Clinicopathological analysis of recurrence and progression of low-grade papillary urothelial carcinoma of the urinary bladder: Predicting the outcome.

BACKGROUND: Urothelial carcinoma of the urinary bladder is the most common malignancy of the urinary system. Patients with low grade papillary urothelial carcinoma (LGPUC) usually have a low risk for tumor recurrence and progression; yet a subset of patients develop recurrence or grade/stage progression to high-grade papillary urothelial carcinoma (HGPUC). The clinicopathological and molecular factors that contribute to this progression are yet to be determined. OBJECTIVES: In our study, we aimed to assess the incidence and clinicopathological factors associated with tumor recurrence/progression of LGPUC. METHODS: Using a pathological database of surgical specimens from patients who underwent bladder biopsies and/or transurethral resection of bladder tumors (TURBTs) between August 01, 2011, and July 31, 2021, at a large academic medical center, a single-center retrospective cohort analysis was performed, and medical charts of patients were reviewed. RESULTS: Of the total 258 patients included, 157 (60.9 %) had "no recurrence", 85 (32.9 %) had ≥1 "recurrence of LGPUC", and 16 (6.2 %) had "grade progression to HGPUC". The mean follow-up time was 31.5 ± 32 months. Patients with "grade progression" and "recurrence of LGPUC" had larger mean tumor size on initial biopsy and multiple lesions on initial cystoscopy compared to those with "no recurrence." Interestingly, former smokers had 2.5- and 8.5-times higher risk of recurrence of LGPUC and grade progression, respectively. CONCLUSION: Since the majority of our patients did not develop recurrence, we question whether there is tendency to overclassify the papillomas as LGPUC based on the 2004 WHO/ISUP consensus grading classification.

Understanding Prescribing Differences Between Urologists and Medical Oncologists in the Management of Advanced Prostate Cancer.

INTRODUCTION: The availability of oral therapies for advanced prostate cancer allows urologists to continue to care for their patients who develop castration resistance. We compared the prescribing practices of urologists and medical oncologists in treating this patient population. METHODS: The Medicare Part D Prescribers data sets were utilized to identify urologists and medical oncologists who prescribed enzalutamide and/or abiraterone from 2013 to 2019. Each physician was assigned to one of 2 groups: enzalutamide prescriber (physicians that wrote more 30-day prescriptions for enzalutamide than abiraterone) or abiraterone prescriber (opposite). We ran a generalized linear regression to determine factors influencing prescribing preference. RESULTS: In 2019, 4,664 physicians met our inclusion criteria: 23.4% (1,090/4,664) urologists and 76.6% (3,574/4,664) medical oncologists. Urologists were more likely to be enzalutamide prescribers (OR 4.91, CI 4.22-5.74, P < .001) and this held in all regions. Urologists with greater than 60 prescriptions of either drug were not shown to be enzalutamide prescribers (OR 1.18, CI 0.83-1.66, P = .349); 37.9% (5,702/15,062) of abiraterone fills by urologists were for generic compared to 62.5% (57,949/92,741) of abiraterone fills by medical oncologists. CONCLUSIONS: There are dramatic prescribing differences between urologists and medical oncologists. A greater understanding of these differences is a health care imperative.

Variations in Opioid Use Following Robotic Radical Prostatectomy in South Florida.

Introduction: Opioid dependency has been a persistent issue in the United States over the past two decades. Increased efforts have been made to reduce opioid prescribing. Our objective was to quantify at-home opioid requirements following radical prostatectomy. Methods: Written questionnaires were administered to patients 1 week following robot-assisted laparoscopic radical prostatectomy (RALP). Patients provided data on opioid use, pain levels, and demographic characteristics. Results: Sixty-five patients were included. Median age (interquartile range [IQR]) was 69 (62-72) years. The majority were white (85%) and hispanic (67%). Prescriptions ranged from 6 to 15 pills of 5-mg oxycodone equivalents. Twenty-two percent (145/663) of the prescribed pills in the study were consumed. Fifty-four percent (35/65) of patients did not take opioids. Of the 30 patients who took opioids, median use (IQR) was 4.5 (3-6) pills. Forty-six percent (30/65) reported catheter-related pain. Patients who took opioids reported higher levels of pain. On generalized linear regression, younger age, lower levels of education, and living with a family member were factors associated with increased risk for opioid use (all p < 0.05). Conclusions: Despite the Florida Department of Health's restriction on narcotic prescriptions to 3-day supplies, opioids are still overprescribed in our region. The majority of patients do not require opioids after RALP, and patients who do require an opioid analgesic can be adequately managed with less than 6 pills of 5-mg oxycodone equivalents.

The Role of Health Literacy in Prostate Cancer Screening.

OBJECTIVE: To determine if there is an association between self-reported health literacy and rates of prostate cancer screening through PSA testing. METHODS: This secondary data analysis utilized information from the 2016 Behavioral Risk Factor Surveillance System (BRFSS). The primary exposure was self-reported health literacy, and the primary outcome was whether patients underwent prior PSA testing. Males 55-69 years old from 13 states were included in the study and were excluded if they had any missing data. Participants were categorized into low, moderate, or high level of health literacy. Confounders were adjusted for using binary logistic regression. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS: A total of 12,149 participants were included. Five percent of participants reported low health literacy, 54% moderate health literacy, and 41% high health literacy. Compared with study participants who self-reported high levels of health literacy, the odds of undergoing PSA testing were 59% lower in those with low health literacy (OR 0.41; 95% CI 0.28-0.64) and 30% lower in those with moderate health literacy (OR 0.70; 95% CI 0.60-0.83). CONCLUSIONS: Our research demonstrates a positive association between self-reported health literacy and the likelihood of PSA screening. While PSA screening can be controversial, health literacy may serve as a window into which patients are more likely to be proactive in their urologic care. Future studies examining how health literacy effects other urologic conditions is necessary.

