Incidence of Clinically Significant Prostate Cancer After a Diagnosis of Atypical Small Acinar Proliferation, High-grade Prostatic Intraepithelial Neoplasia, or Benign Tissue.

OBJECTIVE: To assess the incidence of clinically significant and insignificant prostate cancer after an initial biopsy that revealed either atypical small acinar proliferation (ASAP), high-grade prostatic intraepithelial neoplasia (HGPIN), or benign tissue. MATERIALS AND METHODS: We retrospectively identified patients diagnosed with ASAP, HGPIN, or benign tissue who had a repeat prostate biopsy within 1 year of diagnosis during 1987-2015. We compared the incidence of any prostate cancer and clinically significant prostate cancer (based on Gleason score, prostate-specific antigen (PSA), number of positive cores, and core volume) for each diagnostic group. RESULTS: A total of 17,016 biopsies were performed in 12,817 patients during 1987-2015. Among the 615 patients who had a repeat biopsy within 1 year of their first, 261 (42.4%), 208 (33.8%), and 146 (23.8%) had ASAP, HGPIN, or benign tissue on the initial biopsy, respectively. The second biopsy demonstrated significant differences in prostate cancer detection rates between these 3 groups (34.1%, 20.2%, and 15.8%, respectively; P <.001), with cancer detected significantly more often in the ASAP group relative to other groups (P <.001 vs benign and P = .001 vs HGPIN). The rates of clinically significant prostate cancer did not differ between groups (8.0%, 6.7%, and 4.1%, respectively, P = .31). CONCLUSION: On repeat biopsy, rates of clinically significant prostate cancer did not differ between patients initially diagnosed with ASAP, HGPIN, or benign tissue. Elevated rates of prostate cancer after a diagnosis of ASAP appear to be largely due to differences in the rate of clinically insignificant disease.

A comparison of preliminary oncologic outcome and postoperative complications between patients undergoing either open or robotic radical cystectomy.

PURPOSE: To compare complications and outcomes in patients undergoing either open radical cystectomy (ORC) or robotic-assisted radical cystectomy (RRC). MATERIALS AND METHODS: We retrospectively identified patients that underwent ORC or RRC between 2003- 2013. We statistically compared preliminary oncologic outcomes of patients for each surgical modality. RESULTS: 92 (43.2%) and 121 (56.8%) patients underwent ORC and RRC, respectively. While operative time was shorter for ORC patients (403 vs. 508 min; p<0.001), surgical blood loss and transfusion rates were significantly lower in RRC patients (p<0.001 and 0.006). Length of stay was not different between groups (p=0.221). There was no difference in the proportion of lymph node-positive patients between groups. However, RRC patients had a greater number of lymph nodes removed during surgery (18 vs. 11.5; p<0.001). There was no significant difference in the incidence of pre-existing comorbidities or in the Clavien distribution of complications between groups. ORC and RRC patients were followed for a median of 1.38 (0.55-2.7) and 1.40 (0.58-2.59) years, respectively (p=0.850). During this period, a lower proportion (22.3%) of RRC patients experienced disease recurrence vs. ORC patients (34.8%). However, there was no significant difference in time to recurrence between groups. While ORC was associated with a higher all-cause mortality rate (p=0.049), there was no significant difference in disease-free survival time between groups. CONCLUSIONS: ORC and RRC patients experience postoperative complications of similar rates and severity. However, RRC may offer indirect benefits via reduced surgical blood loss and need for transfusion.

A comparison of preliminary oncologic outcome and postoperative complications between patients undergoing either open or robotic radical cystectomy

ABSTRACT Purpose: To compare complications and outcomes in patients undergoing either open radical cystectomy (ORC) or robotic-assisted radical cystectomy (RRC). Materials and Methods: We retrospectively identified patients that underwent ORC or RRC between 2003- 2013. We statistically compared preliminary oncologic outcomes of patients for each surgical modality. Results: 92 (43.2%) and 121 (56.8%) patients underwent ORC and RRC, respectively. While operative time was shorter for ORC patients (403 vs. 508 min; p<0.001), surgical blood loss and transfusion rates were significantly lower in RRC patients (p<0.001 and 0.006). Length of stay was not different between groups (p=0.221). There was no difference in the proportion of lymph node-positive patients between groups. However, RRC patients had a greater number of lymph nodes removed during surgery (18 vs. 11.5; p<0.001). There was no significant difference in the incidence of pre-existing comorbidities or in the Clavien distribution of complications between groups. ORC and RRC patients were followed for a median of 1.38 (0.55-2.7) and 1.40 (0.582.59) years, respectively (p=0.850). During this period, a lower proportion (22.3%) of RRC patients experienced disease recurrence vs. ORC patients (34.8%). However, there was no significant difference in time to recurrence between groups. While ORC was associated with a higher all-cause mortality rate (p=0.049), there was no significant difference in disease-free survival time between groups. Conclusions: ORC and RRC patients experience postoperative complications of similar rates and severity. However, RRC may offer indirect benefits via reduced surgical blood loss and need for transfusion.

