Does intravesical BCG for bladder cancer protect from COVID-19?

INTRODUCTION: The study aimed to correlate the history of intravesical BCG as well as infantile BCG immunization with the incidence and severity of COVID-19 infection. METHODS: Retrospective data collection of patients with high-risk non muscle invasive bladder cancer (NMIBC) from two Canadian centers. Data collection included a history of BCG instillation, infantile immunization, and the development of COVID-19 infection. Admission and/ or mortality because of COVID-19 was reported. RESULTS: We could include data from 348 patients: including 188 and 160 patients from Ontario and British Columbia respectively. COVID-19 affected 15% of these patients. Intravesical BCG was used in 44% of these patients. Intravesical BCG and/or infantile BCG immunization did not correlate with the incidence of COVID-19 infection. CONCLUSIONS: Previous intravesical BCG and/ or a history of infantile BCG vaccination were not more/ less frequent in patients who had COVID-19 infection.

An analysis of benign prostatic hyperplasia surgical treatment reimbursement trends across Canada: Examining provincial changes over the recent decade with comparison to cost of living changes.

INTRODUCTION: A variety of procedures for the endoscopic surgical treatment of symptomatic benign prostatic hyperplasia (BPH) refractory to medical therapy have existed for decades. The present study examines trends in surgeon compensation for these treatments within Canada. METHODS: The physician fee schedule for BPH surgery across 10 Canadian provinces for the years 2010 and 2023 were obtained. A descriptive study examining first, the provincial reimbursement for transurethral resection of prostate (TURP) and laser ablative/enucleation surgery; second, the difference in TURP reimbursement between 2010 and 2023; and third, the annual change in TURP reimbursement juxtaposed with the annual change in the provincial Consumer Price Index (CPI) and annual salary for the working population aged 35-44. RESULTS: Seven of 10 Canadian provinces reimburse laser BPH surgery equally to TURP. The average provincial TURP reimbursement is $545, ranging from $451 in Ontario to $688 in Saskatchewan. Since 2010, TURP reimbursement has varied by province from a 0% net change in Ontario to an increase of 21% in Nova Scotia. Reimbursement for TURP has increased at a slower pace than the local CPI, and for half of the provinces at a slower pace than the annual salary for people aged 35-44. CONCLUSIONS: The compensation model for endoscopic BPH surgery does not have a unified structure in Canada that is consistent across provinces, nor does it keep up with inflation, possibly impacting future recruitment, increasing geographic disparities, and most importantly, limiting the adoption of new BPH therapies.

Endophytic to total tumour volume ratio: An added variable to patients with T1b/T2 renal tumours undergoing partial nephrectomy.

INTRODUCTION: Partial nephrectomy is the standard of care to patients with small renal masses. It is still encouraged to larger tumours whenever feasible. The aim of this study is to look for the endophytic to total tumour volume ratio as an added variable to study the complexity of partial nephrectomy to patients with T1b/ T2 renal tumours. METHODS: Retrospective data collection of patients that had partial nephrectomy for T1b/T2 renal tumours by a single surgeon was done. Radiological re-assessment for the CT images to measure the endophytic to total tumour volume ratio was done. RESULTS: The mean age of the patients was 63 years. The study included 25 males and 11 females. All cases were managed by open surgery using retroperitoneal transverse lateral lumbotomy and warm ischemia was used in all patients. The mean tumour volume was 74 cc, the mean endophytic tumour volume was 29 cc. The mean percentage of endophytic to total tumour volume was 42%. CONCLUSIONS: Partial nephrectomy is safe for most of the patients with good performance status, having large renal masses. More complex surgery can be predicted in patients with endophytic to total tumour volume greater than 42%.

Top-down holmium laser enucleation of the prostate (HoLEP) versus traditional HoLEP for the treatment of benign prostatic hyperplasia (BPH): 1-year outcomes of a randomized controlled trial.

