and preoperative hydronephrosis. A decrease in GFR of >10 mL/min/1.73 m2 during the follow-up was considered significant. A multivariate Cox regression analysis was performed to identify predictors of GFR decline in each group. RESULTS: Of 1237 patients who underwent RC/ONB, 508 patients were included (254 per group). The mean preoperative GFR was 53.3 mL/min/1.73 m2 in the study group and 78.8 mL/min/1.73 m2 in controls. The median follow-up was 3.7 years. During follow-up, GFR stayed at or above baseline in 51% of the study patients compared to 46% of the controls (P = 0.5). The mean time to a significant GFR decline in the study patients was significantly longer compared to the controls (5.6 vs 2 years, respectively; P < 0.001). In multivariate analysis, neoadjuvant chemotherapy was found to be the strongest predictor of a significant GFR decline as well as GFR decline below baseline (hazard ratio [HR] 2.15, 95% confidence interval [CI] 1.4-3.29, P = 0.004; and HR 2.15, 95% CI 1.4-3.29, P < 0.001, respectively). CONCLUSION: Patients with CKD Stage IIIa who undergo ONB appear to have comparable long-term renal function to those with a GFR of ≥60 mL/min/1.73 m2 . An ONB reconstruction is a safe option for patients with CKD Stage IIIa desiring a continent diversion.

Changes in prostate cancer survival among insured patients in relation to USPSTF screening recommendations.

BACKGROUND: To investigate the effects of the U.S. Preventive Services Task Force's (USPSTF) 2012 recommendation against prostate-specific antigen (PSA)-based screening for prostate cancer on survival disparities based on insurance status. Prior to the USPSTF's 2012 screening recommendation, previous studies found that insured patients with prostate cancer had better outcomes than uninsured patients. METHODS: Using the SEER 18 database, we examined prostate cancer-specific survival (PCSS) based on diagnostic time period and insurance status. Patients were designated as belonging to the pre-USPSTF era if diagnosed in 2010-2012 or post-USPSTF era if diagnosed in 2014-2016. PCSS was measured with the Kaplan-Meier method, while disparities were measured with the Cox proportional hazards model. RESULTS: During the pre-USPSTF era, uninsured patients experienced worse PCSS compared to insured patients (adjusted HR 1.256, 95% CI 1.037-1.520, p = 0.020). This survival disparity was no longer observed during the post-USPSTF era as a result of decreased PCSS among insured patients combined with unchanged PCSS among uninsured patients (adjusted HR 0.946, 95% CI 0.642-1.394, p = 0.780). CONCLUSIONS: Although the underlying reasons are not clear, the USPSTF's 2012 PSA screening recommendation may have hindered insured patients from being regularly screened for prostate cancer and selectively led to worse outcomes for insured patients without affecting the survival of uninsured patients.

An Objective Assessment of Performance during Robotic Partial Nephrectomy: Validation and Correlation of Automated Performance Metrics with Intraoperative Outcomes.

PURPOSE: Automated performance metrics provide a novel approach to the assessment of surgical performance. Herein, we present a construct validation of automated performance metrics during robotic assisted partial nephrectomy. MATERIALS AND METHODS: Automated performance metrics (instrument motion tracking/system events) and synchronized surgical videos from da Vinci® Si systems during robotic assisted partial nephrectomy were recorded using a system data recorder. Each case was segmented into 7 steps: colon mobilization, ureteral identification/dissection, hilar dissection, exposure of tumor within Gerota's fascia, intraoperative ultrasound/tumor scoring, tumor excision, and renorrhaphy. Automated performance metrics from each step were compared between expert (≥150 cases) and trainee (<150 cases) surgeons by Mann-Whitney U test (continuous variables) and Pearson's chi-squared test (categorical variables). Clinical outcomes were collected prospectively and correlated to automated performance metrics and R.E.N.A.L. (radius, exophytic/endophytic, nearness of tumor to collecting system, anterior/posterior, location relative to polar line) nephrometry score by Spearman's correlation coefficients (r). RESULTS: A total of 50 robotic assisted partial nephrectomy cases were included for analysis, performed by 7 expert and 10 trainee surgeons. Automated performance metric profiles significantly differed between experts and novices in the initial 5 steps (p <0.05). Specifically, experts exhibited faster dominant instrument movement and greater dominant instrument usage (bimanual dexterity) than trainees in select steps (p ≤0.045). Automated performance metrics during tumor excision and renorrhaphy were significantly correlated with R.E.N.A.L. score (r ≥0.364; p ≤0.041). These included metrics related to instrument efficiency, task duration, and dominant instrument use. CONCLUSIONS: Experts are more efficient and directed in their movement during robotic assisted partial nephrectomy. Automated performance metrics during key steps correlate with objective measures of tumor complexity and may serve as predictors of clinical outcomes. These data help establish a standardized metric for surgeon assessment and training during robotic assisted partial nephrectomy.