Experienced Open vs Early Robotic-assisted Laparoscopic Radical Prostatectomy: A 10-year Prospective and Retrospective Comparison.

OBJECTIVE: To undertake a prospective/retrospective comparison of longer-term oncologic and quality of life outcomes in open radical prostatectomy (ORP) or robotic-assisted laparoscopic radical prostatectomy (RALP) patients. MATERIALS AND METHODS: The clinical progression of ORP and RALP patients who underwent surgery during 2004 was followed over an extended (10 year) period. Pre- and perioperative parameters, oncologic outcomes, recurrence, mortality, and quality of life were compared between surgical modalities. Follow-up time was calculated from the time of surgery to the latest contact. Postoperative quality of life data were obtained from Expanded Prostate Cancer Index Composite survey questionnaires. Recurrence rates, times to recurrence, surgical time, length of stay, hematocrit, follow-up time, and sexual and urinary bother scores were compared between surgical groups. Multivariate analyses were used to predict positive surgical margins and biochemical recurrence. RESULTS: 63 ORP and 116 RALP patients were included (mean age of 60.4 ± 6.4 and 58.6 ± 5.8 years; P = .067), with follow-up times of 10.3 and 10.1 years (P = .191). RALP patients had longer operative times (P < .001), shorter hospital stays (P < .001), and higher discharge hematocrits (P < .001). With prostate-specific antigen, Gleason score, and T-stage as covariates, time to recurrence (P = .365) and positive margin rate (P = .230) were not statistically different between groups. Ninety-five percent of RALP patients were continent and 48.0% were potent vs 92.6% and 41.5% of ORP patients (P = .720; .497). Urinary and sexual bother were not significantly different between groups (P = .392; .985). CONCLUSION: Our longer-term follow-up data suggest that ORP and RALP patients have comparable oncologic and quality of life outcomes.

Robotic-assisted laparoscopic catheterizable bladder augment: a novel approach to treat recurrent bladder neck contracture following radical prostatectomy.

INTRODUCTION: Bladder neck contractures (BNC) are an uncommon complication following radical prostatectomy. Occasionally, BNCs can be refractory to endoscopic approaches. We describe the effectiveness of a novel robotic-assisted laparoscopic catheterizable bladder augment in treating recalcitrant BNCs. MATERIALS AND METHODS: Patients undergoing robotic-assisted radical prostatectomy (RALP) between 2004-2014 who developed a postoperative BNC were identified. We documented our experience with robotic-assisted laparoscopic catheterizable bladder augment for recalcitrant BNCs. Total operative time, robotic time, estimated surgical blood, length of hospital stay, serum creatinine, complications, and postoperative course/upper tract imaging were recorded. RESULTS: Thirty-six of 2002 RALP patients (1.8%) experienced a post-surgical BNC at 182 days post-surgery. Twenty-two (61.1%) underwent a single dilation and/or transurethral incision. Eleven (30.6%) required = 1 procedure. Three patients (8.3%) had recalcitrant BNCs. One patient with normal bladder capacity elected open urethroplasty. The remaining two had reduced bladder capacity, detrusor over-activity and failed multiple incisions and self-catheterization. In one patient, the stricture was complete. The other patient experienced urethral leakage requiring bladder neck closure. In both patients, a robotic approach, utilizing an ileal-cecal segment as a catheterizable augment, was performed. At 16 and 89 months follow up, both are continent, with stable renal function and normal upper tracts. CONCLUSION: Robotic-assisted laparoscopic catheterizable bladder augment is a viable treatment for recurrent BNCs. This approach may be particularly well suited for patients with concurrent hyperreflexia or decreased bladder capacity.

Multiple intra-renal artery aneurysms causing renal obstruction managed with radical nephrectomy.

