Differential changes in self-reported quality of life in elderly populations after diagnosis of a genitourinary malignancy.

BACKGROUND: The time of cancer diagnosis is a major event during which quality of life (QOL) can be affected and represents a crucial time to identify patients at high risk of decline. We sought to compare the differential effects of the diagnosis of 3 major urologic malignancies on QOL. METHODS: The Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey database was queried for patients who completed a QOL questionnaire (SF-36 or VR-12) before and after a diagnosis of bladder, kidney, or prostate cancer. Primary outcome measures were the mental component summary (MCS), and physical component summary (PCS) scores. Mixed effects linear regression was performed with cancer diagnosis as the primary variable of interest, with race and cardiovascular comorbidity status included as potentially confounding independent variables. RESULTS: There were 3,258 patients with urologic cancers. Both MCS and PCS scores dropped after diagnosis in all disease states. Bladder and kidney cancer patients demonstrated the greatest decline in MCS score (-1.762 points, 95% CI-2.571 to -0.952, P < 0.001) and PCS score (-3.769 points, 95% CI-5.042 to -2.496, P < 0.001), respectively, after adjustment for potential confounders. By contrast, prostate cancer patients demonstrated the smallest decline in both domains. Race and cardiovascular comorbidity status were independently associated with QOL, with an association 2 to 3 times greater than that of cancer diagnosis. CONCLUSIONS: Diagnosis of a urologic cancer was associated with a decline in patient-reported QOL, particularly in those with bladder or kidney cancer. Changes in physical health were more prominent than in mental health. Race and cardiovascular comorbidity status influenced QOL domains to a greater extent than specific urologic cancer diagnosis.

Contemporary Assessment of the Most Cited Clinical, Basic Science, and Guidelines Papers in Urology: A Reference for Urology Journal Club.

OBJECTIVE: To perform bibliometric analysis of the top cited articles in urology as a guide for journal club article selection. METHODS: Bibliometric citation analysis was performed using Scopus. Tables illustrating the top cited clinical, basic science, and guidelines/position statements papers were constructed. Linear regression was used to determine association between h-index and number of citations. RESULTS: A total of 3,188,861 publications from 1788 to 2020 were analyzed. The top 100 cited clinical papers from 1788 to 2020, top 100 cited contemporary clinical papers from 2000 to 2020, top 25 cited basic science papers, and the top 25 cited guidelines/position statement papers were reported. Median number of citations in the top 100 cited clinical papers was 1463 (interquartile range 1186-1821). Memorial Sloan Kettering Cancer Center (12), Johns Hopkins University (6), and Harvard University (6) contributed the most top cited clinical papers in urology. Urologic oncology was the most represented subspecialty in both clinical (75%) and basic science (96%) papers. First author and last author h-index were found to correlate with the number paper citations in the top 100 cited clinical papers from 1788 to 2020 (first author ß:5.3, P= .003, last author ß:4.5, P= .03). Only 7% of the most cited clinical papers in urology were from female first authors, which was not statistically significantly different from those reported in prior publications published in 2009 and 2013. CONCLUSION: Contemporary citation analysis of indexed manuscripts in urology may serve as a valuable educational tool for urologists and trainees.

Reducing preoperative blood orders and costs for radical prostatectomy.

Aim: A maximum surgical blood order schedule (MSBOS) was implemented at our institution to optimize preoperative blood ordering and reduce unnecessary blood preparation for patients undergoing radical prostatectomy (RP), a common urologic procedure. Materials & methods: We conducted a retrospective review of patients who underwent RP from 2010 to 2016 and categorized patients by date of RP (pre- or post-MSBOS) and compared preoperative blood-ordering practices. Results: After MSBOS implementation, preoperative blood orders changed from predominantly type and cross-match 2 units (53%) to no sample (56%) for robot-assisted laparoscopic RP, and from mostly type and cross-match 2 units (62%) to type and screen (75%) for open RP with resultant cost savings. Conclusion: MSBOS implementation and compliance decreases unnecessary preoperative blood orders.

A Nationally Representative Study of Nonindex Hospital Readmissions following Radical Prostatectomy: Implications for Bundled Payment Models.