Timing, Patterns and Predictors of 90-Day Readmission Rate after Robotic Radical Cystectomy.

PURPOSE: We examine the timing, patterns and predictors of 90-day readmission after robotic radical cystectomy. MATERIALS AND METHODS: From September 2009 to March 2017, 271 consecutive patients undergoing robotic radical cystectomy with intent to cure bladder cancer (intracorporeal diversion 253, 93%) were identified from our prospectively collated institutional database. Readmission was defined as any subsequent inpatient admission or unplanned visit occurring within 90 days from discharge after the index hospitalization. Multiple readmissions were defined as 2 or more readmissions within a 90-day period. Logistic regression analysis was used to identify independent factors related to single and multiple 90-day readmissions. RESULTS: A total of 78 (28.8%) patients were readmitted at least once within 90 days after discharge, of whom 20 (25.6%) reported multiple readmissions. The cumulative duration of readmission was 6.2 (6.17) days with 6 (7.6%) patients having less than 24 hours readmission. Metabolic, infectious, genitourinary and gastrointestinal complications were identified as the primary cause of readmission in 39.5%, 23.5%, 22.3% and 17%, respectively. Fifty percent of readmissions occurred in the first 2 weeks after hospital discharge. On multivariable logistic regression analysis in-hospital infections (OR 2.85, p=0.001) were independent predictors for overall readmission. Male gender (OR 3.5, p=0.02) and in-hospital infections (OR 4.35, p=0.002) were independent predictors for multiple readmissions. CONCLUSIONS: The 90-day readmission rate following robotic radical cystectomy is significant. In-hospital infections and male gender were independent factors for readmission. Most readmissions occurred in the first 2 weeks following discharge, with metabolic derangements and infections being the most common causes.

Predictors of need for catheterisation and urinary retention after radical cystectomy and orthotopic neobladder in male patients.

OBJECTIVES: To investigate the prevalence of catheterisation and urinary retention in male patients with bladder cancer after radical cystectomy (RC) and orthotopic neobladder (ONB) and to identify potential predictors. PATIENTS AND METHODS: Using an Institutional Review Board approved, prospectively maintained bladder cancer database, we collected information using a diversion-related questionnaire from 299 consecutive male patients with bladder cancer upon postoperative clinic visit. Urinary retention was defined as ≥3 catheterisations/day or a self-reported inability to void without a catheter. Uni- and multivariable Cox regression analysis was performed to identify predictors of catheterisation and urinary retention. RESULTS: Self-catheterisation was reported in 51 patients (17%), of whom, 22 (7.4% of the total patients) were in retention. Freedom from any catheterisation at 3, 5, and 10 years after RC was 85%, 77%, and 62%, respectively. Freedom from retention at 3, 5, and 10 years after RC was 93%, 88%, and 79%, respectively. Multivariable Cox regression showed that higher body mass index (BMI; ≥27 kg/m2 ) significantly increased the need for catheterisation (hazard ratio [HR] 2.34, 95% confidence interval [CI] 1.26-4.32) as well as retention (HR 5.20, 95% CI 1.74-15.51). Greater medical comorbidity (Charlson Comorbidity Index score ≥2) correlated with the need for any catheterisation (HR 1.84, 95% CI 1.02-3.3), but not retention. Pathological stage and type of diversion were not significant predictors of the need to catheterise or urinary retention. CONCLUSION: In males undergoing RC with ONB, retention requiring catheterisation to void is uncommon. Patients with a BMI of ≥27 kg/m2 are at significantly increased risk of retention and need for self-catheterisation.

