Bladder Cancer Survivors Who Do Not Smoke Have Better Longitudinal Health-Related Quality of Life Measures: An Assessment of the Comparative Effectiveness and Survivorship Health in Bladder Cancer (CEASE-BC) Study.

PURPOSE: Cigarette smoking is the most common risk factor for the development of bladder cancer (BC), yet there is a paucity of data characterizing the relationship between smoking status and longitudinal health-related quality of life (HRQoL) outcomes in patients with BC. We examined the association between smoking status and HRQoL among patients with BC. MATERIALS AND METHODS: Data were sourced from a prospective, longitudinal study open between 2014 and 2017, which examined HRQoL in patients aged ≥ 18 years old diagnosed with BC across North Carolina. The QLQ-C30 (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire core instrument) was administered at 3, 12, and 24 months after BC diagnosis. Our primary exposure of interest was current smoking status. Linear regression using generalized estimating equations was used to analyze the relationship between smoking status and various domains of the QLQ-C30. RESULTS: A total of 154 patients enrolled in the study. Eighteen percent were classified as smoking at 3 months from diagnosis, and packs per day ranged from < 0.5 to 2. When controlling for time from diagnosis, demographic covariates, cancer stage, and treatment type, mean differences for physical function (7.4), emotional function (5.6), and fatigue measures (-8.2) were significantly better for patients with BC who did not smoke. CONCLUSIONS: Patients with BC who do not smoke have significantly better HRQoL scores in the domains of physical function, emotional function, and fatigue. These results underscore the need to treat smoking as an essential component of BC care.

Decisional Conflict Among Patients Newly Diagnosed With Clinical T1 Renal Masses: A Prospective Study.

PURPOSE: Because multiple management options exist for clinical T1 renal masses, patients may experience a state of uncertainty about the course of action to pursue (ie, decisional conflict). To better support patients, we examined patient, clinical, and decision-making factors associated with decisional conflict among patients newly diagnosed with clinical T1 renal masses suspicious for kidney cancer. MATERIALS AND METHODS: From a prospective clinical trial, participants completed the Decisional Conflict Scale (DCS), scored 0 to 100 with < 25 associated with implementing decisions, at 2 time points during the initial decision-making period. The trial further characterized patient demographics, health status, tumor burden, and patient-centered communication, while a subcohort completed additional questionnaires on decision-making. Associations of patient, clinical, and decision-making factors with DCS scores were evaluated using generalized estimating equations to account for repeated measures per patient. RESULTS: Of 274 enrollees, 250 completed a DCS survey; 74% had masses ≤ 4 cm in size, while 11% had high-complexity tumors. Model-based estimated mean DCS score across both time points was 17.6 (95% CI 16.0-19.3), though 50% reported a DCS score ≥ 25 at least once. On multivariable analysis, DCS scores increased with age (+2.64, 95% CI 1.04-4.23), high- vs low-complexity tumors (+6.50, 95% CI 0.35-12.65), and cystic vs solid masses (+9.78, 95% CI 5.27-14.28). Among decision-making factors, DCS scores decreased with higher self-efficacy (-3.31, 95% CI -5.77 to -0.86]) and information-seeking behavior (-4.44, 95% CI -7.32 to -1.56). DCS scores decreased with higher patient-centered communication scores (-8.89, 95% CI -11.85 to -5.94). CONCLUSIONS: In addition to patient and clinical factors, decision-making factors and patient-centered communication relate with decisional conflict, highlighting potential avenues to better support patient decision-making for clinical T1 renal masses.

Untargeted Metabolomics to Characterize the Urinary Chemical Landscape of E-Cigarette Users.

