Contemporary Trends of Holmium Laser Enucleation of the Prostate Utilization in the United States: A Comprehensive Analysis Using the National Surgical Quality Improvement Program Database (2011-2020).

Introduction: The most recent American Urological Association (AUA) Guidelines advocated laser enucleation of the prostate (LEP) as a size-independent surgical option for benign prostatic hyperplasia (BPH). Despite its endorsement by AUA and the growing body of evidence supporting its safety and efficacy, the utilization of LEP remains limited in the United States. This study aimed to evaluate the utilization trends and perioperative outcomes of LEP compared with other surgical procedures used for BPH management. Methods: A retrospective cohort analysis was performed using American College of Surgeons National Surgical Quality Improvement Program data from 2011 to 2020. Patients undergoing prostatectomy for BPH were identified using specific current procedural terminology (CPT) codes. Baseline demographic data, preoperative risk factors, and postoperative outcomes were collected. Multivariable logistic regression was employed to assess predictors of holmium laser enucleation of the prostate (HoLEP) utilization and postoperative complications. Results: Out of 8,415,549 patients, 95,144 underwent prostatectomy for BPH. Procedures included HoLEP 5305 cases, transurethral resection of the prostate (TURP) 57,803 cases, repeated TURP (re-TURP) 5549 cases, photoselective vaporization of the prostate (PVP) 23,739 cases, and simple prostatectomy 2748 cases. HoLEP utilization showed a gradual increase, from 4.8% in 2015 to 7.6% in 2020. Multivariable regression revealed that HoLEP selection significantly increased from 2016 to 2020 (odds ratio [OR]: 1.251, p < 0.001), and there was less likelihood of HoLEP selection for African American patients (OR: 0.752, p < 0.001). HoLEP had significantly lower complication rates, including urinary tract infections, blood transfusions, 30-day readmission, and reoperation. Conclusion: Despite underutilization, the adoption of HoLEP has slightly increased since 2015, rising from 4.8% in 2015 to 7.6% in 2020. The underutilization could be attributed to a lack of availability and the steep learning curve.

Impact of rural residence on the presentation, management and survival of patients with non-metastatic muscle-invasive bladder carcinoma.

PURPOSE: To assess the impact of rural and remote residence on the receipt of guidelines-recommended treatment, quality of treatment and overall survival (OS) in patients with non-metastatic muscle-invasive bladder cancer (MIBC). MATERIALS AND METHODS: Patients with MIBC were identified using National Cancer Database. Patients were classified into three residential areas. Logistic regression models were used to assess associations between geographic residence and receipt of radical cystectomy (RC) or chemoradiation therapy (CRT). Models were fitted to assess quality benchmarks of RC and CRT. RESULTS: We identified 71,395 patients. Of those 58,874 (82.5%) were living in Metro areas, 8,534 (11.9%) in urban-rural adjacent (URA), and 3,987 (5.6%) in urban-rural remote to metro area (URR). URR residence was significantly associated with poor OS compared to URA and Metro residence (HR 0.87, 95% CI 0.81-0.94 and HR 0.90, 95% CI 0.87-0.93, p<0.001). There was no difference in the likelihood of receiving RC and CRT among different residential areas. Among patients who underwent RC; individuals living in URR were less likely to receive neoadjuvant chemotherapy and adequate lymph node dissection, and had a higher probability of positive surgical margin than those living in metro areas. For those who received CRT; individuals living in Metro areas were more likely to receive concomitant systemic therapy compared to URR. CONCLUSIONS: Rural residence is associated with lower OS for MIBC patients and less likelihood of meeting quality benchmarks for RC and CRT. This data should be used to guide further health policy and allocation of resources for rural population.

Diffusion of robot-assisted radical cystectomy: Nationwide trends, predictors, and association with continent urinary diversion.

