Evaluation of the New American Urological Association Guidelines Risk Classification for Hematuria.

PURPOSE: Microhematuria is a prevalent condition and the American Urological Association has developed a new risk-stratified approach for the evaluation of patients with microhematuria. Our objective was to provide the first evaluation of this important guideline. MATERIALS AND METHODS: This multinational cohort study combines contemporary patients from 5 clinical trials and 2 prospective registries who underwent urological evaluation for hematuria. Patients were stratified into American Urological Association risk strata (low, intermediate or high risk) based on sex, age, degree of hematuria, and smoking history. The primary end point was the incidence of bladder cancer within each risk stratum. RESULTS: A total of 15,779 patients were included in the analysis. Overall, 727 patients (4.6%) were classified as low risk, 1,863 patients (11.8%) were classified as intermediate risk, and 13,189 patients (83.6%) were classified as high risk. The predominance of high risk patients was consistent across all cohorts. A total of 857 bladder cancers were diagnosed with a bladder cancer incidence of 5.4%. Bladder cancer was more prevalent in men, smokers, older patients and patients with gross hematuria. The cancer incidence for low, intermediate and high risk groups was 0.4% (3 patients), 1.0% (18 patients) and 6.3% (836 patients), respectively. CONCLUSIONS: The new risk stratification system separates hematuria patients into clinically meaningful categories with differing likelihoods of bladder cancer that would justify evaluating the low, intermediate and high risk groups with incremental intensity. Furthermore, it provides the relative incidence of bladder cancer in each risk group which should facilitate patient counseling regarding the risks and benefits of evaluation for bladder cancer.

Microhematuria: AUA/SUFU Guideline.

PURPOSE: Patients presenting with microhematuria represent a heterogeneous population with a broad spectrum of risk for genitourinary malignancy. Recognizing that patient-specific characteristics modify the risk of underlying malignant etiologies, this guideline sought to provide a personalized diagnostic testing strategy. MATERIALS AND METHODS: The systematic review incorporated evidence published from January 2010 through February 2019, with an updated literature search to include studies published up to December 2019. Evidence-based statements were developed by the expert Panel, with statement type linked to evidence strength, level of certainty, and the Panel's judgment regarding the balance between benefits and risks/burdens. RESULTS: Microhematuria should be defined as ≥ 3 red blood cells per high power field on microscopic evaluation of a single specimen. In patients diagnosed with gynecologic or non-malignant genitourinary sources of microhematuria, clinicians should repeat urinalysis following resolution of the gynecologic or non-malignant genitourinary cause. The Panel created a risk classification system for patients with microhematuria, stratified as low-, intermediate-, or high-risk for genitourinary malignancy. Risk groups were based on factors including age, sex, smoking and other urothelial cancer risk factors, degree and persistence of microhematuria, as well as prior gross hematuria. Diagnostic evaluation with cystoscopy and upper tract imaging was recommended according to patient risk and involving shared decision-making. Statements also inform follow-up after a negative microhematuria evaluation. CONCLUSIONS: Patients with microhematuria should be classified based on their risk of genitourinary malignancy and evaluated with a risk-based strategy. Future high-quality studies are required to improve the care of these patients.

Evaluation of microscopic hematuria and risk of urologic cancer in female patients.