The health and safety of using e-cigarette products (vaping) have been challenging to assess and further regulate due to their complexity. Inhaled e-cigarette aerosols contain chemicals with under-recognized toxicological profiles, which could influence endogenous processes once inhaled. We urgently need more understanding on the metabolic effects of e-cigarette exposure and how they compare to combustible cigarettes. To date, the metabolic landscape of inhaled e-cigarette aerosols, including chemicals originated from vaping and perturbed endogenous metabolites in vapers, is poorly characterized. To better understand the metabolic landscape and potential health consequences of vaping, we applied liquid chromatography-mass spectrometry (LC-MS) based nontargeted metabolomics to analyze compounds in the urine of vapers, cigarette smokers, and nonusers. Urine from vapers (n = 34), smokers (n = 38), and nonusers (n = 45) was collected for verified LC-HRMS nontargeted chemical analysis. The altered features (839, 396, and 426 when compared smoker and control, vaper and control, and smoker and vaper, respectively) among exposure groups were deciphered for their structural identities, chemical similarities, and biochemical relationships. Chemicals originating from e-cigarettes and altered endogenous metabolites were characterized. There were similar levels of nicotine biomarkers of exposure among vapers and smokers. Vapers had higher urinary levels of diethyl phthalate and flavoring agents (e.g., delta-decalactone). The metabolic profiles featured clusters of acylcarnitines and fatty acid derivatives. More consistent trends of elevated acylcarnitines and acylglycines in vapers were observed, which may suggest higher lipid peroxidation. Our approach in monitoring shifts of the urinary chemical landscape captured distinctive alterations resulting from vaping. Our results suggest similar nicotine metabolites in vapers and cigarette smokers. Acylcarnitines are biomarkers of inflammatory status and fatty acid oxidation, which were dysregulated in vapers. With higher lipid peroxidation, radical-forming flavoring, and higher level of specific nitrosamine, we observed a trend of elevated cancer-related biomarkers in vapers as well. Together, these data present a comprehensive profiling of urinary biochemicals that were dysregulated due to vaping.

Does histologic subtype impact overall survival in observed T1a kidney cancers compared with competing risks? Implications for biopsy as a risk stratification tool.

OBJECTIVES: We sought to assess if adding a biopsy proven histologic subtype to a model that predicts overall survival that includes variables representing competing risks in observed, biopsy proven, T1a renal cell carcinomas, enhances the model's performance. METHODS: The National Cancer Database was assessed (years 2004-2015) for patients with observed T1a renal cell carcinoma who had undergone renal mass biopsy. Kaplan-Meier curves were utilized to estimate overall survival stratified by histologic subtype. We utilized C-index from a Cox proportional hazards model to evaluate the impact of adding histologic subtypes to a model to predict overall survival for each stage. RESULTS: Of 132 958 T1a renal masses identified, 1614 had biopsy proven histology and were managed non-operatively. Of those, 61% were clear cell, 33% papillary, and 6% chromophobe. Adjusted Kaplan-Meier curves demonstrated a difference in overall survival between histologic subtypes (P = 0.010) with greater median overall survival for patients with chromophobe (85.1 months, hazard rate 0.45, P = 0.005) compared to clear cell (64.8 months, reference group). Adding histology to a model with competing risks alone did not substantially improve model performance (C-index 0.65 vs 0.64 respectively). CONCLUSIONS: Incorporation of histologic subtype into a risk stratification model to determine prognostic overall survival did not improve modeling of overall survival compared with variables representing competing risks in patients with T1a renal cell carcinoma managed with observation. These results suggest that performing renal mass biopsy in order to obtain tumor histology may have limited utility. Future studies should further investigate the overall utility of renal mass biopsy for observed T1a kidney cancers.

A Systematic Review and Scoping Analysis of Smoking Cessation after a Urological Cancer Diagnosis.

PURPOSE: Smoking cessation after a urological cancer diagnosis significantly benefits patients. It is not well known how often patients quit after diagnosis or how urologists intervene to support patients' smoking cessation efforts. We examined rates of smoking cessation after diagnosis among patients with urological cancers, and assessed how often patients are given advice and support to quit smoking in the urology setting. MATERIALS AND METHODS: Following PRISMA guidelines, a systematic review was conducted of the available studies on smoking cessation after a urological cancer diagnosis during April 2020 by a trained medical librarian using the MEDLINE®, PsycInfo®, Embase® and Cochrane Central databases. Studies were included based on 3 independent reviews and if they met a priori inclusion/exclusion criteria. In total, 2,568 records were identified, 31 of which were included for final analysis. RESULTS: Four studies (587 patients) reported outcomes related to the prospective implementation of a smoking cessation program with patient-level quit rates ranging from 3.2% to 47.3%. A total of 21 studies (3,669 patients) reported outcomes of passive (no directed, active intervention) smoking cessation after the diagnosis of a urological cancer with widely varying quit rates. In general, the quality of included studies was poor. There was no standardization of the measurement or timing of outcomes, and few studies included validated survey instruments or biochemical confirmation of cessation. A total of 17 studies included data on whether patients received advice to quit smoking after diagnosis. The proportion of patients in each study who were told to quit ranged from 2.8% to 78.3%. CONCLUSIONS: There are few smoking cessation interventions that have been prospectively implemented and reported in the urology literature, and studies on quit rates after diagnosis are limited. The paucity of quality data and lack of smoking cessation interventions being used in routine urological oncology care underscores the need for more rigorous study and implementation of evidence-based practices in this area.