PURPOSE: Implementing episode based payment models requires a detailed understanding of health care utilization throughout the 90-day postoperative episode. This includes nonindex hospital readmissions, which currently do not exist for patients treated with radical prostatectomy. We compared the causes, costs and predictors of index vs nonindex hospital readmissions after radical prostatectomy. MATERIALS AND METHODS: We identified patients with prostate cancer who underwent radical prostatectomy from 2010 to 2014 in the Nationwide Readmissions Database. Sociodemographic factors, hospital costs and causes of 90-day readmissions were compared between index and nonindex hospital readmissions. Multivariable regression models were used to determine whether nonindex readmissions were more costly than index readmission for several causes of readmission and also to identify predictors of nonindex readmissions. RESULTS: Of the 214,473 patients treated with radical prostatectomy 12,316 (5.7%) experienced a 90-day readmission and 4,283 (30.6%) had a nonindex readmission. Nonindex readmissions were more likely for complications which were cardiovascular specific (16.6% vs 10.3%) and nonradical prostatectomy specific (49.4% vs 32.8%, each p <0.01). On multivariable modeling readmission costs were significantly higher for nonindex vs index readmissions ($10,751 vs $10,113, p <0.01). Cardiovascular and electrolyte related nonindex readmissions ($12,995 vs $10,108, p <0.001, and $4,962 vs $3,179, p=0.01, respectively) were more expensive. Nonindex hospital readmission predictors included minimally invasive radical prostatectomy (OR 1.28, 95% CI 1.03-1.58), radical prostatectomy done at a high volume institution (OR 2.02, 95% CI 1.41-2.89) and residence in a more rural location (less than 50,000 population OR 1.68, 95% CI 1.21-2.35). CONCLUSIONS: In this nationally representative study nonindex hospital readmissions were associated with higher readmission costs, which were driven by differences in a small subset of readmissions. The benefits of undergoing radical prostatectomy at a high volume center should be carefully balanced with the increased odds of nonindex hospital readmissions and higher costs associated with such centers as regionalization continues.

Hospitalisation and readmission costs after radical cystectomy in a nationally representative sample: does urinary reconstruction matter?

OBJECTIVE: To investigate the impact of continent urinary diversion on readmissions and hospital costs in a nationally representative sample of radical cystectomies (RCs) performed in the USA. PATIENTS AND METHODS: The 2010-2014 Nationwide Readmissions Database was queried for patients with a diagnosis of bladder cancer who underwent RC. We identified patients undergoing continent (neobladder or continent cutaneous reservoir) or incontinent (ileal conduit) diversions. Multivariable logistic regression models were used to identify predictors of 90-day readmission, prolonged length of stay, and total hospital costs. RESULTS: Amongst 21 126 patients identified, 19 437 (92.0%) underwent incontinent diversion and 1 689 (8.0%) had a continent diversion created. Continent diversion patients were younger, healthier, and treated at high-volume metropolitan centres. Continent diversions resulted in fewer in-hospital complications (37.3% vs 42.5%, P = 0.02) but led to more 90-day readmissions (46.5% vs 39.6%, P = 0.004). In addition, continent diversion patients were more often readmitted for infectious complications (38.7% vs 29.4%, P = 0.004) and genitourinary complications (18.5% vs 13.0%, P = 0.01). On multivariable logistic regression, patients with a continent diversion were more likely to be readmitted within 90 days (odds ratio [OR] 1.55, 95% confidence interval [CI]: 1.28, 1.88) and have increased hospital costs during initial hospitalisation (OR 1.99, 95% CI: 1.52, 2.61). Continent diversion led to a $4 617 (American dollars) increase in initial hospital costs ($36 640 vs $32 023, P < 0.001), which was maintained at 30 days ($48 621 vs $44 231, P < 0.001) and at 90 days ($56 380 vs $52 820, P < 0.001). CONCLUSION: In a nationally representative sample of RCs performed in the USA, continent urinary diversion led to more frequent readmissions and increased hospital costs. Interventions designed to address specific outpatient issues with continent diversions can potentially lead to a significant decrease in readmissions and associated hospital costs.

Hospital Charges and Length of Stay Following Radical Cystectomy in the Enhanced Recovery After Surgery Era.