BACKGROUND: Urologic cancer has a lower prevalence in women compared with men; however, there are no differences in the recommended evaluation for women and men with microscopic hematuria. OBJECTIVES: The purpose of this study was to identify risk factors that are associated with urologic cancer in women with microscopic hematuria and to determine the applicability of a hematuria risk score for women. STUDY DESIGN: We conducted a retrospective cohort study within an integrated healthcare system in Southern California. All urinalyses with microscopic hematuria (>3 red blood cells per high-power field) that were performed from 2009-2015 were identified. Women who were referred for urologic evaluation were entered into a prospective database. Clinical and demographic variables that included the presence of gross hematuria in the preceding 6 months were recorded. The cause of the hematuria, benign or malignant, was entered into the database. Cancer rates were compared with the use of chi-square and logistic regression models. Adjusted risk ratios of urologic cancer were estimated with the use of multivariate regression analysis. We also explored the applicability of a previously developed, gender nonspecific, hematuria risk score in this female cohort. RESULTS: A total of 2,705,696 urinalyses were performed in women during the study period, of which 552,119 revealed microscopic hematuria. Of these, 14,539 women were referred for urologic evaluation; clinical data for 3573 women were entered into the database. The overall rate of urologic cancer was 1.3% (47/3573). In women <60 years old, the rate of urologic cancer was 0.6% (13/2053) compared with 2.2% (34/1520) in women ≥60 years old (P<.01). In women who reported a history of gross hematuria, the rate of urologic cancer was 5.8% (20/346) compared with a 0.8% (27/3227) in women with no history of gross hematuria (P<.01). In multivariate analysis, > 60 years old (odds ratio, 3.1; 95% confidence interval, 1.6-5.9), a history of smoking (odds ratio, 3.2; 95% confidence interval, 1.8-5.9), and a history of gross hematuria in the previous 6 months (odds ratio, 6.2; 95% confidence interval, 3.4-11.5) were associated with urologic cancers. A higher microscopic hematuria risk score was associated with an increased risk of cancer in this test cohort (P<.01). Women in the highest risk group had a urologic cancer rate of 10.8% compared with a rate of 0.5% in the lowest risk group. CONCLUSIONS: In this female population, >60 years old and a history of smoking and/or gross hematuria were the strongest predictors of urologic cancer. Absent these risk factors, the rate of urologic cancer did not exceed 0.6%. A higher hematuria risk score correlated significantly with the risk of urologic cancer in this female test cohort.

Preoperative radiographic parameters predict long-term renal impairment following partial nephrectomy.

PURPOSE: We analyzed radiographic parameters describing anatomic features of renal tumors to identify preoperative characteristics that could help predict long-term decline in renal function following partial nephrectomy. METHODS: We retrospectively reviewed the records of 194 consecutive patients who underwent partial nephrectomy from January 2006 to March 2009 and analyzed a cohort of 53 patients for whom complete clinical, radiographic, and operative information was available. Computed tomography images were reviewed by a single radiologist. Radiographic criteria for describing renal tumor size and location included diameter, volume, endophytic properties, proximity to collecting system, anterior/posterior location, location relative to polar lines, and R.E.N.A.L. nephrometry score. Postoperative estimated glomerular filtration rate was calculated using the MDRD study group equation with serum creatinine at last follow-up. RESULTS: The median preoperative and postoperative GFR values were 75 (IQR 65-97) and 66 (IQR 55-84) mL/min/1.73 m(2), respectively. At a median follow-up of 38 months, the median percentage decrease in GFR was 12%. On univariate analyses, tumor diameter (P = 0.002), tumor volume (P < 0.0001), nearness of tumor to collecting system (P = 0.017), and location relative to polar lines (P = 0.017) were associated with percentage decrease in GFR. Furthermore, higher R.E.N.A.L. nephrometry score was also associated with poorer renal functional outcomes following partial nephrectomy (P = 0.019). CONCLUSIONS: Anatomic features of renal tumors defined by preoperative radiographic characteristics correlate with the degree of renal functional decline after partial nephrectomy. Identification of these parameters may assist in patient counseling and clinical decision making following partial nephrectomy. Validation in larger prospective studies is necessary.

Multi-institutional validation of the ability of preoperative hydronephrosis to predict advanced pathologic tumor stage in upper-tract urothelial carcinoma.

OBJECTIVE: The presence of hydronephrosis (HN) has been implicated as a predictor of poor outcomes for patients diagnosed with bladder cancer. Small, single institution preliminary reports suggest a similar negative relationship may exist for upper-tract urothelial carcinoma (UTUC). Herein, we attempt to validate the prognostic value of preoperative HN in a large, multi-institutional cohort of UTUC patients. MATERIALS AND METHODS: Data on 469 patients with localized UTUC from 5 tertiary referral centers who underwent a radical nephroureterectomy (91%) or distal ureterectomy (9%) without neoadjuvant chemotherapy were integrated into a relational database. Preoperative HN data, including presence vs. absence and high vs. low grade, were available in 408 patients. The association of HN with pathologic features was evaluated. RESULTS: A total of 254 men and 154 women with a median age of 69 years (IQR 15) were analyzed. Overall, 192 patients (47%) had ≥pT2 disease, 145 (36%) had non-organ-confined (NOC) cancers (≥pT3 and/or positive lymph nodes), and 298 (73%) had high grade UTUC on final pathology. Forty-six percent of patients had tumors in the renal pelvis, 27% in the ureter, and 27% in both locations. Preoperatively, 223 patients (55%) were noted to have ipsilateral HN (39% low grade and 61% high grade). Hydronephrosis was associated with ≥pT2 stage (P < 0.001), NOC disease (P < 0.001), and high grade cancers (P = 0.04). On multivariate analysis adjusting for gender, age, and tumor location, HN was an independent predictor of muscle invasive (HR 7.4, P < 0.001), NOC (HR 5.5, P < 0.001), and high pathologic grade (HR 1.6, P = 0.03) UTUC disease. CONCLUSION: The presence of preoperative HN was associated with advanced stage UTUC. This readily available imaging modality may improve preoperative risk stratification for UTUC patients thereby guiding use of endoscopic versus extirpative surgery as well as the need for neoadjuvant chemotherapy regimens.

