Long-term oncological outcomes of patients with paratesticular sarcoma.

OBJECTIVES: To present long-term oncological outcomes of patients with paratesticular sarcoma treated by a multidisciplinary team. PATIENTS AND METHODS: Patients managed at the Princess Margaret Cancer Centre, between 1990 and 2012, were analysed. A sarcoma expert performed central pathology review. Kaplan-Meier graphs compared local recurrence (LR), metastasis, and overall survival (OS) of patients treated with hemiscrotectomy vs those who did not. Univariable Cox proportional hazards analysis was performed to delineate predictors of LR, metastasis, and OS. RESULTS: Overall, 51 patients with a median (interquartile range) follow-up of 132 (51.6-226.8) months were analysed. At presentation, 92.2% (47 patients) had localised disease. Only five patients (9.8%) had undergone initially planned hemiscrotectomy. Completion and salvage hemiscrotectomy was performed in 25 (54.3%) and seven (15.2%) patients, respectively. Recurrence and metastasis occurred in 12 (25.5%) and 10 patients (19.6%), respectively. At the last follow-up, 21.6% (11 patients) had died, with eight dying from their disease. Kaplan-Meyer graphs demonstrated that hemiscrotectomy improved LR (median not reached vs 62.4 months, log-rank P = 0.008) and OS (median not reached vs 168 months, log-rank P = 0.081). Univariable analysis found hemiscrotectomy to be associated with a lower LR rate (hazard ratio [HR] 0.21, P = 0.02), whilst positive margins at initial surgery were associated with increased LR (HR 4.81, P = 0.047). No metastasis predictors were found, but age (HR 1.04, 95% confidence interval [CI] 1.0-1.08; P = 0.02) and non-localised disease at presentation (HR5.17, 95% CI 1.33-20.06; P = 0.017) were associated with worse OS. CONCLUSION: Paratesticular sarcoma is a rare tumour, predominantly manifesting as localised disease. Most patients receive an initial suboptimal oncological surgery. Improved long-term outcomes are demonstrated following early hemiscrotectomy.

Evolving patterns of care in the management of stage I non-seminomatous germ cell tumors: data from the California Cancer Registry.

PURPOSE: To assess the shifting population-level practice patterns across a 20-year time span in the management of stage I non-seminomatous germ cell tumors (NSGCT). METHODS: Using the California Cancer Registry, we reviewed all patients with stage I NSGCT between 1988 and 2010. We determined their primary treatment and their overall rates across the years. Other analyzed variables included patient age, T stage, socioeconomic status, race, and year of diagnosis. Predictors of treatment were assessed using logistic regression analysis. Predictors of overall and CSS were assessed using Cox proportional hazards models. RESULTS: Three thousand nine hundred and sixty-one patients with stage I NSGCT were identified. The most common treatment was surveillance (48 %), followed by RPLND (26 %) and chemotherapy (24 %). Rates of surveillance increased from 35 % in 1988 to 61 % in 2010; rates of RPLND decreased from 44 % in 1988 to 10 % in 2010. These were significant changes in treatment strategies (p < 0.01). Significant predictors of undergoing surveillance included diagnosis after 2006 (OR 1.52, CI 1.25-1.84) and age at diagnosis >60 years old (OR 1.63, CI 1.19-5.82). With a median follow-up of 96 months, 5-year overall survival rate was 95 %. CONCLUSIONS: Treatment patterns in the management of stage I NSGCT have shifted in the past two decades with an increased utilization of surveillance and concurrent decrease in use of RPLND. Surveillance is now the dominant strategy, potentially reflecting changes in perception of the oncologic safety and morbidity profile of such an approach.

A phase 2 clinical trial of everolimus plus bicalutamide for castration-resistant prostate cancer.