OBJECTIVE: To report our center's experience with enhanced recovery after surgery (ERAS) pathway for radical cystectomy (RC), specifically evaluating complications, LOS, 30- and 90-day readmissions, and hospital charges. Pathways of this type have been shown to decrease the length of stay (LOS) and postoperative ileus. However, concerns persist that ERAS is costly and increases readmissions. To date, limited studies have evaluated these concerns. MATERIALS AND METHODS: Our ERAS protocol was implemented for RC in December 2015. Outcomes in ERAS patients were compared with those in RC patients from the time period before ERAS. Patients were excluded if they underwent concomitant nephroureterectomy. RESULTS: Fifty-six consecutive ERAS patients were compared with 54 pre-ERAS patients. The median charge for index hospitalization was $31,090 in the ERAS group and $35,489 in the pre-ERAS group (P = .036). The median LOS was 5.0 days in the ERAS group and 8.5 days in the pre-ERAS group (P = < .001). The pre-ERAS group had a significantly increased use of nasogastric tube (13.8% vs 30.0%) and parenteral nutrition (6.9% vs 20.4%). The overall complication rate (including infectious, renal, deep vein thrombosis and pulmonary embolism, myocardial infarction and stroke, and respiratory and gastrointestinal-related complications) was similar between the 2 groups (51.7% in the ERAS group and 62.0% in the pre-ERAS group, P = .28). Thirty- and 90-day readmissions also remained similar (19.0% vs 14.8%, P = .55, and 31.0% vs 27.7%, P = .64). The most common readmission reason was infection, specifically urinary tract infection. CONCLUSION: Implementation of the ERAS pathway at our center resulted in significantly reduced LOS and total hospital charge, with comparable rates of complication and readmission, highlighting the need for ERAS pathways in patients undergoing RC.

Analysis of Hospital Readmissions After Prosthetic Urologic Surgery in the United States: Nationally Representative Estimates of Causes, Costs, and Predictive Factors.

BACKGROUND: The surgical treatment of urinary incontinence and erectile dysfunction by prosthetic devices has become part of urologic practice, although sparse data exist at a national level on readmissions and hospital costs. AIM: To assess causes and costs of early (≤30 days) and late (31-90 days) readmissions after implantation of penile prostheses (PPs), artificial urinary sphincters (AUSs), or PP + AUS. METHODS: Using the 2013 and 2014 US Nationwide Readmission Databases, sociodemographic characteristics, hospital costs, and causes of readmission were compared among PP, AUS and AUS + PP surgeries. Multivariable logistic regression models tested possible predictors of hospital readmission (early, late, and 90 days), increased hospital costs, and prolonged length of stay at initial hospitalization and readmission. OUTCOME: Outcomes were rates, causes, hospital costs, and predictive factors of early, late, and any 90-day readmissions. RESULTS: Of 3,620 patients, 2,626 (73%) had PP implantation, 920 (25%) had AUS implantation, and 74 (2%) underwent PP + AUS placement. In patients undergoing PP, AUS, or PP + AUS placement, 30-day (6.3% vs 7.9% vs <15.0%, P = .5) and 90-day (11.6% vs 12.8% vs <15.0%, P = .8) readmission rates were comparable. Early readmissions were more frequently caused by wound complications compared with late readmissions (10.9% vs <4%, P = .03). Multivariable models identified longer length of stay, Charlson Comorbidity Index score higher than 0, complicated diabetes, and discharge not to home as predictors of 90-day readmissions. Notably, hospital volume was not a predictor of early, late, or any 90-day readmissions. However, within the subset of high-volume hospitals, each additional procedure was associated with increased risk of late (odds ratio = 1.06, 95% CI = 1.03-1.09, P < .001) and 90-day (odds ratio = 1.03 95% CI = 1.02-1.05, P < .001) readmissions. AUS and PP + AUS surgeries had higher initial hospitalization costs (P < .001). A high hospital prosthetic volume decreased costs at initial hospitalization. Mechanical complications led to readmission of all patients receiving PP + AUS. CLINICAL IMPLICATIONS: High-volume hospitals showed a weaker association with increased initial hospitalization costs. Charlson Comorbidity Index, diabetes, and length of stay were predictors of 90-day readmission, showing that comorbidity status is important for surgical candidacy. STRENGTHS AND LIMITATIONS: This is the first study focusing on readmissions and costs after PP, AUS, and PP + AUS surgeries using a national database, which allows ascertainment of readmissions to hospitals that did not perform the initial surgery. Limitations are related to the limited geographic coverage of the database and lack of surgery- and surgeon-specific variables. CONCLUSIONS: Analysis of readmissions can provide better care for urologic prosthetic surgeries through better preoperative optimization, counseling, and resource allocation. Pederzoli F, Chappidi MR, Collica S, et al. Analysis of Hospital Readmissions After Prosthetic Urologic Surgery in the United States: Nationally Representative Estimates of Causes, Costs, and Predictive Factors. J Sex Med 2017;14:1059-1065.