Laparoscopic and open partial nephrectomy: complication comparison using the Clavien system.

BACKGROUND AND OBJECTIVES: To compare postoperative complications in patients undergoing laparoscopic and open partial nephrectomy using a standardized complication-reporting system and a standardized tumor-scoring system. METHODS: We conducted a retrospective analysis of 189 consecutive patients with nephrometry scores available who underwent elective partial nephrectomy for renal masses. Demographic, perioperative, and complication data were recorded. By using the modified Clavien scale, we graded 30- and 90-day complication rates. RESULTS: 107 patients underwent laparoscopic partial nephrectomy and 82 underwent open partial nephrectomy (N=189). Open partial nephrectomy patients had higher nephrometry scores than laparoscopic patients had (7.1±2.4 vs. 5.6±1.8, P<.001). Surgical and hospitalization times were shorter, and estimated blood loss was lower in the laparoscopic group (P<.001). At 30 days, there were more overall complications in the open group, but more major complications in the laparoscopic group (P>.05). After multivariable logistic regression analysis, only higher body mass index and higher estimated blood loss were predictors of more overall complications. CONCLUSIONS: Laparoscopic partial nephrectomy has the advantages of decreased operative time, lower blood loss, and shorter hospital stay. The complication rate in the laparoscopic group is similar to that in the open group, despite favorable tumor characteristics in the laparoscopic group.

Impact of histological variants on clinical outcomes of patients with upper urinary tract urothelial carcinoma.

PURPOSE: We investigated the clinical and prognostic impact of variant histologies on upper tract urothelial carcinoma outcomes after radical nephroureterectomy. MATERIALS AND METHODS: Data on 1,648 patients with upper tract urothelial carcinoma treated with radical nephroureterectomy without preoperative chemotherapy or radiotherapy were reviewed for histological differentiation and variants. We analyzed differences between pure upper tract urothelial carcinoma and upper tract urothelial carcinoma with variant histology, and differences in the histological variants using different stratifications. RESULTS: A total of 398 patients (24.2%) had histological upper tract urothelial carcinoma variants. The most common variants were squamous cell and glandular differentiation in 9.9% and 4.4% of cases, respectively. Histological variants were associated with advanced tumor stage, tumor multifocality, sessile tumor architecture, tumor necrosis, lymphovascular invasion and lymph node metastasis compared to pure upper tract urothelial carcinoma (p ≤0.031). On univariable analysis variant histology was associated with disease recurrence (p = 0.002) and cancer specific mortality (p = 0.003). In 174 patients treated with adjuvant chemotherapy there was no difference in disease recurrence or survival between variant histology and pure upper tract urothelial carcinoma (p = 0.42 and 0.59, respectively). On multivariable analysis adjusted for the effects of standard clinicopathological characteristics variant histology was not associated with either end point. CONCLUSIONS: Almost 25% of patients with upper tract urothelial carcinoma treated with radical nephroureterectomy harbored histological variants. Variant histology was associated with features of biologically aggressive upper tract urothelial carcinoma. While variant histology is associated with worse outcomes on univariable analysis but this effect did not remain significant on multivariable analysis.

Validation of a novel robotic-assisted partial nephrectomy surgical training model.