BACKGROUND: The mammalian target of rapamycin (mTOR) pathway is up-regulated in castration-resistant prostate cancer (CRPC). Nevertheless, inhibition of mTOR is ineffective in inducing apoptosis in prostate cancer cells, likely because of the compensatory up-regulation of the androgen receptor (AR) pathway. METHODS: Patients who were eligible for this study had to have progressive CRPC with serum testosterone levels <50 ng/dL. No prior bicalutamide (except to prevent flare) or everolimus was allowed. Treatment included oral bicalutamide 50 mg and oral everolimus 10 mg, both once daily, with a cycle defined as 4 weeks. The primary endpoint was the prostate-specific antigen (PSA) response (≥30% reduction) from baseline. A sample size of 23 patients would have power of 0.8 and an α error of .05 (1-sided) if the combination had a PSA response rate of 50% versus a historic rate of 25% with bicalutamide alone. RESULTS: Twenty-four patients were enrolled. The mean age was 71.1 years (range, 53.0-87.0 years), the mean PSA level at study entry was 43.4 ng/dL (range, 2.5-556.9 ng/dL), and the mean length of treatment was 8 cycles (range, 1.0-23.0 cycles). Of 24 patients, 18 had a PSA response (75%; 95% confidence interval [CI], 0.53-0.90), whereas 15 (62.5%; 95% CI, 0.41-0.81) had a PSA decrease ≥50%. The median overall survival was 28 months (95% CI, 14.1-42.7 months). Fourteen patients (54%; 95% CI, 0.37-0.78) developed grade 3 (13 patients) or grade 4 (1 patient with sepsis) adverse events that were attributable to treatment. CONCLUSIONS: The combination of bicalutamide and everolimus has encouraging efficacy in men with bicalutamide-naive CRPC, thus warranting further investigation. A substantial number of patients experienced everolimus-related toxicity. Cancer 2016;122:1897-904. © 2016 American Cancer Society.

The role of EGFR family inhibitors in muscle invasive bladder cancer: a review of clinical data and molecular evidence.

PURPOSE: Conventional platinum based chemotherapy for advanced urothelial carcinoma is plagued by common resistance to this regimen. Several studies implicate the EGFR family of RTKs in urothelial carcinoma progression and chemoresistance. Many groups have investigated the effects of inhibitors of this family in patients with urothelial carcinoma. This review focuses on the underlying molecular pathways that lead to urothelial carcinoma resistance to EGFR family inhibitors. MATERIALS AND METHODS: We performed a PubMed® search for peer reviewed literature on bladder cancer development, EGFR family expression, clinical trials of EGFR family inhibitors and molecular bypass pathways. Research articles deemed to be relevant were examined and a summary of original data was created. Meta-analysis of expression profiles was also performed for each EGFR family member based on data sets accessible via Oncomine®. RESULTS: Many clinical trials using inhibitors of EGFR family RTKs have been done or are under way. Those that have concluded with results published to date do not show an added benefit over standard of care chemotherapy in an adjuvant or second line setting. However, a neoadjuvant study using erlotinib before radical cystectomy demonstrated promising results. CONCLUSIONS: Clinical and preclinical studies show that for reasons not currently clear prior treatment with chemotherapeutic agents rendered patients with urothelial carcinoma with muscle invasive bladder cancer resistant to EGFR family inhibitors as well. However, EGFR family inhibitors may be of use in patients with no prior chemotherapy in whom EGFR or ERBB2 is over expressed.

Partial nephrectomy for the treatment of renal cell carcinoma (RCC) and the risk of end-stage renal disease (ESRD).

OBJECTIVE: To assess whether radical nephrectomy (RN) compared with partial nephrectomy (PN) for the treatment of renal cell carcinoma (RCC) is associated with greater risk of end-stage renal disease (ESRD). PATIENTS AND METHODS: We performed a population-based, retrospective cohort study using linked administrative databases in the province of Ontario, Canada. We included individuals with pathologically confirmed RCC diagnosed between 1995 and 2010. Cox proportional hazards, propensity score, and competing risks models were used to assess the impact of treatment choice. The primary outcome was ESRD. Secondary outcomes included overall mortality, myocardial infarction, and new-onset chronic kidney disease (CKD). A modern cohort of patients (2003-2010) was analysed separately. RESULTS: We included 11,937 patients, of whom 2107 (18%) underwent PN. The median follow-up was 57 months. In the full cohort, type of surgery was not associated with the rate of ESRD, whereas PN was associated with a decreased likelihood of ESRD compared with RN in the modern cohort using a multivariable proportional hazards model [hazard ratio (HR) 0.44, 95% confidence interval (CI) 0.25-0.75) or propensity score modelling (HR 0.48, 95% CI 0.27-0.82). PN was also associated with a lower risk of new-onset CKD (HR 0.48, 95% CI 0.41-0.57). CONCLUSIONS: Although it is well-known that RN is associated with more CKD than PN, we provide the first direct evidence that PN is associated with less ESRD requiring renal replacement therapy than RN in a modern cohort of patients with RCC.