Erectile Dysfunction Treatment Following Radical Cystoprostatectomy: Analysis of a Nationwide Insurance Claims Database.

INTRODUCTION: To improve care for patients after radical cystoprostatectomy (RCP), focus on survivorship issues such as sexual function needs to increase. Previous studies have demonstrated the burden of erectile dysfunction (ED) after RCP to be as high as 89%. AIM: To determine the rates of ED treatment use (phosphodiesterase type 5 inhibitors, injectable therapies, urethral suppositories, vacuum erection devices, and penile prosthetics) in patients with bladder cancer before and after RCP to better understand current patterns of care. METHODS: Men with bladder cancer undergoing RCP were identified in the MarketScan database (2010-2014). ED treatment use was assessed at baseline (during the 1 year before RCP) and at 6-month intervals (0-6, 7-12, 13-18, 19-24 months) after RCP. Multivariable logistic regression models were used to identify predictors of ED treatment use at 6-month intervals after RCP. OUTCOMES: ED treatment rates and predictors of ED treatment at 0-6, 7-12, 13-18, 19-24 month follow-up after RCP. RESULTS: At baseline, 6.5% of patients (77 of 1,176) used ED treatments. The rates of ED treatment use at 0 to 6, 7 to 12, 13 to 18, and 19 to 24 months after RCP were 15.2%, 12.7%, 8.1%, and 10.1% respectively. Phosphodiesterase type 5 inhibitors were the most commonly used treatment at all time points. In the multivariable model, predictors of ED treatment use at 0 to 6 months after RCP were age younger than 50 years (odds ratio [OR] = 3.17, 95% CI = 1.68-6.01), baseline ED treatment use (OR = 5.75, 95% CI = 3.08-10.72), neoadjuvant chemotherapy (OR = 1.72, 95% CI = 1.13-2.61), and neobladder diversion (OR = 2.40, 95% CI = 1.56-3.70). Baseline ED treatment use continued to be associated with ED treatment use at 6 to 12 months (OR = 5.63, 95% CI = 2.42-13.10) and 13 to 18 months (OR = 8.99, 95% CI = 3.05-26.51) after RCP. CLINICAL IMPLICATIONS: While the burden of ED following RCP is known to be high, overall ED treatment rates are low. These findings suggest either ED treatment is low priority for RCP patients or education about potential ED therapies may not be commonly discussed with patients following RCP. Urologists should consider discussing sexual function more frequently with their RCP patients. STRENGTHS & LIMITATIONS: Strengths include the use of a national claims database, which allows for longitudinal follow-up and detailed information on prescription medications and devices. Limitations include the lack of pathologic and oncologic outcomes data. CONCLUSION: ED treatment use after RCP is quite low. The strongest predictor of ED treatment use after RCP was baseline treatment use. These findings suggest ED treatment is a low priority for patients with RCP or education about potential ED therapies might not be commonly discussed with patients after RCP. Urologists should consider discussing sexual function more frequently with their patients undergoing RCP. Chappadi MR, Kates M, Sopko NA, et al. Erectile Dysfunction Treatment Following Radical Cystoprostatectomy: Analysis of a Nationwide Insurance Claims Database. J Sex Med 2017;14:810-817.

Evaluation of gender-based disparities in time from initial haematuria presentation to upper tract urothelial carcinoma diagnosis: analysis of a nationwide insurance claims database.