A 46-year-old male with a history of hypertension presented with symptoms of persistent abdominal fullness and a non-pulsatile abdominal mass. Subsequent computed tomographic angiography studies revealed the presence multiple large renal aneurysms from the segmental branches of the renal artery and an enlarged hydronephrotic kidney with minimal parenchyma. The renal deterioration appeared to be as a result of an obstruction caused by the large intra-renal aneurysms at the level of the renal calyces. Since the right kidney had no function, an open radical nephrectomy was subsequently performed without complications at 3 months follow up.

Are Preexisting Retinal and Central Nervous System-Related Comorbidities Risk Factors for Complications Following Robotic-Assisted Laparoscopic Prostatectomy?

PURPOSE: To assess whether retinal and central nervous system (CNS) comorbidities are risk factors for complications following robotic assisted laparoscopic prostatectomy (RALP). MATERIALS AND METHODS: A retrospective review of our RALP database identified 1868 patients who underwent RALP by a single surgeon between December 10, 2003-March 14, 2014. We hypothesized that patients with preexisting retinal or CNS comorbidities were at a greater risk of suffering retinal and CNS complications following RALP. Perioperative complications and risk of recurrence were graded using the Clavien and D'Amico systems, respectively. RESULTS: 40 (2.1%) patients had retinal or CNS-related comorbidities, of which 15 had a history of retinal surgery and 24 had a history of cerebrovascular accident, aneurysm and/or neurosurgery. One additional patient had a history of both retinal and CNS events. Patients with retinal or CNS comorbidities were significantly older, had elevated PSA levels and CCI (Charlson Comorbidity Index) scores than the control group. Blood loss, length of stay, surgical duration, BMI, diagnostic Gleason score and T-stage were not statistically different between groups. No retinal or CNS complications occurred in either group. The distribution of patients between D'Amico risk categories was not statistically different between the groups. There was also no difference in the incidence of total complications between the groups. CONCLUSIONS: RALP-associated retinal and CNS complications are rare. While our RALP database is large, the cohort of patients with retinal or CNS-related comorbidities was relatively small. Our dataset suggests retinal and CNS pathology presents no greater risk of suffering from perioperative complications following RALP.

Penoscrotal lymphedema associated with metastatic renal cell carcinoma.

A 64-year-old male presented with lower back pain, radiating in a sciatic-type distribution, swelling in his lower abdomen and right leg, and edema of the scrotum and penile shaft. A sonogram and CT imaging indicated an enhancing mass in the right kidney and a spinal metastasis. The right lower extremity and penoscrotal lymphedema was caused by lymphatic obstruction due to a sacral metastasis of renal cell carcinoma. He was treated with cytoreductive nephrectomy, radiation and a systemic tyrosine kinase inhibitor. Pelvic imaging is suggested to determine whether malignant lymphatic obstruction is present when presented with idiopathic penoscrotal edema.

Are Preexisting Retinal and Central Nervous System-Related Comorbidities Risk Factors for Complications Following Robotic-Assisted Laparoscopic Prostatectomy?

ABSTRACTPurpose:To assess whether retinal and central nervous system (CNS) comorbidities are risk factors for complications following robotic assisted laparoscopic prostatectomy (RALP).Materials and Methods:A retrospective review of our RALP database identified 1868 patients who underwent RALP by a single surgeon between December 10, 2003-March 14, 2014. We hypothesized that patients with preexisting retinal or CNS comorbidities were at a greater risk of suffering retinal and CNS complications following RALP. Perioperative complications and risk of recurrence were graded using the Clavien and D'Amico systems, respectively.Results:40 (2.1%) patients had retinal or CNS-related comorbidities, of which 15 had a history of retinal surgery and 24 had a history of cerebrovascular accident, aneurysm and/or neurosurgery. One additional patient had a history of both retinal and CNS events.Patients with retinal or CNS comorbidities were significantly older, had elevated PSA levels and CCI (Charlson Comorbidity Index) scores than the control group. Blood loss, length of stay, surgical duration, BMI, diagnostic Gleason score and T-stage were not statistically different between groups.No retinal or CNS complications occurred in either group. The distribution of patients between D'Amico risk categories was not statistically different between the groups. There was also no difference in the incidence of total complications between the groups.Conclusions:RALP-associated retinal and CNS complications are rare. While our RALP database is large, the cohort of patients with retinal or CNS-related comorbidities was relatively small. Our dataset suggests retinal and CNS pathology presents no greater risk of suffering from perioperative complications following RALP.