Objectives: To assess the utilisation trends of robot-assisted radical cystectomy (RARC), rates of performing continent urinary diversions (CUDs), and impact of diffusion of RARC on CUD rates. Methods: We investigated the National Cancer Database for patients with muscle-invasive bladder cancer (MIBC) who underwent RC between 2004 and 2015. Patients were stratified by surgical technique into open (ORC) and RARC groups, and by type of urinary diversion into continent (CUD) and ileal conduit (ICUD) groups. Linear regression models were fitted to evaluate time trends for surgery and conversion techniques. Multivariate logistic regression models were utilised to identify independent predictors of RARC and CUD. Results: A total of 14466 patients underwent RC for MIBC, of which 4914 (34%) underwent RARC. There was a significant increase in adoption of RARC from 22% in 2010 to 40% in 2015 (R2 = 0.96, P < 0.001), this was not associated with a change in the rates of CUD over the same period (P = 0.22). Across all years, ICUD was the primary type of urinary diversion, CUD was only offered in 12% in 2010 compared to 9.9% in 2015 (R2 = 0.33, P = 0.22). Multivariate analysis identified male gender (odds ratio [OR] 1.18, P = 0.03), academic centres (OR 1.74, P = 0.001), and lower T stage (T4 vs T2; OR 0.78, P = 0.03) as independent predictors of CUD, while surgical technique was not associated with odds of receiving CUD (P = 0.8). Conclusions: There is significant nationwide increasing trend of adoption of RARC. This diffusion was not associated with a decline in CUD, which remains significantly underutilised in both ORC and RARC groups. Abbreviations CUD: continent urinary diversion; ICD-O: International Classification of Diseases for Oncology; ICUD: ileal conduit urinary diversion; (N)MIBC: (non-)muscle-invasive bladder cancer; NAC, neoadjuvant chemotherapy; NCDB: National Cancer Database; OR: odds ratio;(O)(RA)RC: (open) (robot-assisted) radical cystectomy.

Survival after minimally invasive vs. open radical nephrectomy for stage I and II renal cell carcinoma.

BACKGROUND: A recently reported phase III randomized trial comparing open and minimally invasive hysterectomy showed significantly higher rates of local recurrence after minimally invasive surgery (MIS) for cervical cancer. This raised concerns regarding patterns of recurrences and survival after MIS in general. This study aims to determine the effect of MIS on all-cause mortality among patients undergoing radical nephrectomy for Stage I and II renal cell carcinoma (RCC). METHODS: We utilized the National Cancer Database to identify patients diagnosed with clinical stage I-II RCCs between 2010 and 2013. Patients for whom a laparoscopic or robotic radical nephrectomy was attempted were compared to patients who underwent open radical nephrectomy (ORN). Adjusted regression models with inverse probability propensity score weighting (IPW) were utilized to identify independent predictors of receiving MIS. All-cause mortality rates were compared using IPW survival functions and log-rank tests. Adjusted Cox proportional hazard models were fitted to determine independent predictors of OS. RESULTS: 27,642 patients were identified; 11,524 (41.7%) had MIS, while 16,118 (58.3%) had ORN. Kaplan-Meier survival curves in the IPW cohort showed significant OS advantage for patients who underwent MIS (p < 0.001). Furthermore, length of hospital stays (3 vs. 4 days), 30 day readmission rates (2.4 vs. 2.87%), 30 day (0.53 vs. 0.96%) and 90 day mortality rates (1.04 vs. 1.77%) were significantly higher in the ORN group (p < 0.001). CONCLUSIONS: MIS was associated with better OS outcomes compared to ORN for stage I and II RCC. In addition, MIS had lower post-operative readmission, 30- and 90 day mortality rates.

Histological variants of non-muscle invasive bladder cancer: Survival outcomes of radical cystectomy vs. bladder preservation therapy.

BACKGROUND: To compare the overall survival (OS) outcomes of non-muscle invasive bladder cancer (NMIBC) patients with variant histology who underwent radical cystectomy (RC) vs. bladder preservation therapy (BPT). METHODS: We investigated the National Cancer Database for NMIBC patients with variant histological features. Patients diagnosed with micropapillary, sarcomatoid, neuroendocrine, squamous, and glandular variants were identified. Inverse probability weighting (IPW)-adjusted Kaplan Meier survival curves and Cox proportional hazard models were utilized to compare OS in the setting of RC versus BPT. RESULTS: A total of 8,920 (2.7%) NMIBC patients presented with variant histology, of whom 2,450 (27.5%) underwent RC, while 6,470 (72.5%) had BPT. When compared with BPT, patients who underwent RC had significantly higher 5-year OS rates for sarcomatoid (31.9% vs. 23.3%, P < 0.001) neuroendocrine (31% vs. 21.7%, P < 0.001), glandular (44% vs. 41%, P = 0.04) and squamous variants (39.7% vs 19.9%, P < 0.001). This OS benefit was not observed with micropapillary variant (43.9% vs. 53.2% P = 0.14). IPW-adjusted log-rank analysis identified RC as an independent predictor of OS for patients with sarcomatoid (hazards ratio [HR] 0.78, confidence interval [CI] 0.71-0.85, P < 0.001), squamous (HR 0.56, CI 0.53-0.59, P < 0.001), and neuroendocrine variants (HR 0.83, CI 0.76-0.91, P < 0.001), but not for micropapillary variant (HR 1.45, CI 1.24-1.7, P < 0.001). CONCLUSIONS: Among NMIBC patients presenting with variant histologies, RC was associated with better OS for sarcomatoid, squamous, glandular, and neuroendocrine variants when compared to BPT. This OS survival benefit was not observed in patients with micropapillary variant suggesting a potential role for bladder preservation in such population.