OBJECTIVE: To investigate the length of time from initial haematuria presentation to upper tract urothelial carcinoma (UTUC) diagnosis and the effect of gender on this duration. PATIENTS AND METHODS: Patients with haematuria claims in the year prior to UTUC diagnosis were identified from the MarketScan database (2010-2014). Delayed diagnosis was defined as >90 days from haematuria presentation to UTUC diagnosis. Multivariable Poisson regression models were used to determine factors associated with delayed UTUC diagnosis. RESULTS: Among 1 326 patients with UTUC, 469 (35.4%) experienced delayed diagnosis. Men (n = 866) had a longer median interval from haematuria to diagnosis than women (60 vs 49 days; P = 0.04). In the multivariable model, male gender (relative risk [RR] 1.13, 95% confidence interval [CI] 0.95-1.34) was not associated with delayed diagnosis, while urinary tract infection (UTI; RR 1.52, 95% CI 1.32-1.76), nephrolithiasis (RR 1.23, 95% CI 1.06-1.44), new (RR 1.37, 95% CI 1.12-1.66) and recurrent prostate-related diagnoses (RR 1.61, 95% CI 1.23-2.10) were. For men presenting to non-urologists, UTI (RR 1.44, 95% CI 1.22-1.71), nephrolithiasis (RR 1.25 95% CI 1.05-1.49), new (RR 1.41, 95% CI 1.12-1.78) and recurrent prostate-related diagnoses (RR 1.94, 95% CI 1.45-2.58) were associated with delayed diagnosis; however, for men presenting to urologists, nephrolithiasis (RR 1.08 95% CI 0.78-1.49), new (RR 1.15, 95% CI 0.79-1.68) and recurrent prostate-related diagnoses (RR 1.17, 95% CI 0.69-1.97) were not associated with delayed diagnosis, while UTI diagnosis (RR 1.74, 95% CI 1.31-2.31) was still associated with delayed diagnosis. CONCLUSION: A UTUC diagnosis was made >90 days after haematuria presentation in approximately one-third of patients. Men experienced a longer median interval from haematuria to UTUC diagnosis compared with women, but male gender was not an independent predictor of delayed diagnosis. Benign diagnoses during haematuria evaluation were strongly associated with delayed diagnosis, especially among patients initially seen by non-urologists. Future interventions should focus on development of non-invasive techniques to improve clinical risk stratification of patients presenting with haematuria and to educate practitioners, especially non-urologists, with regard to the importance of a thoughtful haematuria evaluation and the common mimickers of UTUC, to help reduce delays in diagnosis.

Causes, Timing, Hospital Costs and Perioperative Outcomes of Index vs Nonindex Hospital Readmissions after Radical Cystectomy: Implications for Regionalization of Care.

PURPOSE: We compared the timing, causes, hospital costs and perioperative outcomes of index vs nonindex hospital readmissions after radical cystectomy. MATERIALS AND METHODS: The 2013 Nationwide Readmissions Database was queried for patients with bladder cancer undergoing cystectomy. Sociodemographic characteristics, hospital costs and causes of readmission were compared among index and nonindex readmitted patients. Univariable and multivariable logistic regression models were used to identify predictors of nonindex readmissions, mortality during the first readmission and subsequent readmission. RESULTS: Among 4,991 patients identified 29% (1,447) and 11% (571) experienced an index and nonindex readmission, respectively. Compared to index readmissions, nonindex readmissions were more likely late readmissions (p <0.001) of older patients (p=0.047) who underwent cystectomy at higher volume hospitals (p=0.02) and were readmitted to hospitals located in less populated areas (p <0.001). Compared to index readmissions the percentage of nonindex readmissions for cardiovascular complications was higher (7.6% vs 2.9%, p=0.003), while the percentage of nonindex readmissions for gastrointestinal (6.0% vs 11.0%, p=0.04) and wound (5.3% vs 16.7%, p=0.0001) complications was lower. Predictors of nonindex readmission included longer length of stay (OR 1.02; 95% CI 1.001, 1.04), patient location in less populated areas, nonteaching hospital (OR 0.52; 95% CI 0.31, 0.86) and discharge to facility (OR 2.82; 95% CI 1.75, 4.55) or with home health (OR 1.49; 95% CI 1.05, 2.10). Nonindex readmissions had comparable mean readmission hospital costs ($14,147 vs $15,102, p=0.7), in-hospital mortality (OR 1.11; 95% CI 0.42, 2.87) and subsequent readmission (OR 1.32; 95% CI 0.87, 2.00) to index readmissions. CONCLUSIONS: This nationally representative study of patients undergoing radical cystectomy demonstrated comparable perioperative outcomes and hospital costs between index and nonindex readmitted patients, which supports the continued regionalization of cystectomy care.

Reduction of Costs for Pelvic Exenteration Performed by High Volume Surgeons: Analysis of the Maryland Health Service Cost Review Commission Database.

High volume hospitals (HVHs) and high volume surgeons (HVSs) have better outcomes after complex procedures, but the association between surgeon and hospital volumes and patient outcomes is not completely understood. Our aim was to evaluate the impact of surgeon and hospital volumes, and their interaction, on postoperative outcomes and costs in patients undergoing pelvic exenteration (PE) in the state of Maryland. A review of the Maryland Health Services Cost Review Commission database between 2000 and 2011 was performed. Patients were compared for demographics and clinical variables. The differences in length of hospital stay , length of intensive care unit (ICU) stay, operating room (OR) cost, and total cost were compared for surgeon volume and hospital volume controlling for all other factors. Surgery performed by HVS at HVH had the shortest ICU stay and lowest OR cost. When PE was performed by a low volume surgeon at an HVH, the OR cost and total cost were the highest and increased by $2,683 (P < 0.0001) and $16,076 (P < 0.0001), respectively. OR costs reduced when surgery was performed by an HVS at an HVH ($-1632, P = 0.008). PE performed by HVS at HVH is significantly associated with lower OR costs and ICU stay. We feel this is indicative of lower complication rates and higher quality care.