Urinary Bother as a Predictor of Postsurgical Changes in Urinary Function After Robotic Radical Prostatectomy.

OBJECTIVE: To characterize changes in indices of urinary function in prostatectomy patients with presurgical voiding symptoms. METHODS: A retrospective analysis of our prostate cancer database identified robot-assisted radical prostatectomy patients between April 2007 and December 2011 who completed pre- and postsurgical (24 months) Expanded Prostate Cancer Index Composite-26 surveys. Gleason score, margins, D'Amico risk, prostate-specific antigen, radiotherapy, and nerve-sparing status were tabulated. Survey questions addressed urinary irritation/obstruction, incontinence, and overall bother. Responses were averaged to calculate a urinary sum (US) score. Patients were stratified according to the severity of their baseline urinary bother (UB), and changes in urinary indices determined at 24 months. RESULTS: A total of 737 patients were included. Postsurgical improvement in urinary obstruction, bother, and sum score was related to baseline UB (P <.001). Men with severe baseline bother had the greatest improvement in US (+9.3), whereas those with asymptomatic baseline UB experienced a decline in US (-2.8). All patients experienced a decline in urinary incontinence of 6.3-8.3 that was independent of baseline bother (P = .507). Patients with severe UB experienced positive outcomes, whereas those at asymptomatic baseline experienced negative US outcomes. Negative urinary incontinence outcomes were unrelated to baseline UB. Age, radiotherapy, and nerve-sparing status were not associated with improved UB (P = .029). However, baseline UB was significantly associated with improvement in postsurgical UB (P = .001). CONCLUSION: Baseline UB is a predictor of postsurgical improvement in urinary function. These data are helpful when counseling a subset of robot-assisted laparoscopic radical prostatectomy patients with severe preoperative urinary symptoms.

Construction of a Urologic Robotic Surgery Training Curriculum: How Many Simulator Sessions Are Required for Residents to Achieve Proficiency?

PURPOSE: To define the time needed by urology residents to attain proficiency in computer-aided robotic surgery to aid in the refinement of a robotic surgery simulation curriculum. METHODS: We undertook a retrospective review of robotic skills training data acquired during January 2012 to December 2014 from junior (postgraduate year [PGY] 2-3) and senior (PGY4-5) urology residents using the da Vinci Skills Simulator. We determined the number of training sessions attended and the level of proficiency achieved by junior and senior residents in attempting 11 basic or 6 advanced tasks, respectively. RESULTS: Junior residents successfully completed 9.9 ± 1.8 tasks, with 62.5% completing all 11 basic tasks. The maximal cumulative success rate of junior residents completing basic tasks was 89.8%, which was achieved within 7.0 ± 1.5 hours of training. Of senior residents, 75% successfully completed all six advanced tasks. Senior residents attended 6.3 ± 3.5 hours of training during which 5.1 ± 1.6 tasks were completed. The maximal cumulative success rate of senior residents completing advanced tasks was 85.4%. CONCLUSION: When designing and implementing an effective robotic surgical training curriculum, an allocation of 10 hours of training may be optimal to allow junior and senior residents to achieve an acceptable level of surgical proficiency in basic and advanced robotic surgical skills, respectively. These data help guide the design and scheduling of a residents training curriculum within the time constraints of a resident's workload.

Oncological and functional outcomes of salvage renal surgery following failed primary intervention for renal cell carcinoma.

PURPOSE: To assess the oncologic and functional outcomes of salvage renal surgery following failed primary intervention for RCC. MATERIALS AND METHODS: We performed a retrospective review of patients who underwent surgery for suspected RCC during 2004-2012. We identified 839 patients, 13 of whom required salvage renal surgery. Demographic data was collected for all patients. Intraoperative and postoperative data included ischemic duration, blood loss and perioperative complications. Preoperative and postoperative assessments included abdominal CT or magnetic resonance imaging, chest CT and routine laboratory work. Estimated glomerular filtration rate (eGFR) was calculated according to the Modification of Diet in Renal Disease equation. RESULTS: The majority (85%) of the patients were male, with an average age of 64 years. Ten patients underwent salvage partial nephrectomy while 3 underwent salvage radical nephrectomy. Cryotherapy was the predominant primary failed treatment modality, with 31% of patients undergoing primary open surgery. Pre-operatively, three patients were projected to require permanent post-operative dialysis. In the remaining 10 patients, mean pre- and postoperative serum creatinine and eGFR levels were 1.35 mg/dL and 53.8 mL/min/1.73 m2 compared to 1.43 mg/dL and 46.6 mL/min/1.73 m2, respectively. Mean warm ischemia time in 10 patients was 17.4 min and for all patients, the mean blood loss was 647 mL. The predominant pathological stage was pT1a (8/13; 62%). Negative surgical margins were achieved in all cases. The mean follow-up was 32.9 months (3.5-88 months). CONCLUSION: While salvage renal surgery can be challenging, it is feasible and has adequate surgical, functional and oncological outcomes.