BACKGROUND: The top-down holmium laser enucleation of the prostate (HoLEP) technique recently emerged as a safe and effective modification of traditional HoLEP. In our randomized controlled trial, we compared intraoperative and postoperative outcomes of traditional and top-down HoLEP for the treatment of benign prostatic hyperplasia (BPH) in patients with a prostate size ≥80 g. METHODS: One-hundred patients with BPH and a prostate volume ≥80 cc participated in this prospective randomized controlled trial. Outcome measures were collected and compared, including IPSS, QoL, flow rate, PVR, IIEF-15, PSA, and TRUS prostate volume changes. Perioperative complications were also recorded. All patients were followed up at 1, 3, 6, and 12 months. RESULTS: There were no significant differences in preoperative baseline characteristics between the two surgical groups. The median prostate volume for the traditional and top-down HoLEP groups was 107 and 102 cc, respectively. The operative parameters and postoperative outcomes were comparable for both cohorts. The median enucleation time for traditional HoLEP was 60 min, which was not significantly longer than that of top-down HoLEP (52 min) (p = 0.07). At 3 months follow-up, there was no statistically significant difference in transient stress urinary incontinence (SUI) in the traditional HoLEP (4.1%) versus the top-down HoLEP group (2.2%), (p = 0.61). There were no significant differences in functional and sexual outcomes between the two groups at 12 months. CONCLUSIONS: The HoLEP procedure significantly improves patients' urinary functional outcomes and has comparable postoperative outcomes regardless of the technique utilized.

History of infantile BCG immunization did not predict lamina propria invasion and/or high-grade in patients with non-muscle invasive bladder cancer.

OBJECTIVE: To evaluate the utility of infantile BCG vaccination history in predicting stage and grade of tumours in non-muscle invasive bladder cancer (NMIBC). MATERIALS AND METHODS: We retrospectively analyzed data from patients from a single center who were diagnosed with new NMIBC and underwent transurethral resection of bladder tumour (TURBT) between 2017 and 2022. We assessed BCG immunization status with various demographics and comorbidities, as well as tumour recurrence, progression, stage, and grade. RESULTS: A total of 188 patients met the inclusion criteria for our study. The mean age of patients at the time of diagnosis was significantly lower in those that had been immunized with BCG (71 ± 9) than those who had not (77 ± 10) (p < 0.0001). History of BCG immunization did not correlate with sex, history of diabetes mellitus (DM), prior history of intravesical BCG treatment, and tumour recurrence, progression, stage, and grade. CONCLUSIONS: History of infantile BCG vaccination did not correlate with the depth of invasion and/or the grade in patients with non-muscle invasive bladder cancer. Patients that received infantile BCG vaccination were significantly younger at the time of diagnosis of NMIBC.

Holmium Laser Xpeeda Vaporization vs GreenLight XPS Vaporization of the Prostate for Benign Prostatic Obstruction: 1-Year Results from a Randomized Controlled Clinical Study.

Introduction and Objective: To compare the safety and efficacy of Holmium Laser Xpeeda Vaporization and GreenLight XPS Vaporization of the prostate in patients with prostate size ≤80 g. Methods: Ninety-two men with benign prostatic hyperplasia (BPH) and prostate size ≤80 g scheduled for laser prostatectomy were included in this prospective randomized trial. Outcome measures were collected and compared, including International Prostate Symptom Score (IPSS), quality of life (QoL), flow rate, postvoid residual urine volume (PVR), International Index of Erectile Dysfunction (IIEF)-15, prostate-specific antigen (PSA), transrectal ultrasound prostate volume, and catheterization time. Perioperative complications were also recorded. Patients were offered a trial of void (TOV) 3 hours after their procedures. All patients were followed-up at 1, 3, 6, and 12 months. Results: There were no significant differences in preoperative baseline data between the two surgical groups. Operative parameters and postoperative outcomes were comparable. Effective same-day TOV was noted in 73.1% and 72.7% of the Xpeeda and GreenLight XPS patients, respectively (p = 0.98). All patients were discharged home within 24 hours of their surgeries. The laser energy and postoperative complications were significantly lower in the Xpeeda group (p = 0.002 and p = 0.026, respectively). At 3 months, the PSA levels significantly dropped in both groups (p = 0.002 and p < 0.001). There were no significant differences in functional and sexual outcomes between the two groups at 12 months. Conclusions: Holmium Laser Xpeeda Vaporization and GreenLight XPS Vaporization are safe and effective in the treatment of BPH. Same-day discharge with early TOV is a feasible option. Clinical Trials.gov Identifier: NCT04386941.

Emergency holmium laser enucleation of the prostate (HoLEP): a novel approach in the management of refractory hematuria for patients with benign prostatic hyperplasia (BPH): a single-institution experience.