Factors Associated With Patient-Reported Penile Length Loss After Radical Cystoprostatectomy in Male Patients With Bladder Cancer.

BACKGROUND: The perception of penile length loss is common in male patients undergoing radical prostatectomy; however, this has not been described after radical cystoprostatectomy (RC). AIM: To evaluate perceptions of penile length loss in male patients after RC and contributing factors. METHODS: Patients completed an institutional review board-approved questionnaire comprised the International Index of Erectile Function (IIEF-5) and supplemental questions including perceived changes in penile length after RC. Multivariable analysis was performed to determine associations between the perception of penile length loss and the amount of length lost with patient and surgery-specific factors. OUTCOMES: The rate of patient-reported penile length loss and factors contributing to this perception was the outcome of this study. RESULTS: From October 2017 to January 2019, 151 patients completed the questionnaire. The median age at cystectomy was 66.1 years (interquartile range [IQR]: 59.4-73.3), and the median duration of follow-up was 28.3 months (IQR: 13-74.1). Preoperative IIEF-5 was available in 55 patients with a median score of 14 (IQR: 3-20). The median IIEF-5 score at time of survey completion was 3 (IQR: 1-18). The majority of patients (55.1%) reported a perceived loss of penile length, 20.4% reported no loss, and 24.5% were unsure. Of those who quantified their loss in penile length, 54.6% reported losses of an inch or more. Neurovascular preservation was not found to protect against penile length loss but did correlate with a reduction in the amount reported lost (P = .008). Multivariable logistic regression analysis identified increasing IIEF-5 score at time of survey completion to protect against a perceived loss in penile length (odds ratio: 0.924, 95% confidence interval: 0.878-0.973, P = .0025), whereas increasing body mass index was associated with a loss in perceived penile length (odds ratio: 1.198, 95% confidence interval: 10.53-1.383, P = .0060). CLINICAL IMPLICATIONS: The perception of penile length loss is a commonly held belief in patients after RC, and many patients will perceive losses that exceed 1 inch (2.54 cm). STRENGTHS AND LIMITATIONS: This study is the first series to describe the perception of penile length loss after RC. It is strengthened by the study population's size, heterogeneity, and patient-reported results. It is limited by lack of objective measurements of stretched penile length. CONCLUSIONS: RC can result in significant sexual dysfunction including the perceived loss of penile length. Loh-Doyle JC, Han J, Ghodoussipour S. Factors Associated With Patient-Reported Penile Length Loss After Radical Cystoprostatectomy in Male Patients With Bladder Cancer. J Sex Med 2020;17:957-963.

Using objective robotic automated performance metrics and task-evoked pupillary response to distinguish surgeon expertise.

PURPOSE: In this study, we investigate the ability of automated performance metrics (APMs) and task-evoked pupillary response (TEPR), as objective measures of surgeon performance, to distinguish varying levels of surgeon expertise during generic robotic surgical tasks. Additionally, we evaluate the association between APMs and TEPR. METHODS: Participants completed ten tasks on a da Vinci Xi Surgical System (Intuitive Surgical, Inc.), each representing a surgical skill type: EndoWrist® manipulation, needle targeting, suturing/knot tying, and excision/dissection. Automated performance metrics (instrument motion tracking, EndoWrist® articulation, and system events data) and TEPR were recorded by a systems data recorder (Intuitive Surgical, Inc.) and Tobii Pro Glasses 2 (Tobii Technologies, Inc.), respectively. The Kruskal-Wallis test determined significant differences between groups of varying expertise. Spearman's rank correlation coefficient measured associations between APMs and TEPR. RESULTS: Twenty-six participants were stratified by robotic surgical experience: novice (no prior experience; n = 9), intermediate (< 100 cases; n = 9), and experts (≥ 100 cases; n = 8). Several APMs differentiated surgeon experience including task duration (p < 0.01), time active of instruments (p < 0.03), linear velocity of instruments (p < 0.04), and angular velocity of dominant instrument (p < 0.04). Task-evoked pupillary response distinguished surgeon expertise for three out of four task types (p < 0.04). Correlation trends between APMs and TEPR revealed that expert surgeons move more slowly with high cognitive workload (ρ < - 0.60, p < 0.05), while novices move faster under the same cognitive experiences (ρ > 0.66, p < 0.05). CONCLUSIONS: Automated performance metrics and TEPR can distinguish surgeon expertise levels during robotic surgical tasks. Furthermore, under high cognitive workload, there can be a divergence in robotic movement profiles between expertise levels.

