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INTRODUCTION: We describe the establishment of the Michigan Urological Surgery Improvement Collaborative-Kidney mass: Identifying and Defining Necessary Evaluation and therapY (MUSIC-KIDNEY) to improve the quality of care that patients in Michigan receive for localized, 7 cm or smaller (T1) renal masses. METHODS: The MUSIC-KIDNEY collaborative is comprised of 45 urologists from 8 group practices. From June 2017 to November 2018 surgeons collected data for 821 patients with newly diagnosed T1 renal masses. Goals are to reduce the overall burden of treatment for T1 renal masses specifically by avoiding treatment when a noninterventional approach is appropriate, reducing the treatment of benign renal masses, preventing radical nephrectomy when a kidney sparing approach is appropriate, and decreasing length of hospitalization and readmission rates. RESULTS: Median age at diagnosis was 66 years, 56.8% of patients were male and 83.8% were Caucasian. The patient populations differed across practice sites for age (p <0.001), tumor size (p=0.002), race (p <0.001), Charlson comorbidity index and insurance type (p <0.001). Tumor complexity was infrequently reported (35.1%). Initial management included surveillance/repeat imaging (45.1%), biopsy (15.4%), intervention (39.1%) and second opinion (0.6%). No treatment at initial presentation (0% to 74.5%) and nephron sparing treatment (0% to 100%) varied significantly among practices (p <0.001). Of 133 patients with T1 renal masses who underwent radical nephrectomy (39.8%) 53 had tumors smaller than 4 cm and/or surgical findings without malignancy. Readmission or emergency department visit within 30 days after renal surgery occurred in 7.6%. CONCLUSIONS: Initial findings of MUSIC-KIDNEY indicate practice level variation and several quality improvement opportunities. Focusing on these goals may optimize practice patterns and surgical outcomes across Michigan.
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PURPOSE: We hypothesized that bladder cancer patients with associated lymphovascular invasion (LVI) are at increased risk of occult metastases. METHODS: A multi-institutional group (University of Texas Southwestern [Dallas, TX], Baylor College of Medicine [Houston, TX], Johns Hopkins University [Baltimore, MD]) carried out a retrospective study of 958 patients who underwent cystectomy for bladder cancer between 1984 and 2003. Of patients with transitional-cell carcinoma (n = 776), LVI status was available for 750. LVI was defined as the presence of tumor cells within an endothelium-lined space. RESULTS: LVI was present in 36.4% (273 of 750) overall, involving 26% (151 of 581) and 72% (122 of 169) of node-negative and node-positive patients, respectively. Prevalence of LVI increased with higher pathologic stage (9.0%, 23%, 60%, and 78%, for T1, T2, T3, and T4, respectively; P < .001). Using multivariate Cox regression analyses including age, stage, grade, and number of pelvic lymph nodes removed, LVI was an independent predictor of local (HR = 2.03, P = .049), distant (HR = 2.60, P = .0011), and overall (HR = 2.02, P = .0003) recurrence in node-negative patients. LVI was an independent predictor of overall (HR = 1.84, P = .0002) and cause-specific (HR = 2.07, P = .0012) survival in node-negative patients. LVI maintained its independent predictor status in competing risks regression models (P = .013), where other-cause mortality was considered as a competing risk. LVI was not a predictor of recurrence or survival in node-positive patients. CONCLUSION: LVI is an independent predictor of recurrence and decreased cause-specific and overall survival in patients who undergo cystectomy for invasive bladder cancer and are node-negative. These patients represent a high risk group that may benefit from integrated therapy with cystectomy and perioperative systemic chemotherapy.