INTRODUCTION: Refractory hematuria secondary to prostatic disease typically resolves with conservative management; however, this condition may require hospitalization with extensive measures to control life-threatening bleeding. The aim of this study was to report our experience using holmium laser enucleation of the prostate (HoLEP) as an emergency treatment in this clinical setting. METHODS: We conducted a retrospective review of all patients that presented to the emergency department with refractory hematuria of prostatic origin from October 2017 to September 2021, for whom hospitalization and conservative management failed to control bleeding. All emergency HoLEP procedures were performed by a single surgeon. Preoperative and intraoperative parameters, as well as perioperative outcomes, were collected and analyzed. Postoperative outcomes included duration of foley catheterization, length of postoperative hospital stay, and hospital readmissions. RESULTS: A total of 40 emergency HoLEP procedures were performed. Our cohort had a median prostate volume of 110.5 cc and a median resected weight of 81 g. Twenty-seven patients (67.5%) were on anticoagulant or antiplatelet medications on admission. The urethral catheter was removed within 1 day in 95% of patients with a successful trial of void (TOV). Moreover, 92.5% of patients were discharged home within 24 h of their procedure. Two patients (5%) experienced clot retention within one-week post-discharge with a 2.5% overall readmission rate. All postoperative parameters, including International Prostate Symptom Score (IPSS), quality of life (QoL), maximum flow rate (Qmax), and post-void residual volume (PVR), showed significant improvement at 1 year follow up. CONCLUSION: Our experience demonstrates that emergency HoLEP is an effective treatment option for patients with refractory hematuria of prostatic origin. Further studies are warranted to consolidate our results.

Impact of breath-hold technique on incidence of cardiac events in adjuvant left breast cancer irradiation.

BACKGROUND: This study aims to compare the incidence of cardiac events and to identify its predictors in left breast cancer patients receiving adjuvant radiotherapy using breath-hold technique (DIBH) versus free breathing technique (FB). METHODS: We conducted a retrospective multi-center study of two arms; the free breathing arm included 208 patients who were treated with traditional radiotherapy treatment technique, while DIBH arm included 224 patients who were treated with breath-hold technique using The Varian Real-time Position Management (RPM). We retrospectively reviewed the medical records of the patients from January 2010 to December 2017. RESULTS: The mean dose to the heart and left anterior descending artery were significantly lower in the DIBH arm (2.10 ± 0.39 and 6.16 ± 0.18 Gy) compared with (4.29 ± 0.60 Gy and 12.69 ± 0.93 Gy, respectively) in the FB arm. The incidence of cardiac events was higher in the FB arm than in the DIBH arm, but it was not statically significant. Our analysis revealed that age, diabetes, hypertension, smoking, mean LAD dose, and heart mean dose were significant prognostic factors for the occurrence of cardiac events in the breath-hold arm. Hypertension, smoking, as well as heart mean dose were independent risk factors for the occurrence of cardiac events. CONCLUSION: Use of the DIBH technique resulted in a significant reduction in doses to the heart, LAD and lesser cardiac events incidence compared to free breathing.

Same-day trial of void and discharge following standard vs. MOSESTM holmium laser enucleation of the prostate: A single-center experience.

INTRODUCTION: We aimed to compare perioperative and postoperative outcomes and to assess the safety and feasibility of same-day trial of void (TOV) in patients who underwent standard holmium laser enucleation of the prostate (HoLEP) vs. MOSESTM HoLEP (MoLEP). METHODS: We conducted a retrospective review of prospectively collected data of patients that underwent HoLEP (100 W) or MoLEP (120 W) with same-day catheter removal three hours postoperatively at our institution from August 2018 to September 2021. Patient demographics, intraoperative parameters, and postoperative outcomes were analyzed. Data were compared as means with standard deviation and medians with interquartile range (IQR) or numbers and percentages. Continuous and categorical variables were assessed using the Mann-Whitney U test and Chi-squared test, respectively. Predictors of shorter enucleation time and failed same-day TOV were investigated. RESULTS: Of the 90 patients included, 28 underwent HoLEP while 62 had MoLEP. There was no significant difference between the groups in terms of the successful TOV (23 [82%] vs. 58 [93.5%], p=0.1) and readmission rate (3 [10.7%] vs. 1 [1.6%], p=0.08); however, the MoLEP group had a significantly shorter mean enucleation time (p<0.001), mean hemostasis time (p<0.001), mean morcellation time (p=0.003), and lower mean energy used (p<0.001). On the logistic regression model, MoLEP (odds ratio [OR] 0.03, 95% confidence interval [CI] 0.007-0.19, p<0.001), lower preoperative prostate-specific antigen (PSA) test (OR 1.25, 95% CI 1.01-1.55, p=0.03), and smaller prostate size (OR 1.06, 95% CI 1.02-1.09, p<0.001) were independent predictors of shorter enucleation time. History of preoperative retention was the only significant factor associated with a failed same-day TOV (p=0.04). There was no difference in intraoperative or postoperative complication rates or postoperative functional outcomes between the two technologies. CONCLUSIONS: Same-day TOV and discharge are feasible following standard HoLEP and MoLEP, with comparable outcomes; however, the use of MOSESTM technology offered better enucleation efficiency with excellent hemostatic potential. Preoperative retention was the only predictor of failed same-day TOV.