Comparison of clinical outcomes and automated performance metrics in robot-assisted radical prostatectomy with and without trainee involvement.

PURPOSE: In this study, we investigate the effect of trainee involvement on surgical performance, as measured by automated performance metrics (APMs), and outcomes after robot-assisted radical prostatectomy (RARP). METHODS: We compared APMs (instrument tracking, EndoWrist® articulation, and system events data) and clinical outcomes for cases with varying resident involvement. Four of 12 standardized RARP steps were designated critical ("cardinal") steps. Comparison 1: cases where the attending surgeon performed all four cardinal steps (Group A) and cases where a trainee was involved in at least one cardinal step (Group B). Comparison 2, where Group A is split into Groups C and D: cases where attending performs the whole case (Group C) vs. cases where a trainee performed at least one non-cardinal step (Group D). Mann-Whitney U and Chi-squared tests were used for comparisons. RESULTS: Comparison 1 showed significant differences in APM profiles including camera movement time, third instrument usage, dominant instrument moving time, velocity, articulation, as well as non-dominant instrument moving time and articulation (all favoring Group A p < 0.05). There was a significant difference in re-admission rates (10.9% in Group A vs 0% in Group B, p < 0.02), but not for post-operative outcomes. Comparison 2 demonstrated a significant difference in dominant instrument articulation (p < 0.05) but not in post-operative outcomes. CONCLUSIONS: Trainee involvement in RARP is safe. The degree of trainee involvement does not significantly affect major clinical outcomes. APM profiles are less efficient when trainees perform at least one cardinal step but not during non-cardinal steps.

Internal audit of an enhanced recovery after surgery protocol for radical cystectomy.

PURPOSE: To perform an internal audit 5 years after implementation of our enhanced recovery after surgery (ERAS) protocol for patients undergoing radical cystectomy and to investigate the importance of physician driven compliance on outcomes. METHODS: Using a prospectively maintained database, 472 consecutive patients were identified who underwent radical cystectomy with ERAS from July 2013 to July 2017. Compliance was measured by a Composite Compliance Score (CCS) generated as a percentage of 16 interventions. Patients with higher than median compliance were compared to patients with lower compliance. The primary outcome was length of stay. Secondary outcomes included complication and readmission rates. Multivariable regressions were used to control for differences between groups. RESULTS: In 2013, median CCS was 81% and subsequently ranged from 81 to 88%. Five-year median CCS was 88%. Patients with higher compliance (CCS ≥ 88%, n = 262), as compared to those with lower compliance (CCS < 88%, n = 210), were younger (median 70.3 vs 72.7 years, p = 0.047), healthier (ASA3-4 81% vs 89.9%, p = 0.007), received more orthotopic diversions (59.2% vs 37.6%, p < 0.0001), more often had open surgery (78.5% vs 51.9%, p < 0.0001) and had shorter median operative times (5.5 vs 6.3 h, p = 0.005). Median length of stay was 4 days. Higher compliance was associated with shorter hospital stays (ß = - 0.85, 95% CI - 1.62 to - 0.07) and decreased 30-day readmissions (OR 0.58, 95% CI 0.35-0.96). CONCLUSIONS: Greater ERAS compliance was achieved in younger and healthier patients. Patients with greater compliance had a decreased length of stay by almost 1 day and reduced odds of 30-day readmissions.

Effect of surgeon experience and bony pelvic dimensions on surgical performance and patient outcomes in robot-assisted radical prostatectomy.