Ablative efficiency of 532-nm laser vaporization compared to transurethral resection of the prostate: results from a prospective three-dimensional ultrasound volumetry study.

PURPOSE: To assess and compare postoperative prostate volume changes following 532-nm laser vaporization (LV) and transurethral resection of the prostate (TURP). To investigate whether differences in volume reduction are associated with differences in clinical outcome. METHODS: In this prospective, non-randomized study, 184 consecutive patients undergoing 120 W LV (n = 98) or TURP (n = 86) were included. Transrectal three-dimensional ultrasound and planimetric volumetry of the prostate were performed preoperatively, after catheter removal, 6 weeks, 6 and 12 months. Additionally, clinical outcome parameters were recorded. Mann-Whitney U test and analysis of covariance were utilized for statistical analysis. RESULTS: Postoperatively, a significant prostate volume reduction was detectable in both groups. However, the relative volume reduction was lower following LV (18.4 vs. 34.7 %, p < 0.001). After 6 weeks, prostate volumes continued to decrease in both groups, yet differences between the groups were less pronounced. Nonetheless, the relative volume reduction remained significantly lower following LV (12 months 43.3 vs. 50.3 %, p < 0.001). All clinical outcome parameters improved significantly in both groups. However, the maximum flow rate (Q max) and prostate-specific antigen (PSA) reduction were significantly lower following LV. Subgroup analyses revealed significant differences only if the initial prostate volume was >40 ml. Re-operations were necessary in three patients following LV. CONCLUSIONS: The modest but significantly lower volume reduction following LV was associated with a lower PSA reduction, a lower Q max and more re-operations. Given the lack of long-term results after LV, our results are helpful for preoperative patient counseling. Patients with large prostates and no clear indication for the laser might not benefit from the procedure.

Ipsilateral adrenalectomy at the time of radical nephrectomy impacts overall survival.

UNLABELLED: Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Adrenal-sparing approaches should be utilized when performing radical nephrectomy unless there are specific concerns for adrenal involvement. Although current literature demonstrates 10-year cancer control equivalence with adrenal-sparing approaches, such approaches remain under-used. Furthermore, we have yet to clearly define the long-term consequences of an iatrogenic solitary adrenal gland on overall patient health. In our study, we demonstrate worse overall survival in patients undergoing ipsilateral adrenalectomy with radical nephrectomy for renal cell carcinoma. We provide some of the only data demonstrating an association between adrenalectomy and long-term survival, and further emphasize the importance of adrenal-sparing approaches when performing radical nephrectomy. OBJECTIVE: To assess the impact of ipsilateral adrenalectomy on overall survival, we performed a population-level analysis. Ipsilateral adrenal-gland-sparing approaches during radical nephrectomy (RN) remain under-utilized and the long-term consequences of an iatrogenic solitary adrenal gland are poorly understood. PATIENTS AND METHODS: Using the Ontario Cancer Registry we identified 1651 patients in the province of Ontario, Canada, with pT1a renal cell carcinoma who underwent RN between 1995 and 2004. We linked individual patient information with pathological data from abstracted pathology reports and determined whether the ipsilateral adrenal gland was removed at the time of RN. We utilized univariable and multivariable (adjusting for age, gender, tumour size and tumour grade) Cox proportional hazard models and Kaplan-Meier curves to assess predictors of overall and cancer-specific survival. RESULTS: The overall rate of ipsilateral adrenalectomy at the time of RN was 30%. Median follow-up for the cohort was 109 months. Adrenal removal was associated with worse overall survival: 10-year mortality 26% compared with 20% for those in whom the adrenal gland was left in situ. Factors predictive of worse overall survival on multivariable analysis were increasing age (hazard ratio [HR] 1.07 per year, CI 1.06-1.08), high grade tumours (HR 1.38, 1.00-1.90) and having undergone ipsilateral adrenalectomy (HR 1.23, 1.00-1.50). Ipsilateral adrenalectomy was not predictive of cancer-specific survival (HR 1.18, 0.78-1.79). CONCLUSIONS: We demonstrated a significant association between ipsilateral adrenalectomy and overall survival. Our findings further support the importance of adrenal-sparing approaches at the time of RN.

Renal biopsies for small renal masses. For whom, when and how.