Outcomes of Top-Down Holmium Laser Enucleation of Prostate for Recurrent/Residual Benign Prostatic Hyperplasia: One-Year Follow-Up.

Materials and Methods: We carried out a retrospective analysis of patients who underwent top-down HoLEP for the management of recurrent BPH at our institution. Patients who had previously undergone TURP were assigned to group I, while those with no history of prostate surgery were allocated to group II. Preoperative clinical characteristics, enucleation time, resected tissue weight, morcellation time, energy used, and intraoperative and postoperative complications were recorded and statistically analyzed. Patients were followed up postoperatively at 1, 3, 6, and 12 months. The evaluation included the International Prostate Symptom Score (IPSS), quality of life assessment (QoL), maximum urinary flow rate (Q max), postvoid residual urine test (PVR), and continence status. Results: Two hundred and sixty-nine patients were included in this study. Group I consisted of 68 patients with recurrent BPH, while group II included 201 patients. There were no statistically significant differences in preoperative characteristics between both groups. The median enucleation time for group I (67.5 min (25-200)) was not significantly longer than that for group II (60 min (19-165) (p=0.25)). Operative outcomes, including morcellation time, resected weight, catheter duration, and hospital stay, were comparable between both groups. At 1, 3, 6, and 12 months, all urinary functional outcomes showed significant improvement, and there were no significant differences between the two groups. At 3 months' follow-up, two patients in group I and three patients in group II experienced stress urinary incontinence (SUI). At the last follow-up visit, one patient from group I presented with persistent SUI. Conclusions: For managing recurrent and nonrecurrent cases of BPH, top-down HoLEP is safe with comparable urinary functional outcomes. Patients with a history of previous prostate surgery can be counselled that their prior transurethral procedure does not reduce the benefits of HoLEP.

Partial Nephrectomy for T1b/T2 Renal Mass: An Added Shift from Radical Nephrectomy.

The aim of our study was to show our short-term experience in managing large renal masses (cT1b/T2) through partial nephrectomy (PN) over the last 3 years. Retrospective data collection for all patients managed by PN for renal masses larger than 4 cm over the last 3 years. Epidemiological data were collected. Surgical data including surgical and ischemic times as well as intra and postoperative complications were collected. Pre- and postoperative estimated glomerular filtration rate (eGFR) data were collected and correlated as well as postoperative complications and recurrence. We could identify 47 patients managed by PN for radiologically confirmed >4 cm renal masses. The mean age of the patients was 55.7 ± 13.4, including 29 males and 18 females. Masses were T1b and T2 in 40 and 7 patients, respectively. The mean tumor size was 6.2 ± 1.5 cm. Using renal nephrometry score; 8, 28, and 11 had low, moderate, and high complexity, respectively. Renal cell carcinoma (RCC) was identified in 42 patients. Five patients out of 42 cancerous cases (12%) had pathological T3 RCC. The mean preoperative and postoperative eGFR were 89.09 ± 12.41 and 88.50 ± 10.50, respectively (P 0.2). The median follow-up was 14 months and within that short time, no patient had evidence for cancer recurrence. PN for large renal masses is safe in experienced hands and should be attempted in a higher percentage of patients, regardless of the tumor complexity. No cancer recurrence or deterioration of renal function was observed within our short-term follow-up.

Radical cystectomy for bladder urothelial carcinoma with aggressive variant histology.