UNLABELLED: What's known on the subject? and What does the study add? One area of particular growth for robotic surgery has been partial nephrectomy. Despite a perceived notion that robotic-assisted partial nephrectomy is more easily adaptable compared to laparoscopic partial nephrectomy, there is nonetheless an associated learning curve. Validated training models with a corresponding assessment method for robotic-assisted partial nephrectomy were previously unavailable. We have designed and validated a RAPN surgical model appropriate for resident and fellow training. OBJECTIVE: To evaluate the face, content and construct validities of a novel ex vivo surgical training model for robotic-assisted partial nephrectomy (RAPN). METHODS: We prospectively identified participants as novice (not completed any robotic console cases), intermediate (at least one robotic console case but <100 cases), and expert (≥100 robotic console cases). Each participant performed a partial nephrectomy using the da Vinci Si Surgical System on an ex vivo porcine kidney with an embedded Styrofoam ball that mimics a renal tumour. Subjects completed a post-study questionnaire assessing training model realism and utility. Participants were anonymously judged by three expert reviewers using a validated laparoscopic assessment tool. Performance between groups was compared using the tukey-kramer test. RESULTS: The 46 participants recruited for this study included 24 novices, nine intermediates, and 13 experts. Overall, expert surgeons rated the training model as 'very realistic' (median visual analogue score 7/10) (face validity). Experts also rated the model as an 'extremely useful' training tool for residents (median 9/10) and fellows (9/10) (content validity), although less so for experienced robotic surgeons (5/10). Experts outscored novices on overall performance (P = 0.0002) as well as individual metrics, including 'depth perception,''bimanual dexterity,''efficiency,''tissue handling,''autonomy,''precision,' and 'instrument and camera awareness' (P < 0.05) (construct validity). Experts similarly outperformed intermediates in most metrics (P < 0.05). CONCLUSION: Our novel ex vivo RAPN surgical model has demonstrated face, content and construct validity. Future development of this model should include simulation of haemostasis management and renal reconstruction.

Predicting clinical outcomes after radical nephroureterectomy for upper tract urothelial carcinoma.

BACKGROUND: Novel prognostic factors for patients after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC) have recently been described. OBJECTIVE: We tested the prognostic value of pathologic characteristics and developed models to predict the individual probabilities of recurrence-free survival (RFS) and cancer-specific survival (CSS) after RNU. DESIGN, SETTING, AND PARTICIPANTS: Our study included 2244 patients treated with RNU without neoadjuvant or adjuvant therapy at 23 international institutions. Tumor characteristics included T classification, grade, lymph node status, lymphovascular invasion, tumor architecture, location, and concomitant carcinoma in situ (CIS). The cohort was randomly split for development (12 centers, n=1273) and external validation (11 centers, n=971). INTERVENTIONS: All patients underwent RNU. MEASUREMENTS: Univariable and multivariable models addressed RFS, CSS, and comparison of discrimination and calibration with American Joint Committee on Cancer (AJCC) stage grouping. RESULTS AND LIMITATIONS: At a median follow-up of 45 mo, 501 patients (22.3%) experienced disease recurrence and 418 patients (18.6%) died of UTUC. On multivariable analysis, T classification (p for trend <0.001), lymph node metastasis (hazard ratio [HR]: 1.98; p=0.002), lymphovascular invasion (HR: 1.66; p<0.001), sessile tumor architecture (HR: 1.76; p<0.001), and concomitant CIS (HR: 1.33; p=0.035) were associated with disease recurrence. Similarly, T classification (p for trend<0.001), lymph node metastasis (HR: 2.23; p=0.001), lymphovascular invasion (HR: 1.81; p<0.001), and sessile tumor architecture (HR: 1.72; p=0.001) were independently associated with cancer-specific mortality. Our models achieved 76.8% and 81.5% accuracy for predicting RFS and CSS, respectively. In contrast to these well-calibrated models, stratification based upon AJCC stage grouping resulted in a large degree of heterogeneity and did not improve discrimination. CONCLUSIONS: Using standard pathologic features, we developed highly accurate prognostic models for the prediction of RFS and CSS after RNU for UTUC. These models offer improvements in calibration over AJCC stage grouping and can be used for individualized patient counseling, follow-up scheduling, risk stratification for adjuvant therapies, and inclusion criteria for clinical trials.

Subclassification of pT3 urothelial carcinoma of the renal pelvicalyceal system is associated with recurrence-free and cancer-specific survival: proposal for a revision of the current TNM classification.