Patterns of Current Cigarette Smoking, Quit Attempts and Cessation Counseling among Survivors of Smoking-Related and Nonsmoking-Related Urological Malignancies: A Nationally Representative Cross-Sectional Analysis.

PURPOSE: Cigarette smoking is the leading modifiable risk factor for several genitourinary malignancies. Although smoking cessation after genitourinary cancer diagnosis is a critical component of survivorship, factors related to continued smoking are under studied. MATERIALS AND METHODS: A cross-sectional analysis was conducted using data from the National Health Interview Survey (2014-2018). Our primary study outcome was the prevalence and correlates of cigarette smoking among adults with a history of smoking-related (kidney or bladder) urological cancer compared to a nonsmoking-related control (prostate cancer). We used regression analyses to assess the association of having a smoking-related genitourinary cancer history with continued cigarette smoking after diagnosis. Secondary outcomes were yearly smoking trends, quit attempts and reported receipt of smoking cessation counseling. RESULTS: A total of 2,664 respondents reported a history of genitourinary cancer, representing weighted estimates of 990,820 (smoking-related genitourinary cancer) and 2,616,596 (prostate cancer) adults. Survivors of smoking-related genitourinary cancers had a significantly higher overall prevalence of current cigarette use (14.8% vs 8.6%, p <0.001) and also reported more frequent receipt of counseling (79.8% vs 66.2%, p=0.02) but did not attempt to quit any more often than those with prostate cancer (52.4% vs 47.2%, p=0.44). Time trends demonstrated stable and persistent cigarette use among survivors of all genitourinary cancers. After adjustment for sociodemographic confounders, cancer type was not associated with current cigarette smoking (OR 1.23, 95% CI 0.86-1.77). However, older age and more advanced educational attainment were associated with lower odds of current cigarette smoking, while single marital status was associated with higher odds. CONCLUSIONS: In this population-based cross-sectional study of survivors of genitourinary cancers, those with a reported smoking-related genitourinary cancer had a higher prevalence of current cigarette smoking compared to those with prostate cancer, our nonsmoking-related control. Those with smoking-related genitourinary cancers reported more frequent receipt of smoking cessation counseling.

Tobacco Screening and Treatment during Outpatient Urology Office Visits in the United States.

PURPOSE: Tobacco use is a causative or exacerbating risk factor for benign and malignant urological disease. However, it is not well known how often urologists screen for tobacco use and provide tobacco cessation treatment at the population level. We sought to evaluate how often urologists see patients for tobacco-related diagnoses in the outpatient setting and how often these visits include tobacco use screening and treatment. MATERIALS AND METHODS: We used the National Ambulatory Medical Care Survey public use files for the years 2014-2016 to identify all outpatient urology visits with adults 18 years old or older. Clinic visit reasons were categorized according to diagnoses associated with the encounter: all urological diagnoses, a tobacco-related urological condition or a urological cancer. Our primary outcome was the percentage of visits during which tobacco screening was reported. Secondary outcomes included reported delivery of cessation counseling and provision of cessation pharmacotherapy. RESULTS: We identified 4,625 unique urological outpatient encounters, representing a population-weighted estimate of 63.9 million visits over 3 years. Approximately a third of all urology visits were for a tobacco-related urological diagnosis and 15% were for urological cancers. An estimated 1.1 million visits over 3 years were with patients who identified as current tobacco users. Of all visits, 70% included tobacco screening. However, only 7% of visits with current smokers included counseling and only 3% of patients were prescribed medications. No differences in screening and treatment were observed between visit types. CONCLUSIONS: Urologists regularly see patients for tobacco-related conditions and frequently, although not universally, screen patients for tobacco. However, urologists rarely offer counseling or cessation treatment. These findings may represent missed opportunities to decrease the morbidity associated with tobacco use.

Impairment and Longitudinal Recovery of Older Adults Treated with Radical Cystectomy for Muscle Invasive Bladder Cancer.