Sickle Cell Disease in Priapism: Disparity in Care?

OBJECTIVE: To determine the effect of sickle cell disease (SCD) on hospital resource use among patients admitted for priapism. MATERIALS AND METHODS: Using the Nationwide Inpatient Sample, a weighted sample of 12,547 patients was selected with a primary diagnosis of priapism from 2002 to 2011. Baseline differences for patient demographics and hospital characteristics were compared between SCD and non-SCD patients. Multivariate analysis was performed to identify the effect of SCD on length of stay, use of penile operations, blood transfusion, and cost. RESULTS: The proportion of SCD patients was 21.5%. SCD patients were younger, more often black, more likely to have Medicaid insurance, and treated more frequently in Southern urban teaching hospitals. SCD was a significant predictor of having a blood transfusion (odds ratio [OR], 16.3; P <.001), and an elongated length of stay (OR, 1.42; P <.001). SCD was associated with less penile operations (OR, 0.40; P <.001). When SCD patients did have an operation, it was performed later in the admission (mean, 0.87 vs 0.47 days; P <.001). SCD was not a significant predictor of increased cost (OR, 1.02; P = .869). CONCLUSION: SCD patients represent a demographically distinct subgroup of priapism patients with different patterns of resource use manifested by longer hospital stays and more blood transfusions. Moreover, despite evidence that immediate treatment of priapism results in improved erectile function outcomes, SCD patients had less surgical procedures for alleviation of acute priapism events.

The International Society for Sexual Medicine's Process of Care for the Assessment and Management of Testosterone Deficiency in Adult Men.

INTRODUCTION: In 2014, the International Society for Sexual Medicine (ISSM) convened a panel of experts to develop an evidence-based process of care for the diagnosis and management of testosterone deficiency (TD) in adult men. The panel considered the definition, epidemiology, etiology, physiologic effects, diagnosis, assessment and treatment of TD. It also considered the treatment of TD in special populations and commented on contemporary controversies about testosterone replacement therapy, cardiovascular risk and prostate cancer. AIM: The aim was to develop clearly worded, practical, evidenced-based recommendations for the diagnosis and treatment of diagnosis and management of TD for clinicians without expertise in endocrinology, such as physicians in family medicine and general urology practice. METHOD: A comprehensive literature review was performed, followed by a structured, 3-day panel meeting and 6-month panel consultation process using electronic communication. The final guideline was compiled from reports by individual panel members on areas reflecting their special expertise, and then agreed by all through an iterative process. RESULTS: This article contains the report of the ISSM TD Process of Care Committee. It offers a definition of TD and recommendations for assessment and treatment in different populations. Finally, best practice treatment recommendations are presented to guide clinicians, both familiar and unfamiliar with TD. CONCLUSION: Development of a process of care is an evolutionary process that continually reviews data and incorporates the best new research. We expect that ongoing research will lead to new insights into the pathophysiology of TD, as well as new, efficacious and safe treatments. We recommend that this process of care be reevaluated and updated by the ISSM in 4 years.

Multicenter assessment of neoadjuvant chemotherapy for muscle-invasive bladder cancer.