Objective of this manuscript is to provide an evidence-based analysis of the current status and future perspectives in kidney biopsies in small renal masses (BSRM). A PubMed search has been performed for all relevant urological literature regarding BSRM. A literature research of English, French and Spanish languages was performed using the Pubmed database from 2000 to February 2012 using the terms renal mass biopsy and renal tumor biopsy. Manuscripts providing a highest level of evidence were selected for the review.Clinical experience from author's Institutions is also reflected in the manuscript. Considerable technical advances have been made in imaging over the last decade. The latter allow for a comprehensive sharp diagnosis of small renal masses (SRM). Therapeutic decision for SRM's is supported by objective knowledge of histological features and renal biopsy represents an accurate and safe option to particularize treatment in renal incidentalomas. Furthermore, renal biopsies are incorporated in the application and follow-up of patients undergoing ablative therapies. An important number of clinical reports have been published in the subject but there is lack of technical standardization. The available experience is limited to referral centers and there are still up to 30% of biopsies that fail to provide clear diagnosis. Renal biopsies have significantly improved in its diagnostic accuracy and it is indicated when tissue diagnosis can change the therapeutic approach of SRM's. Meantime, the role of renal biopsies keeps on growing and limitations of the procedure are less when compared to the benefits it provides.

Do we continue to unnecessarily perform ipsilateral adrenalectomy at the time of radical nephrectomy? A population based study.

PURPOSE: Since the mid 1990s evidence has supported ipsilateral adrenal gland sparing radical nephrectomy unless the gland appears involved on imaging or the primary tumor is large and located in the upper pole. However, it is unclear whether this shift in surgical practice has been adopted at the population level. MATERIALS AND METHODS: Using the Ontario Cancer Registry we identified 5,135 patients in the province of Ontario who underwent radical nephrectomy between 1995 and 2004. Ipsilateral adrenalectomy and tumor involvement of the adrenal gland were ascertained from pathology reports. Further variables analyzed included age, gender, pathology, surgeon year of graduation, academic status of hospital/surgeon, hospital and surgeon volume, and year of surgery. We used multivariable logistic regression to assess outcomes. RESULTS: The overall rate of adrenal gland involvement with cancer was 1.4%. The adrenal was involved in 3.2% of tumors larger than 7 cm vs only 0.89% of tumors 4 to 7 cm and 0.63% of tumors smaller than 4 cm. Factors predictive of adrenal involvement on multivariable analysis were tumor size greater than 7 cm and fat invasion. The overall adrenalectomy rate was 40.1%, which decreased slightly over time (40.6% in 1995 vs 34.8% in 2004). Variables predictive of adrenal removal on multivariable analysis included tumor size greater than 7 cm, presence of venous thrombus, upper pole location, higher hospital volume, and academic status of hospital or surgeon. CONCLUSIONS: Despite evidence to support preservation of the ipsilateral adrenal gland during radical nephrectomy, the rate of adrenalectomy decreased only slightly in 10 years. Adrenalectomy remains overused in populations that are unlikely to benefit from the procedure.

Impact of multiparametric endorectal coil prostate magnetic resonance imaging on disease reclassification among active surveillance candidates: a prospective cohort study.

PURPOSE: We report magnetic resonance imaging findings among unselected men with low risk prostate cancer before active surveillance. MATERIALS AND METHODS: We prospectively enrolled men with low grade, low risk, localized prostate cancer. All patients underwent multiparametric endorectal coil magnetic resonance imaging and were offered confirmatory biopsy within 1 year of imaging. The primary outcome was the impact of magnetic resonance imaging on identifying patients who were reclassified by confirmatory biopsy as no longer fulfilling active surveillance criteria. We further identified clinical parameters associated with reclassification. The cohort was stratified as patients with 1) normal magnetic resonance imaging, 2) cancer on magnetic resonance imaging concordant with initial biopsy (less than 1 cm) and 3) cancer on magnetic resonance imaging larger than 1 cm. We performed univariate analysis to assess differences in clinical parameters among the groups. RESULTS: Magnetic resonance imaging did not detect cancer in 23 cases (38%) while magnetic resonance imaging and initial biopsy were concordant in 24 (40%). Magnetic resonance imaging detected a 1 cm or larger lesion in 13 patients (22%). Of the cases 18 (32.14%) were reclassified. When no cancer was identified on magnetic resonance imaging, only 2 cases (3.5%) were reclassified. The positive and negative predictive values for magnetic resonance imaging predicting reclassification were 83% (95% CI 73-93) and 81% (95% CI 71-91), respectively. Prostate specific antigen density was increased in patients with lesions larger than 1 cm on magnetic resonance imaging compared to those with no cancer on imaging (median 0.15 vs 0.07 ng/ml/cc, p=0.016). CONCLUSIONS: Magnetic resonance imaging appears to have a high yield for predicting reclassification among men who elect active surveillance. Upon confirmation of our results magnetic resonance imaging may be used to better select and guide patients before active surveillance.