OBJECTIVES: To evaluate the effects of surgeon experience, body habitus, and bony pelvic dimensions on surgeon performance and patient outcomes after robot-assisted radical prostatectomy (RARP). PATIENTS, SUBJECTS AND METHODS: The pelvic dimensions of 78 RARP patients were measured on preoperative magnetic resonance imaging and computed tomography by three radiologists. Surgeon automated performance metrics (APMs [instrument motion tracking and system events data, i.e., camera movement, third-arm swap, energy use]) were obtained by a systems data recorder (Intuitive Surgical, Sunnyvale, CA, USA) during RARP. Two analyses were performed: Analysis 1, examined effects of patient characteristics, pelvic dimensions and prior surgeon RARP caseload on APMs using linear regression; Analysis 2, the effects of patient body habitus, bony pelvic measurement, and surgeon experience on short- and long-term outcomes were analysed by multivariable regression. RESULTS: Analysis 1 showed that while surgeon experience affected the greatest number of APMs (P < 0.044), the patient's body mass index, bony pelvic dimensions, and prostate size also affected APMs during each surgical step (P < 0.043, P < 0.046, P < 0.034, respectively). Analysis 2 showed that RARP duration was significantly affected by pelvic depth (ß = 13.7, P = 0.039) and prostate volume (ß = 0.5, P = 0.024). A wider and shallower pelvis was less likely to result in a positive margin (odds ratio 0.25, 95% confidence interval [CI] 0.09-0.72). On multivariate analysis, urinary continence recovery was associated with surgeon's prior RARP experience (hazard ratio [HR] 2.38, 95% CI 1.18-4.81; P = 0.015), but not on pelvic dimensions (HR 1.44, 95% CI 0.95-2.17). CONCLUSION: Limited surgical workspace, due to a narrower and deeper pelvis, does affect surgeon performance and patient outcomes, most notably in longer surgery time and an increased positive margin rate.

Experts vs super-experts: differences in automated performance metrics and clinical outcomes for robot-assisted radical prostatectomy.

OBJECTIVES: To evaluate automated performance metrics (APMs) and clinical data of experts and super-experts for four cardinal steps of robot-assisted radical prostatectomy (RARP): bladder neck dissection; pedicle dissection; prostate apex dissection; and vesico-urethral anastomosis. SUBJECTS AND METHODS: We captured APMs (motion tracking and system events data) and synchronized surgical video during RARP. APMs were compared between two experience levels: experts (100-750 cases) and super-experts (2100-3500 cases). Clinical outcomes (peri-operative, oncological and functional) were then compared between the two groups. APMs and outcomes were analysed for 125 RARPs using multi-level mixed-effect modelling. RESULTS: For the four cardinal steps selected, super-experts showed differences in select APMs compared with experts (P < 0.05). Despite similar PSA and Gleason scores, super-experts outperformed experts clinically with regard to peri-operative outcomes, with a greater lymph node yield of 22.6 vs 14.9 nodes, respectively (P < 0.01), less blood loss (125 vs 130 mL, respectively; P < 0.01), and fewer readmissions at 30 days (1% vs 13%, respectively; P = 0.02). A similar but nonsignificant trend was seen for oncological and functional outcomes, with super-experts having a lower rate of biochemical recurrence compared with experts (5% vs 15%, respectively; P = 0.13) and a higher continence rate at 3 months (36% vs 18%, respectively; P = 0.14). CONCLUSION: We found that experts and super-experts differed significantly in select APMs for the four cardinal steps of RARP, indicating that surgeons do continue to improve in performance even after achieving expertise. We hope ultimately to identify associations between APMs and clinical outcomes to tailor interventions to surgeons and optimize patient outcomes.

A deep-learning model using automated performance metrics and clinical features to predict urinary continence recovery after robot-assisted radical prostatectomy.