BACKGROUND: The clinical course of pT3 upper tract urothelial carcinoma (UTUC) is highly variable. OBJECTIVES: The aim of the current study was to validate the clinical and prognostic importance of pT3 subclassification in the renal pelvicalyceal system in a large international cohort of patients. DESIGN, SETTING, AND PARTICIPANTS: From a multi-institutional international database, 858 renal pelvicalyceal tumors treated with radical nephroureterectomy (RNU) were systematically reevaluated by genitourinary pathologists. Category pT3 pelvic tumors were categorized as pT3a (infiltration of the renal parenchyma on a microscopic level only) versus pT3b (macroscopic infiltration of the renal parenchyma and/or infiltration of peripelvic adipose tissue). INTERVENTION: RNU. MEASUREMENTS: Associations of pT3 subclassifications with clinicopathologic features were assessed with the chi-square test. Prognostic impact was assessed with the log-rank test and multivariable Cox regression analyses. RESULTS AND LIMITATIONS: Of 858 patients with renal pelvicalyceal tumors, 266 (31%) had pT3 disease. Of these, 146 (54.9%) were classified as pT3a and 120 (45.1%) as pT3b. Compared with pT3a, pT3b cancers were associated with higher tumor grade, nodal disease, and tumor necrosis. Ten-year recurrence-free (pT3a 58% vs pT3b 38%; p<0.001) and cancer-specific (pT3a 60% vs pT3b 39%; p=0.002) survival rates were lower for patients with pT3b disease. In multivariable analyses, classification pT3b was an independent predictor of both disease recurrence (hazard ratio [HR]: 1.8, p=0.003) and cancer-specific mortality (HR: 1.7; p=0.02). The major limitation is the retrospective character of the study. CONCLUSIONS: Subclassification of pT3 renal pelvicalyceal UTUC helps identify patients who are at increased risk of disease progression and cancer-related death. Further research may help assess the value of subclassification and its inclusion in future editions of the American Joint Committee on Cancer-International Union Against Cancer TNM classification system.

Anatomic renal artery branch microdissection to facilitate zero-ischemia partial nephrectomy.

BACKGROUND: Robot-assisted and laparoscopic partial nephrectomies (PNs) for medial tumors are technically challenging even with the hilum clamped and, until now, were impossible to perform with the hilum unclamped. OBJECTIVE: Evaluate whether targeted vascular microdissection (VMD) of renal artery branches allows zero-ischemia PN to be performed even for challenging medial tumors. DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort evaluation of 44 patients with renal masses who underwent robot-assisted or laparoscopic zero-ischemia PN either with anatomic VMD (group 1; n=22) or without anatomic VMD (group 2; n=22) performed by a single surgeon from April 2010 to January 2011. INTERVENTION: Zero-ischemia PN with VMD incorporates four maneuvers: (1) preoperative computed tomographic reconstruction of renal arterial branch anatomy, (2) anatomic dissection of targeted, tumor-specific tertiary or higher-order renal arterial branches, (3) neurosurgical aneurysm microsurgical bulldog clamp(s) for superselective tumor devascularization, and (4) transient, controlled reduction of blood pressure, if necessary. MEASUREMENTS: Baseline, perioperative, and postoperative data were collected prospectively. RESULTS AND LIMITATIONS: Group 1 tumors were larger (4.3 vs 2.6 cm; p=0.011), were more often hilar (41% vs 9%; p=0.09), were medial (59% and 23%; p=0.017), were closer to the hilum (1.46 vs 3.26 cm; p=0.0002), and had a lower C index score (2.1 vs 3.9; p=0.004) and higher RENAL nephrometry scores (7.7 vs 6.2; p=0.013). Despite greater complexity, no group 1 tumor required hilar clamping, and perioperative outcomes were similar to those of group 2: operating room time (4.7 and 4.1h), median blood loss (200 and 100ml), surgical margins for cancer (all negative), major complications (0% and 9%), and minor complications (18% and 14%). The median serum creatinine level was similar 2 mo postoperatively (1.2 and 1.3mg/dl). The study was limited by the relatively small sample size. CONCLUSIONS: Anatomic targeted dissection and superselective control of tumor-specific renal arterial branches facilitate zero-ischemia PN. Even challenging medial and hilar tumors can be excised without hilar clamping. Global surgical renal ischemia has been eliminated for most patients undergoing PN at our institution.

Concurrent and predictive validation of a novel robotic surgery simulator: a prospective, randomized study.