Predictors of early mortality after radical nephrectomy with renal vein or inferior vena cava thrombectomy - a population-based study.

UNLABELLED: Study Type - Prognosis (cohort) Level of Evidence 2a. What's known on the subject? and What does the study add? Surgical volume has been well established as a predictor of outcomes for several complex surgical procedures, yet few studies have evaluated this relationship with regards to radical nephrectomy with either renal vein or inferior vena cava thrombectomy. In addition, most published literature consists of single-institution series from centres of excellence. We performed a population-level analysis and identified surgeon volume as a significant predictor of short-term mortality for this procedure. Such findings have potential implications regarding future policy and regionalization of care. OBJECTIVE: • To study the short-term mortality associated with radical nephrectomy with renal vein or inferior vena cava thrombectomy and the variables associated with this adverse outcome. METHODS: • Using the Ontario Cancer Registry, we identified 433 patients in the province of Ontario, Canada undergoing radical nephrectomy with venous thrombectomy between 1995 and 2004. • We determined mortality rates at postoperative days 30 and 90. • Other variables analysed include pathological tumour characteristics, surgeon graduation year, hospital/surgeon academic status, surgery year and hospital/surgeon volume. • We used multivariable logistic regression to assess outcomes. RESULTS: • Overall mortality was 2.8% (30-day) and 5.8% (90-day). • Surgeons performing a single nephrectomy with venous thrombectomy performed 14% of the cases and had the highest 30-day (6.7%) and 90-day (10%) mortality. The mortality rate for surgeons performing more than one surgery was 2.1% (30-day) and 5.1% (90-day). • In recent years, this procedure was performed more commonly by the highest volume surgeons - 67% of cases in 2004 vs 40% in 1995. • Significant predictors of 30-day mortality included procedure year and low surgeon volume. • Significant predictors of 90-day mortality included procedure year, low surgeon volume, left-sided tumour and increasing hospital volume. CONCLUSIONS: • For radical nephrectomy with venous thrombectomy, surgeon volume predicts short-term mortality, emphasizing the importance of experience in patient outcome. • Despite a shift towards high-volume surgeons, 13.8% of cases continued to be performed by low-volume providers. • If these results are confirmed in other jurisdictions, radical nephrectomy with venous thrombectomy should be regionalized and performed by surgeons who manage these cases regularly.

The emerging role of percutaneous biopsy in diagnosis and management of small renal masses.

PURPOSE OF REVIEW: Percutaneous biopsy has an emerging role in the diagnosis and management of small renal masses. The increasing importance of percutaneous biopsy is related to both a better understanding of the natural history of these tumors as well as new developments in treatment strategies. RECENT FINDINGS: We discuss the emerging role of biopsy in the current practice setting. Additionally, we review recent data regarding its diagnostic accuracy, important technical considerations, and possible complications. Finally, we speculate on its future role in managing these patients. SUMMARY: The role of percutaneous renal biopsy in the management of small renal masses continues to evolve. It is critically important at this juncture to evaluate the benefits and shortcomings of such an approach.

Small renal mass: what the urologist needs to know for treatment planning and assessment of treatment results.

OBJECTIVE: Small renal mass is a new distinct clinical entity. Detection of these tumors has increased with increased use of imaging. CONCLUSION: We know that a proportion of these tumors are not renal cell carcinoma, and imaging-guided biopsy is being increasingly used for treatment planning. The objectives of this review are to provide an update on our current understanding of the biology of small renal masses and to review approaches to the diagnosis and treatment of these lesions.

Manuscript publication by urology residents and predictive factors.