Seminal vesicle cyst with ipsilateral renal agenesis and ectopic ureter (Zinner syndrome).

The symptomatic presentation of seminal vesicle cysts with ipsilateral renal agenesis and ectopic ureter (Zinner syndrome) is rare. Patients are typically diagnosed at the third or the fourth decade of life and often present with infertility. Although the diagnosis can generally be made with magnetic resonance imaging, cystography can also be useful in indeterminate cases. We report on the unusual case of an 18-year-old man who presented with pelvic pain that was intensified by ejaculation. Computed tomography and magnetic resonance imaging revealed a cystic structure in the area of the right seminal vesicle that was successfully excised robotically without complications.

Weighted Gleason scores do not outperform standard clinical Gleason scores.

INTRODUCTION: Predicting patient survival rates following radical prostatectomy remains an area of clinical interest. We compared the ability of standard clinical Gleason scores and alternative 'weighted' Gleason scores to predict pathology, margin status and recurrence in prostate cancer. MATERIALS AND METHODS: Patients who underwent robotic radical prostatectomy performed by a single surgeon between Jan 2007 - Dec 2008 were included. Tumor at the inked margin in pathologic samples was considered a positive margin. Recurrence was defined as PSA ≥ 0.2 or the institution of salvage therapy. Standard pathologic Gleason scores were recorded. The proportion of tumor in each core was used to calculate 'weighted' and 'rounded weighted ' Gleason scores. The ability of each Gleason score to predict pathology, margin status and recurrence were statistically compared. RESULTS: Of 433 cases, 281 with uniform Gleason 6 cores were excluded. One hundred and fifty-two cases had Gleason scores ≥ 7, of which complete data were unavailable for three patients. In the final cohort of 149 cases, 72 (48.3%) patients had uniformly scored biopsies, while 77 (51.7%) had biopsies with non-uniform Gleason scores. The positive margin rate and recurrence free rates were 30.2% and 77.2%, respectively. Analyses of the entire patient cohort, and patients with non-uniform cores, found no significant difference between the predictive capacities of each scoring system. The alternative algorithms were not shown to be better predictors of pathologic Gleason score, margin status or recurrence. CONCLUSIONS: Using the highest standard Gleason score of all cores to define a preoperative Gleason score remains an appropriate clinical practice.

Gross haematuria associated with penetration of an inferior vena cava filter into the right renal collecting system.

Inferior vena cava (IVC) filters are a viable alternative for patients with venous thromboembolic disease for whom standard anticoagulation therapy is contraindicated. Rare complications associated with their use, however, include misplacement and IVC penetration. We report a case of a 63-year-old woman who developed gross haematuria following IVC filter penetration into both the right renal collecting system and renal pelvis, for which open caval removal and reconstruction was required. This is an unusual case of IVC filter penetration causing symptomatic haematuria and requiring surgical intervention.

Surgical complications associated with robotic urologic procedures in elderly patients.

INTRODUCTION: Urologic malignancies are often diagnosed at an older age, and are increasingly managed utilizing robotic-assisted surgical techniques. As such, we assessed and compared peri-postoperative complication rates following robotic urologic surgery in elderly and younger patients. MATERIALS AND METHODS: A retrospective analysis of IRB-approved databases and electronic medical records identified patients who underwent robotic-assisted urologic surgery between December 2003-September 2013. Patients were grouped according to surgical procedure (partial nephrectomy, radical cystectomy, radical prostatectomy) and age at surgery (≤ 74 or ≥ 75 years old). Associations between age, comorbidities, Charlson comorbidity index (CCI), and patient outcomes were evaluated within each surgery type. RESULTS: 97.5% and 2.5% of patients were ≤ 74 or ≥ 75 years old, respectively. Cystectomies, partial nephrectomies and prostatectomies accounted for 3.5%, 9.5% and 87.1% of surgeries, respectively. Within cystectomy, nephrectomy and prostatectomy groups, 24.4%, 12.5% and 0.6% patients were ≥ 75 years old. Within each surgical type, elderly patients had significantly elevated CCI scores. Length of stay was significantly prolonged in elderly patients undergoing partial nephrectomy or prostatectomy. In elderly cystectomy, partial nephrectomy and prostatectomy patients, 36.7%, 14.3% and 5.9% suffered ≥ 1 Clavien grade 3-5 complication, respectively. Major complications were not significantly different between age groups. A qualitatively similar pattern was observed regarding Clavien grade 1-2 complications. CONCLUSIONS: The risks of robotic-assisted urologic surgery in elderly patients are not significantly elevated compared to younger patients.