PURPOSE: We evaluated the concurrent and predictive validity of a novel robotic surgery simulator in a prospective, randomized study. MATERIALS AND METHODS: A total of 24 robotic surgery trainees performed virtual reality exercises on the da Vinci® Skills Simulator using the da Vinci Si™ surgeon console. Baseline simulator performance was captured. Baseline live robotic performance on ex vivo animal tissue exercises was evaluated by 3 expert robotic surgeons using validated laparoscopic assessment metrics. Trainees were then randomized to group 1-simulator training and group 2-no training while matched for baseline tissue scores. Group 1 trainees underwent a 10-week simulator curriculum. Repeat tissue exercises were done at study conclusion to assess performance improvement. Spearman's analysis was used to correlate baseline simulator performance with baseline ex vivo tissue performance (concurrent validity) and final tissue performance (predictive validity). The Kruskal-Wallis test was used to compare group performance. RESULTS: Groups 1 and 2 were comparable in pre-study surgical experience and had similar baseline scores on simulator and tissue exercises (p >0.05). Overall baseline simulator performance significantly correlated with baseline and final tissue performance (concurrent and predictive validity each r = 0.7, p <0.0001). Simulator training significantly improved tissue performance on key metrics for group 1 subjects with lower baseline tissue scores (below the 50th percentile) than their group 2 counterparts (p <0.05). Group 1 tended to outperform group 2 on final tissue performance, although the difference was not significant (p >0.05). CONCLUSIONS: Our study documents the concurrent and predictive validity of the Skills Simulator. The benefit of simulator training appears to be most substantial for trainees with low baseline robotic skills.

High-grade ureteroscopic biopsy is associated with advanced pathology of upper-tract urothelial carcinoma tumors at definitive surgical resection.

BACKGROUND AND PURPOSE: Accurate assessment of upper-tract urothelial carcinoma (UTUC) pathology may guide use of endoscopic vs extirpative therapy. We present a multi-institutional cohort of patients with UTUC who underwent surgical resection to characterize the association of ureteroscopic (URS) biopsy features with final pathology results. PATIENTS AND METHODS: URS biopsy data were available in 238 patients who underwent surgical resection of UTUC. Biopsies were performed using a brush biopsy kit, mechanical biopsy device, or basket. Stage was classified as a positive brush, nonmuscle-invasive (

Face, content and construct validity of a novel robotic surgery simulator.

PURPOSE: We evaluated the face, content and construct validity of the novel da Vinci® Skills Simulator™ using the da Vinci Si™ Surgeon Console as the surgeon interface. MATERIALS AND METHODS: We evaluated a novel robotic surgical simulator for robotic surgery using the da Vinci Si Surgeon Console and Mimic™ virtual reality. Subjects were categorized as novice-no surgical training, intermediate-surgical training with fewer than 100 robotic cases or expert-100 or more primary surgeon robotic cases. Each participant completed 10 virtual reality exercises with 3 repetitions and a questionnaire with a 1 to 10 visual analog scale to assess simulator realism (face validity) and training usefulness (content validity). The simulator recorded performance based on specific metrics. The performance of experts, intermediates and novices was compared (construct validity) using the Kruskal-Wallis test. RESULTS: We studied 16 novices, 32 intermediates with a median surgical experience of 6 years (range 1 to 37) and a median of 0 robotic cases (range 0 to 50), and 15 experts with a median of 315 robotic cases (range 100 to 800). Participants rated the virtual reality and console experience as very realistic (median visual analog scale score 8/10) while expert surgeons rated the simulator as a very useful training tool for residents (10/10) and fellows (9/10). Experts outperformed intermediates and novices in almost all metrics (median overall score 88.3% vs 75.6% and 62.1%, respectively, between group p<0.001). CONCLUSIONS: We confirmed the face, content and construct validity of a novel robotic skill simulator that uses the da Vinci Si Surgeon Console. Although it is currently limited to basic skill training, this device is likely to influence robotic surgical training across specialties.

The economics of robotic cystectomy: cost comparison of open versus robotic cystectomy.