PURPOSE: Many academic institutions have set expectations for peer reviewed publications, yet there is no objective guideline to gauge the performance of a urology resident or program. We quantified and determined predictive factors for resident manuscript production. MATERIALS AND METHODS: Electronic surveys were sent to 255 chief residents and recent graduates of 83 accredited urological training programs in the United States and Canada. Survey questions pertained to manuscript submission and acceptance before and during residency, months of research incorporated into residency, PhD degree status and the pursuit of fellowship training. RESULTS: Surveys were completed by 127 residents from 83 programs. The median number of manuscripts submitted and accepted during residency was 3 (range 0 to 32) and 2 (range 0 to 25), respectively. Months of protected research time and the number of publications before residency were significantly predictive of the number of manuscripts submitted during residency (p <0.001 and p <0.001, respectively). The number of manuscripts submitted during residency was significantly associated with entering fellowship training (p <0.05). CONCLUSIONS: Manuscript preparation and publication are important aspects of the training process at a number of urological surgery residency programs. While the majority of residents are not involved in publication before residency, most submit and publish at least 1 manuscript as first author in a peer reviewed journal during residency. The number of prior publications and months of allotted research time are significantly predictive of resident manuscript productivity. In turn, manuscript submission is indicative of the decision to pursue fellowship training.

Incontinent ileovesicostomy: Long-term outcomes and complications.

AIMS: Incontinent ileovesicostomy was popularized in the mid-1990s as a surgical option for patients with neurogenic voiding dysfunction who lack the dexterity to perform clean catheterization. There are several case series in the literature, but few studies look at the long-term outcomes and complications associated with this procedure. METHODS: We review the outcomes of 12 patients who underwent incontinent ileovesicostomy for management of neurogenic voiding dysfunction since its introduction at our institution in 1998. We discuss, specifically, the preoperative and postoperative problems encountered as well as complications pertaining to ileovesicostomy itself. RESULTS: At an average of 5 1/2 years follow-up, all 12 patients who underwent incontinent ileovesicostomy have experienced some form of urinary tract problem either associated with the ileovesicostomy or with their underlying neurogenic voiding dysfunction. After ileovesicostomy, seven of 12 patients (58%) have been able to reduce antibiotic usage and/or hospital admission related to chronic upper tract infection. Two patients (17%) have subsequently been converted to ileal conduit. CONCLUSIONS: Incontinent ileovesicostomy is a useful option for patients with lower urinary tract dysfunction who are unable to perform clean intermittent catheterization. It should be reserved for those patients who have exhausted less invasive therapy and in whom quality of life benefits cannot be achieved without diversion. Experience shows that there are no absolute indications for this procedure. The clinician and the patient must be aware of the importance of continued surveillance after this procedure for problems related to neurogenic voiding dysfunction and/or the ileovesicostomy itself.

Training residents in hypospadias repair: variations of involvement.

PURPOSE: Hypospadias repair is a complex and seminal procedure that has defined the subspecialty of pediatric urology. We sought to determine the degree of training and opinions regarding the need for fellowship training to achieve necessary competence in hypospadias repair. MATERIALS AND METHODS: An electronic survey was sent to 518 urology residents and recent graduates, and to 168 practicing pediatric urologists. Nonresponders were resent the survey 2 additional times. The survey consisted of basic questions on level of training or years in practice. Residents and practicing pediatric urologists were asked about the level of resident participation for each step of the hypospadias procedure, and opinions on the necessity of fellowship training. Data were analyzed for statistical differences with Wilcoxon rank sum and multiple and logistic regression tests. RESULTS: Surveys were completed by 89 pediatric urologists and 208 urology residents or recent graduates (response rate 53% and 40%, respectively). Approximately 70% of residents and attending physicians report that less than 50% of the overall hypospadias procedure is performed by the resident. There appears to be agreement between residents and attending physicians regarding the perceived amount of resident participation for all steps of the procedure except glanular mobilization. Additionally, 71% of residents and 86% of attending physicians believe that a pediatric fellowship is necessary to perform hypospadias surgery. CONCLUSIONS: The majority of residents and attending physicians report limited resident participation in hypospadias surgery. Residents and attending physicians have significant agreement on perceived participation. Our data do not corroborate the program data regarding the role of urology residents in hypospadias repair. The majority of residents and pediatric urologists believe specialized training is required to perform hypospadias surgery.

Sociodemographic disparities in chemotherapy treatment and impact on survival among patients with metastatic bladder cancer.