Impact of facility type and volume on survival in patients with metastatic renal cell carcinoma.

INTRODUCTION: To investigate the impact of facility type and volume on survival in patients with metastatic renal cell carcinoma (mRCC). MATERIALS AND METHODS: We investigated the National Cancer Database for patients with mRCC. Patients were stratified according to treatment facility type (academic vs. non-academic) and facility volume (high, intermediate, and low). Kaplan-Meier survival estimates and Cox proportional hazard models were fitted to evaluate overall survival (OS) as a function of facility type, volume, and different treatment modalities. RESULTS: A total of 27,598 patients were identified, of which 10,938 (40%) were treated at academic centers (AC) and 16,131 (60%) at non-academic centers (non-AC). Overall, 19,904 patients (72%) were treated in high-volume hospitals (HVH). Among patients treated at AC, 94% were treated at HVHs. Patients treated at AC were more likely to receive immunotherapy, undergo cytoreductive nephrectomy (CN) and metastasectomy. The 2 and 5 year OS rates for patients treated in AC were 29.7% (CI 28.8%-30.6%) and 13% (CI 12%-14%) vs. 21.7% (CI 21%-22.4%) and 8.4% (CI %7.91-%8.99) in the Non-AC, respectively (p < 0.001). Multivariate Cox regression analysis identified treatment at AC as an independent predictor of survival (HR 0.85, 95% CI 0.81-0.91, p < 0.001). Undergoing CN and receipt of immunotherapy was also associated with a survival benefit (HR 0.41, CI 0.40-0.43 and HR 0.63, CI 0.59-0.68 respectively, p < 0.001). CONCLUSIONS: Treatment at ACs and HVHs was associated with a survival benefit in patients with mRCC. Patients treated at AC were more likely to receive immunotherapy, undergo CN and metastasectomy.

Correlates of refusal of radical cystectomy in patients with muscle-invasive bladder cancer.

PURPOSE: To evaluate factors associated with radical cystectomy (RC) refusal, subsequent treatment decisions, and their influence on overall survival (OS). MATERIALS AND METHODS: We queried the National Cancer Database for patients with non-metastatic muscle-invasive bladder cancer (MIBC), cT2-T4M0. Patients who refused recommended RC were further stratified by treatment into chemotherapy, radiation therapy, chemoradiotherapy, and no treatment groups. Patients were excluded from the analysis if surgery was not planned, not recommended; or if survival data were unknown. Multivariate logistic regression modeling was utilized to identify independent predictors of refusing RC. Cox proportional hazards model with propensity score overlap weighting was utilized to identify survival predictors. Kaplan-Meier analysis was utilized to evaluate survival according to treatment. RESULTS: A total of 74,159 MIBC patients were identified. Among patients with documented reasons for no surgery, 5.4% refused RC despite physician recommendation. Predictors of refusal on multivariate analysis included female gender (P = 0.016), advancing age ≥80 (vs. <60, P < 0.001), African American race (vs. white, P < 0.001) Medicaid (vs. private insurance, P < 0.001) and advancing T stage (T4 vs. T2, P < 0.001). Patients treated at academic centers were less likely to decline RC (vs. community centers, P < 0.001). Median survival after RC was 40.44 months vs. 12.52 months in refusal group. Undergoing chemoradiation had significantly improved survival in those patients compared to monotherapy or no treatment (hazard ratio 0.25, P < 0.001). Overlap weighted model Identified RC refusal as an independent predictor of poor OS (P < 0.001). CONCLUSIONS: Several sociodemographic and clinical factors are associated with refusing radical cystectomy. Such refusal is associated with poor survival outcomes.

Analyzing National Incidences and Predictors of Open Conversion During Minimally Invasive Partial Nephrectomy for cT1 Renal Masses.

Objectives: To analyze predictors of open conversion during minimally invasive partial nephrectomy (MIPN) for cT1 renal masses. Methods: The National Cancer Database (NCDB) was investigated for kidney cancer patients who underwent partial nephrectomy (PN) between 2010 and 2015. Patients who underwent MIPN were stratified into converted and nonconverted groups. Sociodemographics, facility characteristics, and surgical outcomes were compared between the two groups, and multivariate logistic regression model was fitted to identify independent predictors of open conversion. Results: In total, 54,246 patients underwent PN for kidney cancer during the 6-year period. Of those, 18,994 (35%) were open partial nephrectomies (OPNs) and 35,252 (64%) were MIPN. Overall, 1010 (2.87%) of MIPNs were converted to OPN. There was an increasing utilization of MIPN from 50.35% in 2010 to 74.73% in 2015. Patients who had open conversion had more 30-day readmissions (5.95% vs 3.31%, p < 0.01). On multivariate analysis; high-volume facility (>30 MIPNs/year), year of surgery (2015 vs 2010), and robotic approach predicted a lower likelihood of conversion (odds ratio [OR] 0.52, confidence interval [CI] 0.44-0.62; OR 0.59, CI 0.47-0.73; and OR 0.31, CI 0.27-0.35; respectively, p < 0.001 for all). Conversely, Medicaid (vs private insurance; OR 1.75, CI 1.39-2.19, p < 0.001) and male sex (OR 1.26, CI 1.11-1.44, p < 0.001) were independent predictors of conversion. Conclusions: Open conversion in MIPN occurred in 2.87% of cases. There was an increasing utilization of MIPN associated with decreased conversion rates. Higher volume hospitals and progressing year of surgery were associated with less likelihood of conversion.