PURPOSE: The aim of this study is to report our experience in managing bladder cancer in patients with variant pathology. METHODS: Retrospective data collection for all patients managed by radical cystectomy over the last 3 years for a variant pathol-ogy was completed. We specifically included micropapillary and nested variants. RESULTS: Ten patients were identified, with eight having micropapillary carcinoma (MPC) and two having nested vari-ants. Nine patients were male. The median age was 75. The two patients with nested variant were 56 and 62 years old, respec-tively, whereas all patients with MPC were over the age of 70. Upon cystectomy of all micropapillary cases, three patients (37.5%) had positive lymph node invasion and the final patholo-gy was T2 (two patients), T3 (two patients), and T4 (four patients). Barring a grade III complication Clavien-Dindo classi-fication due to wound dehiscence that necessitated secondary surgical closure, there were no specific perioperative complica-tions. Given the urethral invasion, cystourethrectomy was per-formed on the female patient. Within a median 13-month fol-low-up, three patients developed local recurrence, including two urethral and one new lateral pelvic mass. CONCLUSIONS: Considering the muscle invasive nature of micropapillary and nested bladder cancer, aggressive surgical management should not be postponed. Moreover, due to notable prevalence of concurrent and/or recurrent urethral involvement, initial urethrectomy or early and frequent postoperative ure-throscopy should be provided. Patients with variant histology bladder cancer may benefit from early radical cystectomy when compared to bladder sparing protocols and prostate sparing cystectomy treatment options.

Successful Surgical Management of Locally Advanced Renal Cell Carcinoma Invading Spleen and Pancreas.

Over the last two decades, the treatment of metastatic RCC has changed significantly, and the role of surgery is being debated. A 50-year-old man presented with pain in his left loin. An ultrasound, followed by a CT scan, revealed a 17.5 cm left renal mass invading the left suprarenal gland, spleen, and pancreatic tail. Radical nephrectomy through chevron incision under epidural block with general anesthesia was performed. The entire mass was removed en bloc. The estimated blood loss was 300 mL, and no blood transfusions were performed. The operation took approximately 2 h. Histological examination revealed clear cell renal carcinoma with extension into the spleen, pancreatic tail, and diaphragmatic fibers with negative resection margin. The patient discharged after a 3-day uneventful hospital stay. Aggressive surgical removal of a locally invasive renal cell carcinoma is feasible and should be considered in patients with good performance status and no or minimal distant metastases.

Comparative analysis of MOSESTM technology versus novel thulium fiber laser (TFL) for transurethral enucleation of the prostate: A single-institutional study.

INTRODUCTION: Novel laser technologies have been developed for the minimally invasive surgical management of benign prostatic hyperplasia (BPH). The objective of this study was to assess the safety and efficacy of MOSESTM technology versus the thulium fiber laser (TFL) in patients with BPH undergoing transurethral enucleation of the prostate. METHODS: We conducted a retrospective review of prospectively collected data of eighty-two patients who underwent transurethral enucleation of the prostate using MOSESTM or TFL technologies from August 2020 to September 2021. Preoperative and intraoperative parameters, in addition to postoperative outcomes, were collected and analyzed. RESULTS: Twenty patients underwent transurethral enucleation of the prostate with TFL, while 62 had MOSESTM HoLEP. No statistically significant difference in preoperative characteristics was observed between the groups. Patients in the TFL group had longer median enucleation, hemostasis, and morcellation times (p < 0.001) than those in the MOSESTM cohort. The longer morcellation time of TFL is mostly related to less visibility. The postoperative outcomes IPSS, QoL, Qmax, and post void residual (PVR), were comparable between the groups at 1, 3 and 6 months. The incidence of urge urinary incontinence (p = 0.79), stress urinary incontinence (p = 0.97), and hospital readmission rates (p = 0.1) were comparable between the two groups. CONCLUSIONS: A satisfactory safety and efficacy profile with comparable postoperative outcomes was demonstrated for both techniques; though, MOSESTM technology was superior to TFL in terms of shorter overall operative time.

Adverse pathological outcomes of patients with de novo muscle invasive bladder cancer in Northern Ontario.