PURPOSE: Treatment for muscle invasive bladder cancer includes radical cystectomy, a major surgery that can be associated with significant toxicity. Limited data exist related to changes in patient global health status and recovery following radical cystectomy. We used geriatric assessment to longitudinally compare health related impairments in older and younger patients with muscle invasive bladder cancer who undergo radical cystectomy. MATERIALS AND METHODS: Older and younger patients (70 or older and younger than 70 years) with muscle invasive bladder cancer undergoing radical cystectomy at an academic institution were enrolled between 2012 and 2019. Patients completed the geriatric assessment before radical cystectomy, and 1, 3 and 12 months after radical cystectomy. For each geriatric assessment measure the Wilcoxon rank sum test was used to compare score distribution between age groups at each time point. The Wilcoxon signed rank test was used to compare distributions between time points within each age group. RESULTS: A total of 80 patients (42 younger and 38 older) were enrolled. Before radical cystectomy 78% of patients were impaired on at least 1 geriatric assessment measure. Both age groups had worsening physical function and nutrition at 1 month after radical cystectomy, with older patients having a greater decline in function than younger patients. Both groups recovered to baseline at 3 months after radical cystectomy and maintained this status at 1 year. CONCLUSIONS: High rates of impairments were found across age groups in the short term after radical cystectomy, followed by recovery to baseline.

Update of the Standard Operating Procedure on the Use of Multiparametric Magnetic Resonance Imaging for the Diagnosis, Staging and Management of Prostate Cancer.

PURPOSE: We update the prior standard operating procedure for magnetic resonance imaging of the prostate, and summarize the available data about the technique and clinical use for the diagnosis and management of prostate cancer. This update includes practical recommendations on the use of magnetic resonance imaging for screening, diagnosis, staging, treatment and surveillance of prostate cancer. MATERIALS AND METHODS: A panel of clinicians from the American Urological Association and Society of Abdominal Radiology with expertise in the diagnosis and management of prostate cancer evaluated the current published literature on the use and technique of magnetic resonance imaging for this disease. When adequate studies were available for analysis, recommendations were made on the basis of data and when adequate studies were not available, recommendations were made on the basis of expert consensus. RESULTS: Prostate magnetic resonance imaging should be performed according to technical specifications and standards, and interpreted according to standard reporting. Data support its use in men with a previous negative biopsy and ongoing concerns about increased risk of prostate cancer. Sufficient data now exist to support the recommendation of magnetic resonance imaging before prostate biopsy in all men who have no history of biopsy. Currently, the evidence is insufficient to recommend magnetic resonance imaging for screening, staging or surveillance of prostate cancer. CONCLUSIONS: Use of prostate magnetic resonance imaging in the risk stratification, diagnosis and treatment pathway of men with prostate cancer is expanding. When quality prostate imaging is obtained, current evidence now supports its use in men at risk of harboring prostate cancer and who have not undergone a previous biopsy, as well as in men with an increasing prostate specific antigen following an initial negative standard prostate biopsy procedure.

Blunt trauma pelvic fracture-associated genitourinary and concomitant lower gastrointestinal injury: incidence, morbidity, and mortality.

PURPOSE: Limited data exist on the characteristics, risk factors, and management of blunt trauma pelvic fractures causing genitourinary (GU) and lower gastrointestinal (GI) injury. We sought to determine these parameters and elucidate independent risk factors. METHODS: The National Trauma Data Bank for years 2010-2014 was queried for pelvic fractures by ICD-9-CM codes. Exclusion criteria included age ≤ 17 years, penetrating injury, or incomplete records. Patients were divided into three cohorts: pelvic fracture, pelvic fracture with GU injury, and pelvic fracture with GU and GI injury. Between-group comparisons were made using stratified analysis. Multivariable logistic regression was used to determine independent risk factors for concomitant GI injury. RESULTS: In total, 180,931 pelvic fractures were found, 3.3% had GU, and 0.15% had GU and GI injury. Most common mechanism was vehicular collision. Injury severity score, pelvic AIS, and mortality were higher with combined injury (p < 0.001), leading to longer hospital and ICU stays and ventilator days (p < 0.001) with more frequent discharges to acute rehabilitation (p < 0.01). Surgical management of concomitant injuries involved both urinary (62%) and rectal repairs (81%) or diversions (29% and 46%, respectively). Male gender (OR = 2.42), disruption of the pelvic circle (OR = 6.04), pubis fracture (OR = 2.07), innominate fracture (OR = 1.84), and SBP < 90 mmgh (OR = 1.59) were the strongest independent predictors of combined injury (p < 0.01). CONCLUSION: Pelvic fractures with lower GU and GI injury represent < 1% of pelvic fractures. They are associated with more severe injuries and increased hospital resource utilization. Strongest independent predictors are disruption of the pelvic circle, male gender, innominate fracture, and SBP < 90mm Hg.