National Trends and Impact of Regionalization of Radical Cystectomy on Survival Outcomes in Patients with Muscle Invasive Bladder Cancer.

OBJECTIVE: To evaluate national trends and the effect of surgical volume on perioperative mortality and overall survival (OS)in patients undergoing radical cystectomy (RC) for muscle invasive bladder cancer (MIBC). METHODS: We investigated the National Cancer Database to identify patients with localized MIBC (cT2a-T4, M0) who underwent RC from 2004 to 2014. Demographics, 30- and 90-day mortality rates, as well as OS were analyzed. Hospitals were stratified into low-, medium-, and high-volume centers according to median number of RCs performed per year. Multivariate logistic regression models were fitted to identify independent predictors of perioperative mortality. Kaplan-Meier survival curves were generated to evaluate OS. Cox proportional hazard modeling was performed to identify independent predictors of OS. RESULTS: A total of 24,763 patients with localized MIBC who underwent RC from 2004 to 2014 were included in the study. Overall, most (70.85%) RCs occurred at low-volume hospitals, whereas only 15.83% were performed at high-volume hospitals. Thirty-day mortality rates were 2.87%, 2.19%, and 1.83% (P < .01); and 90-day mortality rates were 8.25%, 6.9%, and 5.9% (P < .01) at low-, medium-, and high-volume hospitals, respectively. Multivariate analyses identified RC volume as an independent predictor of 30- and 90-day mortality. RC in high-volume hospitals was associated with a 35% risk reduction in 30-day mortality (odds ratio 0.65, 95% confidence interval [CI] 0.49-0.85; P < .01), and a 26% risk reduction in 90-day mortality (0.74, 95% CI, 0.63-0.87; P < .01). CONCLUSIONS: Treatment at high-volume centers offers improved outcomes and OS benefit. However, in the United States, only 16% of RCs are performed in high-volume hospitals.

Pathological downstaging following radical cystectomy for muscle-invasive bladder cancer: Survival outcomes in the setting of neoadjuvant chemotherapy versus transurethral resection only.

INTRODUCTION: Neoadjuvant chemotherapy (NAC) improves survival for patients undergoing radical cystectomy for muscle-invasive bladder cancer (MIBC). The overall survival (OS) advantage with NAC is primarily seen in patients who achieve pathological downstaging. However, a substantial number of patients achieve pathological downstaging following transurethral resection (TUR) without NAC. OBJECTIVES: To analyze the OS outcomes in patients who achieve pathological downstaging in the setting of NAC vs. TUR only. MATERIALS AND METHODS: We reviewed the National Cancer Database (NCDB) for patients diagnosed with MIBC who underwent radical cystectomy between 2004 and 2014. Patients who achieved complete downstaging (CD) (pT0N0) or noninvasive downstaging (NID) (pT0/Tis/TaN0) were further analyzed. OS was evaluated by comparing those who underwent NAC to those who underwent TUR only. RESULTS: A total of 24,763 patients with MIBC were identified. 1,781 (7.2%) patients had NID and 1,015 (4.1%) had CD. Of all patients, 3,838 (15.5%) underwent NAC. In patients with NID, 757 (42.5%) underwent NAC and 1024 (57.5%) had cystectomy after TUR only. In patients with CD, 465 (45.8%) had NAC, while 550 (54.2%) had TUR only. In both NID and CD, cT2 patients were more likely to have TUR only (P = 0.019, P < 0.001), cT3 patients were more likely to receive NAC (P = 0.008, P < 0.001). Compared to the TUR only group, NAC was associated with improved 5-year OS in those with NID, 77% compared to 68% (HR 0.68, 95% CI [0.52-0.90]), as well as those with CD, 80% vs. 70% (HR 0.59, 95% CI [0.39-0.89]). CONCLUSIONS: NAC was associated with significant overall survival benefit in the subset of patients who achieved CD and NID at radical cystectomy. Overall, NAC was underutilized in patients with MIBC.