BACKGROUND: The efficacy of neoadjuvant chemotherapy (NAC) for muscle-invasive bladder cancer (BCa) was established primarily with methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC), with complete response rates (pT0) as high as 38%. However, because of the comparable efficacy with better tolerability of gemcitabine and cisplatin (GC) in patients with metastatic disease, GC has become the most commonly used regimen in the neoadjuvant setting. OBJECTIVE: We aimed to assess real-world pathologic response rates to NAC with different regimens in a large, multicenter cohort. DESIGN, SETTING, AND PARTICIPANTS: Data were collected retrospectively at 19 centers on patients with clinical cT2-4aN0M0 urothelial carcinoma of the bladder who received at least three cycles of NAC, followed by radical cystectomy (RC), between 2000 and 2013. INTERVENTION: NAC and RC. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was pathologic stage at cystectomy. Univariable and multivariable analyses were used to determine factors predictive of pT0N0 and ≤pT1N0 stages. RESULTS AND LIMITATIONS: Data were collected on 935 patients who met inclusion criteria. GC was used in the majority of the patients (n=602; 64.4%), followed by MVAC (n=183; 19.6%) and other regimens (n=144; 15.4%). The rates of pT0N0 and ≤pT1N0 pathologic response were 22.7% and 40.8%, respectively. The rate of pT0N0 disease for patients receiving GC was 23.9%, compared with 24.5% for MVAC (p=0.2). There was no difference between MVAC and GC in pT0N0 on multivariable analysis (odds ratio: 0.89 [95% confidence interval, 0.61-1.34]; p=0.6). CONCLUSIONS: Response rates to NAC were lower than those reported in prospective randomized trials, and we did not discern a difference between MVAC and GC. Without any evidence from randomized prospective trials, the best NAC regimen for invasive BCa remains to be determined. PATIENT SUMMARY: There was no apparent difference in the response rates to the two most common presurgical chemotherapy regimens for patients with bladder cancer.

Robotic surgery in urological oncology: patient care or market share?

Surgical robotic use has grown exponentially in spite of limited or uncertain benefits and large costs. In certain situations, adoption of robotic technology provides value to patients and society. In other cases, however, the robot provides little or no increase in surgical quality, with increased expense, and, therefore, does not add value to health care. The surgical robot is expensive to purchase, maintain and operate, and can contribute to increased consumerism in relation to surgical procedures, and increased reliance on the technology, thus driving future increases in health-care expenditure. Given the current need for budget constraints, the cost-effectiveness of specific procedures must be evaluated. The surgical robot should be used when cost-effective, but traditional open and laparoscopic techniques also need to be continually fostered.

Impact of hospital volume on perioperative outcomes and costs of radical cystectomy: analysis of the Maryland Health Services Cost Review Commission database.

INTRODUCTION: The objective of this study was to evaluate the impact of hospital case volume on perioperative outcomes and costs of radical cystectomy (RC) after controlling for differences in patient case mix. MATERIALS AND METHODS: The Maryland Health Services Cost Review Commission database was queried for patients who underwent an open RC between 2000 and 2011. Patients were divided into tertiles based on hospital case volume. Groups were compared for differences in length of intensive care unit (ICU) stay, length of total hospital stay, rate of in-hospital deaths and procedure-related costs. RESULTS: In total, 1620 patients underwent a RC during the study period. Of these patients, 457 (28.2%) underwent surgery at 37 low volume centers, 465 (28.7%) at six mid volume centers and 698 (43.1%) at a single high volume center. The mean case volume of each group was 1.1, 7.0 and 63.5 RC/center/year, respectively. After controlling for marked differences in patient case mix, having surgery at the single high-volume center was independently associated with a decrease in length of ICU stay (coefficient = -0.41 days, 95% CI -0.78--0.05, p = 0.03), in-hospital mortality (OR 0.18, 95% CI 0.04-0.80, p = 0.02) and total medical costs (coefficient = -2.91k USD, 95% CI -4.15--1.67, p < 0.001). Decreased total costs were driven by reductions in charges associated with the operating room, drugs, radiology tests, labs, supplies and physical/occupational therapy (all p < 0.001). CONCLUSIONS: Undergoing RC at a high volume medical center was associated with improved outcomes and reduced costs. These data support the centralization of RC to high volume centers.

In-hospital death and hospital-acquired complications among patients undergoing partial cystectomy for bladder cancer in the United States.

BACKGROUND: Partial cystectomy (PC) is a therapeutic option for select patients with bladder cancer, but its associated perioperative risks and costs are unknown. We estimated annual rates of PC in a nationally representative sample of hospitals, and analyzed whether hospital volume affects postoperative outcomes and costs in patients undergoing PC. METHODS: From the Nationwide Inpatient Sample, we selected a weighted cohort of patients with bladder cancer who underwent PC between 2002 and 2008. Differences in length of stay, charges, and clinical outcomes were calculated based on operative volume, and univariate and multivariate regression models were fitted to predict in-hospital mortality (IHM) and hospital-acquired conditions. RESULTS: A total of 10,780 patients with bladder cancer who underwent PC were identified with an annual rate between 1457 and 1628 cases. IHM rates were 1.8%, constituting 195 patients (between 9 and 46 annually). A total of 417 patients (3.9%) experienced a "never event" complication, which Medicare no longer reimburses. The mean annual hospital volume of patients who died was 1.7 cases/y compared with 2.4 cases/y among those without fatal complications. No cases of IHM were identified among hospitals performing at least 5 partial cystectomies/y. In a multivariate regression model increased hospital volume was independently associated with decreased mortality (odds ratio = 0.70, 95% confidence interval; 0.60-0.80). CONCLUSIONS: Approximately 1 in 25 patients undergoing PC experience a hospital-acquired complication, and nearly 1 in 50 die as a result of the operation. For each additional case a hospital performs annually, the risk of IHM decreases by 30%.