OBJECTIVE: To evaluate how socioeconomic status and other demographic factors are associated with the receipt of chemotherapy and subsequent survival in patients diagnosed with metastatic bladder cancer. METHODS: Using data from the California Cancer Registry, we identified 3,667 patients diagnosed with metastatic urothelial carcinoma of the urinary bladder between 1988 and 2014. The characteristics of patients who did and did not receive chemotherapy as part of the first course of treatment were compared using chi-square tests. Logistic regression was used to identify predictors of chemotherapy treatment. Fine and Gray competing-risks regression and Cox proportional hazards regression were used to estimate bladder cancer-specific and all-cause mortality, respectively. RESULTS: Less than half (46.3%) of patients received chemotherapy. Patients from the lowest socioeconomic quintile were half as likely to have chemotherapy as those from highest quintile (odds ratio = 0.5, 95% CI: 0.4, 0.7). Unmarried patients were significantly less likely to receive treatment (odds ratio = 0.6, 95% CI: 0.5, 0.7). Not receiving chemotherapy was associated with greater mortality from bladder cancer (subdistribution hazard ratio = 1.4, 95% CI: 1.3, 1.5) and from all causes (hazard ratio = 2.0, 95% CI: 1.8, 2.1). CONCLUSIONS: We found clear disparities in chemotherapy treatment and survival with respect to socioeconomic and marital status. Future studies should explore the possible reasons why patients with low socioeconomic status and who are unmarried are less likely to have chemotherapy.

Immediate intravesical chemotherapy for low-grade bladder tumors in California: An underutilized practice and its impact on recurrence.

OBJECTIVES: To demonstrate patterns of uptake and impact on recurrence of intravesical chemotherapy (IC) immediately following transurethral resection of bladder tumor (TURBT) for low-grade non-muscle-invasive bladder cancer (NMIBC) at a population level. METHODS: Incident cases of low-grade (LG) Ta or T1 NMIBC from 2005 to 2012 were identified from the California Cancer Registry. We determined rates of IC utilization following TURBT. Multivariable logistic regression models were utilized to assess predictors of IC utilization. Multivariable Cox proportional hazards regression was used to assess the association of IC utilization with recurrence-free survival, bladder cancer-specific survival, and overall survival. RESULTS: Ten thousand thirty-one patients with LG NMIBC diagnosed in California between 2005 and 2012. The overall rate of IC utilization was 5.1%, and increased from 1.7% (2005-2006) to 9.6% (2011-2012). More recent year of diagnosis (Odds ratio 1.74, confidence interval 1.60-1.90 for 2-year increments) was associated with an increased likelihood of undergoing immediate postoperative IC. The cumulative incidence of recurrence at 24 months for patients who received IC was 25.2% compared to 30.2% among those who did not receive IC. Use of IC was significantly associated with improved recurrence-free survival (Hazards ratio 0.82, confidence interval 0.70-0.97). CONCLUSION: Utilization of IC for LG NMIBC remains dismally low, with less than 10% of patients receiving this standard of care. Low utilization is associated with increased rates of recurrence. We demonstrate a major shortcoming in quality of care with potential widespread impact on outcomes and cost of care.

The Promise and Disappointment of Neoadjuvant Chemotherapy and Transurethral Resection for Muscle Invasive Bladder Cancer: Updated Results and Long-Term Followup.

INTRODUCTION: Radical cystectomy with neoadjuvant chemotherapy is the standard of care for patients with localized muscle invasive urothelial carcinoma of the bladder. One of the strongest predictors of survival in these patients is pathological response to initial treatment. Our objective was to determine whether we could stratify the need for radical cystectomy based on pathological response to neoadjuvant chemotherapy. METHODS: We present a cohort of patients with muscle invasive urothelial carcinoma of the bladder to whom surveillance and bladder preservation were offered if complete response was achieved following neoadjuvant chemotherapy. Descriptive statistics and survival analysis were performed to assess overall, cancer specific and metastasis-free survival. Patients were stratified based on pathological response to neoadjuvant chemotherapy. RESULTS: A total of 60 patients were included in the cohort, of whom 32 (55%) had absence of residual disease on post-neoadjuvant chemotherapy transurethral resection and 27 (45%) had persistent disease. Of patients undergoing surveillance 52% maintained the bladder without evidence of recurrence. By comparison, of those with recurrence only 20% preserved the bladder and were without evidence of disease. CONCLUSIONS: Long-term followup shows a subset of patients achieving good outcomes while preserving the bladder. However, we also observed an inability to reliably identify this subset of patients given current clinical and pathological markers. Until we are able to achieve that goal, the safest oncologic approach remains neoadjuvant chemotherapy followed by radical cystectomy.