OBJECTIVES: To predict urinary continence recovery after robot-assisted radical prostatectomy (RARP) using a deep learning (DL) model, which was then used to evaluate surgeon's historical patient outcomes. SUBJECTS AND METHODS: Robotic surgical automated performance metrics (APMs) during RARP, and patient clinicopathological and continence data were captured prospectively from 100 contemporary RARPs. We used a DL model (DeepSurv) to predict postoperative urinary continence. Model features were ranked based on their importance in prediction. We stratified eight surgeons based on the five top-ranked features. The top four surgeons were categorized in 'Group 1/APMs', while the remaining four were categorized in 'Group 2/APMs'. A separate historical cohort of RARPs (January 2015 to August 2016) performed by these two surgeon groups was then used for comparison. Concordance index (C-index) and mean absolute error (MAE) were used to measure the model's prediction performance. Outcomes of historical cases were compared using the Kruskal-Wallis, chi-squared and Fisher's exact tests. RESULTS: Continence was attained in 79 patients (79%) after a median of 126 days. The DL model achieved a C-index of 0.6 and an MAE of 85.9 in predicting continence. APMs were ranked higher by the model than clinicopathological features. In the historical cohort, patients in Group 1/APMs had superior rates of urinary continence at 3 and 6 months postoperatively (47.5 vs 36.7%, P = 0.034, and 68.3 vs 59.2%, P = 0.047, respectively). CONCLUSION: Using APMs and clinicopathological data, the DeepSurv DL model was able to predict continence after RARP. In this feasibility study, surgeons with more efficient APMs achieved higher continence rates at 3 and 6 months after RARP.

Factors influencing intraoperative conversion from planned orthotopic to non-orthotopic urinary diversion during radical cystectomy.

OBJECTIVES: To determine and investigate the intraoperative factors that contribute to a change in plan from continent orthotopic neobladder to ileal conduit or continent cutaneous diversion at the time of radical cystectomy. SUBJECTS AND METHODS: A retrospective review of our prospectively maintained bladder cancer database was performed. Of the 711 patients who underwent radical cystectomy from 2012 to 2016, 387 (54.4%) had given consent to have a NB. Of these 387 patients, 348 (89.9%) ultimately received a neobladder while 34 (8.8%) received an ileal conduit and 5 (1.3%) continent cutaneous diversion. The factors involved in the intraoperative change of plan were examined in this study. RESULTS: Patients who ultimately received a neobladder were significantly more likely to have clinical node-negative disease (p = 0.045), negative soft tissue margins (p = 0.001), lower body mass index (p = 0.045) and higher volume surgeons (p < 0.001). Oncologic reasons for intraoperative conversions were more common than technical reasons (58.3% vs 35.9%), in both robotic and open surgical techniques. The choice of surgical approach (open vs robotic) did not influence the rate of intraoperative conversion. CONCLUSION: The factors influencing intraoperative decision not to perform neobladder are predominantly oncologic rather than technical. A clear understanding of the factors involved in influencing the intraoperative change in the urinary diversion plan may improve shared decision making in patients undergoing radical cystectomy in the future.

Upper urinary tract recurrence following bladder cancer therapy: a review of surveillance and management.

PURPOSE OF REVIEW: Our aim is to review recent investigations into the recurrence of urothelial carcinoma in the upper urinary tract following bladder cancer therapy focusing on surveillance and management. RECENT FINDINGS: After radical cystectomy, rates of recurrence in the upper tract are between 0.75 and 6.4%. The poor prognosis of upper tract urothelial carcinoma (UTUC) is in part attributable to delayed diagnosis. Guidelines recommend a gradual de-escalation of surveillance in disease-free patients with the potential for discontinuation beyond 5 years. Previous guideline audits have shown that recurrences are still missed, suggesting a need for longer follow-up. Studies propose risk stratifying patients by age, comorbidities, and tumor stage to warrant closer surveillance and identify adjuvant therapy candidates. Larger studies are needed to advise treatment of UTUC after a urothelial bladder cancer (UBC) diagnosis, as these patients face poorer outcomes following radical nephroureterectomy. Clinical trials have demonstrated the efficacy of neoadjuvant and adjuvant systemic therapy after radical nephroureterectomy for primary UTUC; however, the literature is lacking robust data on patients who develop urothelial carcinoma in the upper tract following an initial UBC diagnosis. SUMMARY: Many asymptomatic recurrences of urothelial carcinoma in the upper tract are undetected by current surveillance guideline recommendations. Higher level evidence is needed to confirm the efficacy of prolonged and risk-adapted surveillance of patients with UBC and the extirpative management of recurrence in the upper tract after UBC treatment.