Smoking knowledge assessment and cessation trends in patients with bladder cancer presenting to a tertiary referral center.

OBJECTIVE: To determine the knowledge level of patients with bladder cancer (BC) regarding smoking risks. We also sought to determine the role of their urologists in initiating smoking cessation at the diagnosis. Smoking is the leading risk factor for BC in industrialized nations. However, little information is available regarding patients' knowledge of the risks of smoking and the role of their urologists in initiating smoking cessation at diagnosis. METHODS: A smoking knowledge and cessation questionnaire was administered to 71 patients referred to the Johns Hopkins Hospital for BC from April 2008 to June 2009. The questionnaire captured data on demographics, BC history, smoking status and history, risk factor knowledge, and cessation patterns. RESULTS: The mean age of the cohort was 65.1 years (range 42-86) and 72% were men. At the referral, all 71 patients (100%) knew smoking was a risk factor for lung cancer compared with 61 (86%) who knew it was for BC. Only 36 patients (51%) knew smoking was the leading risk factor for BC. Of the 17 patients (24%) who were smokers at their BC diagnosis, 12 (71%) were counseled by their referring urologist to quit smoking; however, the significant majority (76%) was not offered any specific intervention. CONCLUSION: The association between smoking and BC was not as well known as that of lung cancer in our cohort of patients. Most current smokers were advised to stop smoking by their primary urologist; however, few were offered any intervention to aid in cessation. Urologists should assume a more active role both in educating patients regarding smoking's link to BC and in initiating smoking cessation.

Priapism: new concepts in medical and surgical management.

Advances have recently been made in both medical and surgical management of priapism, and these offer improvements in the level of care afforded such patients. Further developments can be expected based on ongoing progress, particularly in the area of molecular science, which is the primary source for driving novel therapeutic approaches. Continued action to address the health care administrative concerns of those most commonly affected by priapism, specifically individuals with sickle cell disease, is also appropriate. All successes in these arenas ensure that afflicted individuals avoid the health burdens of priapism and preserve sexual function.

Priapism: pathogenesis, epidemiology, and management.

INTRODUCTION: Priapism describes a persistent erection arising from dysfunction of mechanisms regulating penile tumescence, rigidity, and flaccidity. A correct diagnosis of priapism is a matter of urgency requiring identification of underlying hemodynamics. AIMS: To define the types of priapism, address its pathogenesis and epidemiology, and develop an evidence-based guideline for effective management. METHODS: Six experts from four countries developed a consensus document on priapism; this document was presented for peer review and debate in a public forum and revisions were made based on recommendations of chairpersons to the International Consultation on Sexual Medicine. This report focuses on guidelines written over the past decade and reviews the priapism literature from 2003 to 2009. Although the literature is predominantly case series, recent reports have more detailed methodology including duration of priapism, etiology of priapism, and erectile function outcomes. MAIN OUTCOME MEASURES: Consensus recommendations were based on evidence-based literature, best medical practices, and bench research. RESULTS: Basic science supporting current concepts in the pathophysiology of priapism, and clinical research supporting the most effective treatment strategies are summarized in this review. CONCLUSIONS: Prompt diagnosis and appropriate management of priapism are necessary to spare patients ineffective interventions and maximize erectile function outcomes. Future research is needed to understand corporal smooth muscle pathology associated with genetic and acquired conditions resulting in ischemic priapism. Better understanding of molecular mechanisms involved in the pathogenesis of stuttering ischemic priapism will offer new avenues for medical intervention. Documenting erectile function outcomes based on duration of ischemic priapism, time to interventions, and types of interventions is needed to establish evidence-based guidance. In contrast, pathogenesis of nonischemic priapism is understood, and largely attributable to trauma. Better documentation of onset of high-flow priapism in relation to time of injury, and response to conservative management vs. angiogroaphic or surgical interventions is needed to establish evidence-based guidance.