OBJECTIVE: This study aimed to investigate the clinical and pathological characteristics of patients with de novo muscle-invasive bladder cancer (MIBC) who underwent radical cystectomy in Northern Ontario. METHODS: This is a retrospective cross-sectional study of patients with de novo T2 MIBC who underwent radical cystectomy over a 2-year-period in Thunder Bay Regional Health Sciences Centre. Clinical and pathological characteristics of Trans Urethral Resection of Bladder Tumors and cystectomy specimens were analyzed. RESULTS: Of the 59 patients aged 67 ± 8.8 years, predominated by males (80%), 27.1% were younger than age 60. After surgery, upstaging was noted in 59.3% (T3 in 27.1% and T4 in 32.2%) while node positive was noted in 36% of patients. Prostate adenocarcinoma was incidentally discovered in 20 (34%) of patients with 50% considered significant (Gleason score ≥ 7). Downstaging was found in those who had neoadjuvant chemotherapy (p = 0.001). CONCLUSIONS: The high prevalence of younger ages (less than 60), a high rate of upstaging, the presence of high-grade incidental prostate cancer, and lymph node positives in T2 de novo MIBC in Northern Ontario, warrants further investigation of potential causes and risk factors at individual, public, and population health levels in the region.

Aristolochic acid: What urologists should know.

To the Editor, Aristolochic acid is one of major causes for upper tract urothelial carcinoma, especially in younger population. While it is mentioned as a cause in guidelines, little is actually known about the toxin by urologists. We are aiming in our letter to provide some direct and clear information to ourselves that would help us to know more about that toxin and how it can adversely affect our patients [...].

Factors Predicting Successful Same-Day Trial of Void (TOV) After Laser Vaporization of the Prostate.

OBJECTIVE: To determine the safety and efficacy of same-day urethral catheter removal after laser vaporization of the prostate and to identify factors contributing to a successful trial of void (TOV). METHODS: We conducted a retrospective analysis of 98 patients who underwent laser vaporization of the prostate using GreenLight or Holmium Xpeeda laser fibers from April 2018 to March 2021. All patients included in the study were offered a same-day TOV and had their catheters removed 3 hours postoperatively. Patient demographics, intraoperative parameters, and postoperative outcomes were collected and analyzed. Patients who were medically unfit or those on antiplatelet or anticoagulant medications were excluded. Multivariate logistic regression analyses were used to determine potential predictors of a failed TOV. RESULTS: The median age of included patients was 69 years (56-86) with a prostate size of 54 grams (40-78.4). The median operative time was 50 minute (20-93). 72 patients (73.5%) had a successful TOV without the need for urethral catheter reinsertion. The median hospital stay for patients was 5 hours. Preoperative post-void residual (PVR) urine was the only predictor of a successful TOV on both univariate and multivariate logistic regression analyses. CONCLUSION: Same-day catheter removal following laser vaporization of the prostate is a feasible option with a 73.5% success rate.

Radical cystectomy for clinical T4b urothelial carcinoma: An Ontario, single-center experience.

INTRODUCTION: Guidelines surrounding the management of T4b muscle-invasive bladder cancer (MIBC) with radical cystectomy (RC) are limited and lack clarity. Our objective was to analyze our single-center experience to provide additional insight into the role of RC. METHODS: We performed a retrospective data analysis using clinical, radiological, and pathological information for all patients managed by RC for cT4b MIBC at the Thunder Bay Regional Health Sciences Centre (July 2015 to July 2020). Patients that had MIBC as their first diagnosis were termed the de novo group and patients that were initially diagnosed as having non-MIBC were termed the progressive group. RESULTS: Nineteen consecutive patients (16 males and three females), with a median age of 68 years, managed by two urologists over the last five years, met study criteria. Eleven (58%) of the patients had de novo MIBC while eight (42%) presented with progressive disease. All patients had dysuria as a presenting symptom. Only one (5%) patient received neoadjuvant chemotherapy. There were low rates of perioperative transfusion (11%), bowel resections (5%), postoperative transfusions (0%), ileus (32%), urine leak (16%), and wound dehiscence (5%). Fourteen patients (74%) had positive lymph nodes. All patients had adjuvant chemotherapy. The one-year recurrence rate in these patients was 53%, with 32% of recurrence being distant metastasis. The one-year survival rate was 95%. CONCLUSIONS: Patients in the de novo and progressive arms of our cohort had similar rates of surgical complications and disease recurrence. We found operative morbidity and disease control to be reasonable, suggesting RC can be considered more often in the management of T4b MIBC patients.