OBJECTIVE: • To assess and compare the economic burden of open radical cystectomy (OC) vs robotic-assisted laparoscopic radical cystectomy (RC) with pelvic lymph node dissection and urinary diversion. PATIENTS AND METHODS: • A series of 103 and 83 consecutive patients undergoing OC and RC, respectively, were prospectively studied at a tertiary care institution from April 2002 to February 2009. • Data were collected on patient demographics, perioperative parameters and length of stay (LOS) in hospital. Cohorts were subdivided into ileal conduit (IC), continent cutaneous diversion (CCD) and orthotopic neobladder (ON) subgroups. • A linear cost model was created to simulate treatment with OC vs RC. Procedural costs were derived from the Medicare Resource Based Relative Value Scale. Materials costs were obtained from the respective suppliers. The indirect costs of complications were considered. • Sensitivity analyses were performed. RESULTS: • Despite a higher cost of materials, RC was less expensive than OC for IC and CCD, although the cost advantage deteriorated for ON. • The per-case costs of RC with IC, CCD and ON were $20,659, $22,102 and $22,685, respectively, compared to $25,505, $22,697 and $20,719 for their OC counterparts. • The largest cost driver in the study was LOS in hospital. • RC showed a shorter LOS compared to OC, although this effect was insufficient to offset the higher cost of robotic surgery. • Complications materially affected cost performance. CONCLUSIONS: • Despite a higher cost of materials, RC can be more cost efficient than OC as a treatment for bladder cancer at a high-volume, tertiary care referral centre, particularly with IC. • Complications significantly impact cost performance.

Urinary cytology has a poor performance for predicting invasive or high-grade upper-tract urothelial carcinoma.

OBJECTIVE: • To evaluate the diagnostic accuracy of urine cytology for detecting aggressive disease in a multi-institutional cohort of patients undergoing extirpative surgery for upper-tract urothelial carcinoma (UTUC). METHODS: • We reviewed the records of 326 patients with urinary cytology data who underwent a radical nephroureterectomy or distal ureterectomy without concurrent or previous bladder cancer. • We assessed the association of cytology (positive, negative and atypical) with final pathology. Sensitivity and positive predictive value (PPV) of a positive (± atypical) cytology for high-grade and muscle-invasive UTUC was calculated. RESULTS: • On final pathology, 53% of patients had non-muscle invasive disease (pTa, pTis, pT1) and 47% had invasive disease (≥ pT2). Low-grade and high-grade cancers were present in 33% and 67% of patients, respectively. • Positive, atypical and negative urine cytology was noted in 40%, 40% and 20% of cases. Positive urinary cytology had sensitivity and PPV of 56% and 54% for high-grade and 62% and 44% for muscle-invasive UTUC. • Inclusion of atypical cytology with positive cytology improved the sensitivity and PPV for high-grade (74% and 63%) and muscle-invasive (77% and 45%) UTUC. Restricting analysis to patients with selective ureteral cytologies further improved the diagnostic accuracy when compared with bladder specimens (PPV > 85% for high-grade and muscle-invasive UTUC). CONCLUSIONS: • In this cohort of patients with UTUC treated with radical surgery, urine cytology in isolation lacked performance characteristics to accurately predict muscle-invasive or high-grade disease. • Improved surrogate markers for pathological grade and stage are necessary, particularly when considering endoscopic modalities for UTUC.

Early oncological outcomes for bladder urothelial carcinoma patients treated with robotic-assisted radical cystectomy.

OBJECTIVE: • To determine oncological outcomes including early survival rates among unselected bladder urothelial carcinoma (BUC) patients treated with robotic-assisted radical cystectomy (RRC). PATIENTS AND METHODS: • Clinicopathologic and survival data were prospectively gathered for 85 consecutive BUC patients treated with RRC. • The decision to undergo a robotic rather than open approach was made without regard to tumor volume or surgical candidacy. • Kaplan-Meier survival rates were determined and stratified by tumor stage and LN positivity, and multivariate analysis was performed to identify independent predictors of survival. RESULTS: • Patients were relatively old (25% >80 years; median 73.5 years), with frequent comorbidities (46% with ASA class ≥ 3). Of these patients 28% had undergone previous pelvic radiation or pelvic surgery, and 20% had received neoadjuvant chemotherapy. • Extended pelvic lymphadenectomy was performed in 98% of patients, with on average 19.1 LN retrieved. • On final pathology, extravesical disease was common (36.5%). • Positive surgicalmargins were detected in five (6%) patients, all of whom had extravesical tumors with perineural and/or lymphovascular invasion, and most of whom were >80 years old. • At a mean postoperative interval of 18 months, 20 (24%) patients had developed recurrent disease, but only three (4%) patients had recurrence locally. Disease-free, cancer-specific and overall survival rates at 2 years were 74%, 85% and 79%, respectively. Patients with low-stage/LN(-) cancers had significantly better survival than extravesical/LN(-) or any-stage/LN(+) patients, with stage being the most important predictor on multivariate analysis. CONCLUSION: • RRC can achieve adequately high LN yields with a low positive margin rate among unselected BUC patients. • Early survival outcomes are similar to those reported in contemporary open series, with an encouragingly low incidence of local recurrence, however long-term follow-up and head-to-head comparison with the open approach are still needed.