Salvage Pelvic Lymph Node Dissection and Current State of Imaging for Recurrent Prostate Cancer: Does a Standard Exist?

PURPOSE OF REVIEW: We aim to evaluate the efficacy of salvage lymph node dissection (SLND) for nodal recurrent prostate cancer after primary treatment. We also provide a review of the diagnostic performance of next-generation sequencing (next-generation imaging (NGI)) radiotracers in the salvage setting. RECENT FINDINGS: Most studies evaluating SLND include a heterogeneous population with a small sample size and are retrospective in design. The 5-year clinical recurrence-free and cancer-specific survival following SLND are 26-52% and 57-89%, respectively, among prospective studies. NGI improves accuracy in detecting nodal recurrence compared to conventional CT, with PMSA PET-CT showing the most promise. However, limited studies exist comparing imaging modalities and performance is variable at low PSA values. SLND is a promising treatment option, but more prospective data are needed to determine the ideal surgical candidate and long-term oncologic outcomes. More studies comparing different NGI are needed to determine the best imaging modality in patients who may be candidates for salvage treatment.

Development of novel prognostic models for predicting complications of urethroplasty.

INTRODUCTION AND OBJECTIVE: To identify predictors of thirty-day perioperative complications after urethroplasty and create a model to predict patients at increased risk. METHODS: We selected all patients recorded in the National Surgery Quality Improvement Program (NSQIP) from 2005 to 2015 who underwent urethroplasty, determined by Current Procedural Terminology (CPT) codes. The primary outcome of interest was a composite 30-day complication rate. To develop predictive models of urethroplasty complications we used random forest and logistic regression with tenfold cross-validation employing demographic, comorbidity, laboratory, and wound characteristics as candidate predictors. Models were selected based on the receiver operating characteristic (ROC) curve, with the primary measure of performance being the area under curve (AUC). RESULTS: We identified 1135 patients who underwent urethroplasty and met inclusion criteria. The mean age was 53 years with 84% being male. The overall incidence of complications was 8.6% (n = 98). Patients who experienced a complication more commonly had diabetes, a preoperative blood transfusion, preoperative sepsis, lower hematocrit and albumin, as well as a longer operative time (p < 0.05). LASSO logistic and random forest logistic models for predicting urethroplasty complications had an AUC (95% CI) 0.73 (0.58-0.87), and 0.48 (0.33-0.68), respectively. The variables that were determined to be most important and included in the predictive models were operative time, age, American Society of Anesthesiologists (ASA) classification and preoperative laboratory values (white blood cell count, hematocrit, creatinine, platelets). CONCLUSION: Our predictive models of complications perform well and may allow for improved preoperative counseling and risk stratification in the surgical management of urethral stricture.

Perceptions of dietary factors promoting and preventing nephrolithiasis: a cross-sectional survey.

OBJECTIVE: To assess knowledge of both promoting and preventive dietary factors on nephrolithiasis in a diverse patient population. Precipitating factors of kidney stone disease include diet, lifestyle, socioeconomic status, and race/ethnicity. However, patient awareness of these influences is poorly described. MATERIALS AND METHODS: A 24-question survey, assessing intake-related risk factors for stone disease, was administered prospectively to 1018 patients. Responses were summarized with frequency and percent. Statistical comparisons were made using a propensity scoring method in order to account for potential confounding variables. Propensity scores were stratified into quintiles. Further analysis with multiple imputation was performed to account for any missing data in the survey. The results of the propensity-adjusted log-binomial regression model are presented as prevalence ratios (PRs) and 95% confidence intervals (CIs). RESULTS: Respondents demonstrated limited knowledge of nutrient factors that influence stone development. However, most study participants (70.3%) reported a willingness to make lifestyle changes aimed at lowering their risk for stone disease. Respondents reporting previous nephrolithiasis education were less likely to report that diet had no effect on kidney stone formation (PR = 0.795, 95% CI 0.65, 0.96, p = 0.01) The type of physician who counseled the respondent had no association with patient knowledge for stone disease (PR = 0.83, 95% CI 0.63, 1.10, p = 0.2). CONCLUSIONS: Knowledge of diet-related risk factors for nephrolithiasis is limited among this population. Respondents who received prior education appeared to maintain the knowledge of dietary risk for nephrolithiasis. Participants also expressed a willingness to make requisite dietary changes if that information is provided. Given that most stone formers experience a recurrence, these findings highlight the need for more comprehensive patient education strategies on the modifiable risk factors for nephrolithiasis.