Oncological and functional outcomes of salvage renal surgery following failed primary intervention for renal cell carcinoma

Purpose To assess the oncologic and functional outcomes of salvage renal surgery following failed primary intervention for RCC. Materials and Methods We performed a retrospective review of patients who underwent surgery for suspected RCC during 2004-2012. We identified 839 patients, 13 of whom required salvage renal surgery. Demographic data was collected for all patients. Intraoperative and postoperative data included ischemic duration, blood loss and perioperative complications. Preoperative and postoperative assessments included abdominal CT or magnetic resonance imaging, chest CT and routine laboratory work. Estimated glomerular filtration rate (eGFR) was calculated according to the Modification of Diet in Renal Disease equation. Results The majority (85%) of the patients were male, with an average age of 64 years. Ten patients underwent salvage partial nephrectomy while 3 underwent salvage radical nephrectomy. Cryotherapy was the predominant primary failed treatment modality, with 31% of patients undergoing primary open surgery. Pre-operatively, three patients were projected to require permanent post-operative dialysis. In the remaining 10 patients, mean pre- and postoperative serum creatinine and eGFR levels were 1.35 mg/dL and 53.8 mL/min/1.73 m2 compared to 1.43 mg/dL and 46.6 mL/min/1.73 m2, respectively. Mean warm ischemia time in 10 patients was 17.4 min and for all patients, the mean blood loss was 647 mL. The predominant pathological stage was pT1a (8/13; 62%). Negative surgical margins were achieved in all cases. The mean follow-up was 32.9 months (3.5-88 months). Conclusion While salvage renal surgery can be challenging, it is feasible and has adequate surgical, functional and oncological outcomes. .

Pre-Operative Education Classes Prior to Robotic Prostatectomy Benefit Both Patients and Clinicians.

As part of a process improvement initiative, we designed, implemented, and assessed the impact of pre-surgical education classes for patients scheduled to undergo robotic prostatectomy. Our aim was to both enhance patient access to important procedural information related to their surgery, and also limit the need for the repeated dissemination of information during patient calls to the office.

Process Improvements Positively Impact the Use of Intravesical Mitomycin C after Transurethral Resection of Nonmuscle Invasive Bladder Cancer in a Large, Urban Urology Practice.

INTRODUCTION: We assessed the rate of intravesical mitomycin C therapy in patients with nonmuscle invasive bladder cancer who underwent transurethral resection of the bladder, as well as the impact of procedural changes governing its use. METHODS: A retrospective review of our bladder cancer database identified patients who underwent transurethral resection of the bladder with mitomycin C therapy during January 2008 to July 2014. Since our mitomycin C protocols were revised during 2013, patients were stratified based on date of service. Patient demographics and data describing mitomycin C use were tabulated. RESULTS: During January 2008 to May 2013, 276 of 737 (37.5%) ideal patients received mitomycin C (not accounting for patients in whom mitomycin C was contraindicated). Conversely 461 of 737 patients (62.5%) did not receive mitomycin C. Shortages of mitomycin C were responsible for nonuse in 18.4% of cases while no specified reason for nonuse was given in 59%. When cases in which mitomycin C use was contraindicated were taken into account, mitomycin C was used in 51.6% overall. After the implementation of new mitomycin C operating procedures, mitomycin C use increased significantly to 76.0% (p <0.001) (accounting for appropriate nonuse). During this period mitomycin C shortages were not responsible for any case in which mitomycin C was not used. CONCLUSIONS: During 2008 to 2013 mitomycin C was not used in a significant proportion of patients who underwent transurethral resection of the bladder. The implementation of a revised protocol governing mitomycin C use significantly and positively impacted mitomycin C use. Importantly, pharmacy shortages no longer contribute to the nonuse of mitomycin C in patients with bladder cancer. These data highlight the impact of continual improvement initiatives on standard clinical practice.