Does preoperative symptom classification impact prognosis in patients with clinically localized upper-tract urothelial carcinoma managed by radical nephroureterectomy?

OBJECTIVES: To evaluate if preoperative symptom classification could refine prediction of outcomes for patients with clinically localized upper-tract urothelial carcinoma (UTUC) managed by radical nephroureterectomy (RNU). METHODS: Data on 654 patients with localized UTUC who underwent RNU were reviewed. Preoperative symptoms were classified as incidental (S1), local (S2), and systemic (S3). Clinical and pathologic data were compared between the cohorts. Kaplan-Meier analyses and Cox proportional hazard modeling were used to determine recurrence-free and cancer-specific survival amongst the symptom cohorts. RESULTS: Symptom classification was S1 in 213 (33%) patients, S2 in 402 (61%), and S3 in 39 (6%). S3 symptoms were associated with advanced pathology, including higher stage, grade, and lymph node (LN) positivity. Five and 10-year recurrence-free and cancer-specific survival estimates were similar for patients with S1 and S2 symptoms (P = 0.75 and 0.58, respectively), but was worse for patients with S3 symptoms (P < 0.001 for both). On multivariate analysis adjusting for final pathologic stage, grade, and LN status, S3 symptoms were not an independent predictor of recurrence (HR 1.44, P = 0.19) or death due to disease (HR 1.66, P = 0.07). Addition of symptom classification, however, increased the accuracy of a model consisting of stage, grade, and LNs for prediction of recurrence-free and cancer-specific survival by 1.4% and 1.3%, respectively (P < 0.001 for both). CONCLUSIONS: Local symptoms do not confer worse prognosis compared with patients with incidentally detected UTUC. However, systemic symptoms are associated with worse outcomes despite apparently effective RNU. Patients with systemic symptoms may harbor micrometastatic disease and could potentially benefit from a more rigorous metastatic evaluation or perioperative chemotherapy regimens.

Does the presence of hydronephrosis on preoperative axial CT imaging predict worse outcomes for patients undergoing nephroureterectomy for upper-tract urothelial carcinoma?

OBJECTIVES: Hydronephrosis at the time of diagnosis of bladder cancer is associated with advanced disease and is a predictor of poorer outcomes. There is, however, limited information addressing whether a similar relationship exists for upper-tract urothelial carcinoma (UTUC). We investigate the prognostic impact of hydronephrosis on preoperative axial imaging on clinical outcomes after radical nephroureterectomy. MATERIALS AND METHODS: The records for 106 patients with UTUC who underwent radical nephroureterectomy at 2 medical centers were reviewed. Preoperative computed tomography (CT) images were evaluated for ipsilateral hydronephrosis by radiologists blinded to clinical outcomes. Association of hydronephrosis with pathologic features and oncologic outcomes after surgery was assessed. RESULTS: Sixty-seven men and 39 women with a median age of 69 years (range, 36 to 90) were evaluated. One-third of these patients had muscle invasive disease or greater (≥T2), 44% had high grade tumors, and 3% had lymph node (LN) metastases. At a median follow-up of 47 months (range, 1 to 164), 43% of patients experienced disease recurrence, 18% developed metastasis, and 12% died of their cancer. Thirty-nine patients (37%) had hydronephrosis on preoperative axial imaging; 35% of these patients had ureteral tumors, and 27% had multifocal disease. The presence of hydronephrosis was associated with advanced pathologic stage (P = 0.03) and disease in the ureter (vs. renal pelvis) (P = 0.007). Hydronephrosis was a predictor of non-organ confined disease on final pathology (hazard ratio [HR] 3.7, P = 0.01). On preoperative multivariable analysis controlling for age, gender, tumor location, ureteroscopic biopsy grade, and urinary cytology, hydronephrosis was independently associated with cancer metastasis (HR 8.2, P = 0.02) and cancer-specific death (HR 12.1, P = 0.03). CONCLUSIONS: Preoperative hydronephrosis on axial imaging is associated with features of aggressive disease and predicts advanced pathologic stage for UTUC. Hydronephrosis can be a valuable prognostic tool for preoperative planning and counseling regarding disease outcomes.