Perioperative systemic therapy for bladder cancer.

PURPOSE OF REVIEW: Recent advances in research related to biomarkers and immunotherapy has the potential to transform the landscape for the use of perioperative systemic therapy in patients with bladder cancer. RECENT FINDINGS: Predictive biomarkers including DNA damage repair genes and gene expression profiling may soon lead to better selection of patients for neoadjuvant cisplatin-based chemotherapy. Success of immunotherapy for the treatment of metastatic bladder cancer has led to promising trials exploring immunotherapy in muscle-invasive disease. SUMMARY: Current trials employing predictive biomarkers as well as those using immunotherapy have the potential to significantly improve the outcome of patients with muscle-invasive bladder cancer.

The Charlson Index Is Insufficient to Control for Comorbidities in a National Trauma Registry.

BACKGROUND: The Charlson Comorbidity Index (CCI) is frequently used to control for confounding by comorbidities in observational studies, but its performance as such has not been studied. We evaluated the performance of CCI and an alternative summary method, logistic principal component analysis (LPCA), to adjust for comorbidities, using as an example the association between insurance and mortality. MATERIALS AND METHODS: Using all admissions in the National Trauma Data Bank 2010-2015, we extracted mortality, payment method, and 36 International Classification of Disease, Ninth Revision-derived comorbidities. We estimated odds ratios (ORs) for the association between uninsured status and mortality before and after adjusting for CCI, LPCA, and separate covariates. We also calculated standardized mean differences (SMDs) of comorbidity variables before and after weighting the sample using inverse probability of treatment weights for CCI, LPCA, and separate covariates. RESULTS: In 4,936,880 admissions, most (68.3%) had at least one comorbidity. Considerable imbalance was observed in the unweighted sample (mean SMD = 0.086, OR = 1.17), which was almost entirely eliminated by inverse probability of treatment weights on separate covariates (mean SMD = 0.012, OR = 1.36). The CCI performed similarly to the unweighted sample (mean SMD = 0.080, OR = 1.25), whereas two LPCA axes were better able to control for confounding (mean SMD = 0.04, OR = 1.31). Using covariate adjustment, the CCI accounted for 56.1% of observed confounding, whereas two LPCA axes accounted for 91.3%. CONCLUSIONS: The use of the CCI to adjust for confounding may result in residual confounding, and alternative strategies should be considered. LPCA may be a viable alternative to adjusting for each comorbidity when samples are small or positivity assumptions are violated.

Interfacility Transfer is Associated With Lower Mortality in Undertriaged Gunshot Wound Patients.

BACKGROUND: Treatment at a Level I trauma center yields better outcomes for patients with moderate-to-severe injury as compared with treatment in nontrauma centers. We examined the association between interfacility transfer to a level I or II trauma center and mortality for gunshot wound patients, among patients initially transported to a lower level or undesignated facility. MATERIALS AND METHODS: This retrospective cohort study included all patients from the National Trauma Data Bank (2010-2015) with firearm as the external cause of injury, who met CDC criteria for emergency medical services triage to a higher level (American College of Surgeons [ACS] Level II or above) trauma center. We compared outcomes between patients (a) treated in an ACS level III or below facility and not transferred versus (b) transferred to an ACS level II or above facility, adjusting for confounders using inverse probability of treatment weights. RESULTS: Of the total 62,277 patients, 10,968 (17.6%) were transferred to a level II center or above, and 51,309 (82.4%) were treated at a level III or below or undesignated center. In adjusted analysis comparing transferred versus not transferred patients, risk was lower for mortality (risk ratio [RR] 0.81, 95% confidence interval [CI] 0.70 to 0.95 P = 0.011) but similar for any complication (RR 1.02, 95% CI 0.83 to 1.25 P = 0.87) and the five most common complications. Results were consistent when accounting for data missing at random, and when including state trauma center designations in the definition of Level II or greater versus III and below. CONCLUSIONS: Our study found lower mortality but similar complication risk associated with interfacility transfer for undertriaged gunshot wound patients. This suggests that transfer to a higher level center is warranted among these patients, with improved care potentially outweighing potential harms because of transfer.

The Institutional Learning Curve of Magnetic Resonance Imaging-Ultrasound Fusion Targeted Prostate Biopsy: Temporal Improvements in Cancer Detection in 4 Years.

PURPOSE: While magnetic resonance imaging-ultrasound fusion targeted biopsy allows for improved detection of clinically significant prostate cancer, a concerning amount of clinically significant disease is still missed. We hypothesized that a number of these misses are due to the learning curve associated with magnetic resonance imaging-ultrasound fusion targeted biopsy. We report the results of repeat magnetic resonance imaging-ultrasound fusion targeted biopsy in men with continued suspicion for cancer and the institutional learning curve in the detection of clinically significant prostate cancer with time. MATERIALS AND METHODS: We analyzed the records of 1,813 prostate biopsies in a prospectively acquired cohort of men who presented for prostate biopsy in a 4-year period. All men were offered prebiopsy magnetic resonance imaging and were assigned a maximum PI-RADS™ (Prostate Imaging Reporting and Data System version 2) score. Biopsy outcomes in men with a suspicious region of interest were compared. The relationship between time and clinically significant prostate cancer detection was analyzed. RESULTS: The clinically significant prostate cancer detection rate increased 26% with time in men with a PI-RADS 4/5 region of interest. On repeat magnetic resonance imaging-ultrasound fusion targeted biopsy in men with continued suspicion for cancer 53% of those with a PI-RADS 4/5 region of interest demonstrated clinically significant discordance from the initial magnetic resonance imaging-ultrasound fusion targeted biopsy compared to only 23% with a PI-RADS 1/2 region of interest. Significantly less clinically significant prostate cancer was missed or under graded in the most recent biopsies compared to the earliest biopsies. CONCLUSIONS: The high upgrade rate on repeat magnetic resonance imaging-ultrasound fusion targeted biopsy and the increasing cancer detection rate with time show the significant learning curve associated with magnetic resonance imaging-ultrasound fusion targeted biopsy. Men with low risk or negative biopsies with a persistent, concerning region of interest should be promptly rebiopsied. Improved targeting accuracy with operator experience can help decrease the number of missed cases of clinically significant prostate cancer.

Discordance between Ureteroscopic Biopsy and Final Pathology for Upper Tract Urothelial Carcinoma.

PURPOSE: We evaluated the discordance between ureteroscopic biopsy and surgical pathology findings for grading and staging upper tract urothelial carcinoma. We also sought to establish preoperative predictors of aggressive tumors. MATERIALS AND METHODS: We retrospectively reviewed the records of 314 patients who underwent ureteroscopic biopsy followed by surgical management of upper tract urothelial carcinoma from 2000 to 2016 at a total of 3 institutions. Our primary outcomes were muscle invasive (pT2 or greater) disease at surgical pathology and upgrading of clinical low grade tumors to pathological high grade. RESULTS: At biopsy 61% of the patients had clinical high grade tumors and 21% had subepithelial connective tissue invasion (cT1+). On final pathology 79% of the patients had pathological high grade tumors and 45% had stage pT2 or greater. On multivariate analysis advanced patient age, clinical high grade and cT1+ were independently associated with pT2 or greater. The combined presence of clinical high grade and cT1+ had 86% positive predictive value for muscle invasion while the combined absence of clinical high grade and cT1+ had 80% negative predictive value. The likelihood of missing invasion on biopsy in patients with muscle invasive disease was increased when biopsy fragments were limited to 1 mm or less. Of clinical low grade cases on biopsy 51% were upgraded at surgery. The presence of positive urine cytology was associated with an increased risk of upgrading but this was not statistically significant. CONCLUSIONS: Clinical high grade, cT1+ on biopsy and advanced patient age are independent risk factors for muscle invasive upper tract urothelial carcinoma. There is a significant risk of upgrading in patients with clinical low grade tumors on biopsy, especially when urine cytology is positive. The predictive value of biopsy can likely be improved by more extensive ureteroscopic sampling.