Overcoming Drug Resistance in Advanced Prostate Cancer by Drug Repurposing.

Prostate cancer (PCa) is the second most common cancer in men. Common treatments include active surveillance, surgery, or radiation. Androgen deprivation therapy and chemotherapy are usually reserved for advanced disease or biochemical recurrence, such as castration-resistant prostate cancer (CRPC), but they are not considered curative because PCa cells eventually develop drug resistance. The latter is achieved through various cellular mechanisms that ultimately circumvent the pharmaceutical's mode of action. The need for novel therapeutic approaches is necessary under these circumstances. An alternative way to treat PCa is by repurposing of existing drugs that were initially intended for other conditions. By extrapolating the effects of previously approved drugs to the intracellular processes of PCa, treatment options will expand. In addition, drug repurposing is cost-effective and efficient because it utilizes drugs that have already demonstrated safety and efficacy. This review catalogues the drugs that can be repurposed for PCa in preclinical studies as well as clinical trials.

Trends in Positioning for Robotic Prostatectomy: Results From a Survey of the Endourological Society.

PURPOSE: most robot-assisted laparoscopic prostatectomies (RALP) are performed with the patient in lithotomy, carrying risks of positioning-related complications. Newer robot models have allowed for supine positioning, potentially avoiding these pitfalls. We gauged the current sentiment on patient positioning among surgeons who perform robot-assisted surgery. METHODS: we surveyed members of the Endourological Society regarding their practice settings and their opinions on positioning for robot-assisted laparoscopic prostatectomy. Summary statistics were reviewed and data were analyzed using chi-square tests and t-tests. RESULTS: our survey had 92 eligible respondents. The majority were fellowship-trained, with 51% trained in robotics and 57% practicing in the U.S. with a mean of 13 years of practice. Most were working in an academic setting (69%) and performing at least 25 robotic prostatectomies yearly. 28 respondents used the Intuitive Surgical Inc. da Vinci® Xi™ exclusively (30%), and nearly two-thirds used it sometimes. Although 54% of respondents considered using supine positioning, less than half of these surgeons used it regularly, while 75% overall preferred lithotomy. A majority attributed this choice to surgical team familiarity with lithotomy positioning. Surgeons in the U.S. and those using the da Vinci® Xi™ were more likely to consider supine positioning. CONCLUSIONS: lithotomy position is the standard for RALP procedures; nonetheless, it poses significant risks that might be avoided with supine positioning. Our survey suggests that, although supine positioning has been considered, it has not gained momentum in practice. Addressing factors of inertia in training practices and one's surgical team might allow for novel and safer approaches.

The Association Between Race and 5-year Survival in Patients With Clear Cell Renal Cell Carcinoma: A Cohort Study.

OBJECTIVE: To determine if race was associated with 5-year cause-specific survival in patients with clear cell renal cell carcinoma. MATERIALS AND METHODS: Outcomes were investigated using the Surveillance Epidemiology and End Results database with data from 13 states between the years 2007-2015. Covariates included age, sex, insurance, marital status, and tumor stage at diagnosis. Patients <18 years old or with missing data for race, survival time or insurance status were excluded. Cox regression models were used to determine associations through hazard ratios (HR) with 95% confidence intervals (CI) and to adjust for covariates. RESULTS: A total of 8421 subjects were included in the analysis. After adjustment, there was no association between race and 5-year cause-specific survival in patients with ccRCC (Black- HR: 0.96, 95%CI: 0.83,1.12; American Indian/Alaskan- HR: 1.01, 95%CI: 0.75,1.36; Asian Pacific Islander- HR: 0.99, 95%CI: 0.82,1.12). Older individuals and those with regional or distant tumors showed an increased hazard of death, while females and insured patients showed decreased hazard. CONCLUSION: Our study found that race was not associated with 5-year cause-specific survival from clear cell renal cell carcinoma. However inferior overall survival in Blacks with RCC has been well demonstrated in the literature. Our findings suggest that differences in survival may not be driven by cause-specific factors such as renal cell carcinoma, but rather social determinants of health which disproportionality affect Black patients. Further studies with more power that incorporate information on income, comorbidities, education status, and access to care are therefore necessary.

A Comparison Between AMS 700 and Coloplast Titan: A Systematic Literature Review.

There are only two three-piece inflatable penile prostheses (IPP) available to patients in the American market: the AMS (American Medical Systems) 700TM series (Boston Scientific, Massachusetts) and the Coloplast Titan® series (Coloplast, Minnesota), and data comparing the two are scant. The aim of our study was to summarize the current scientific evidence comparing the two. A systematic literature review was conducted on PubMed. A 10-year filter was placed to include only studies published after Coloplast launched the Titan Touch® release pump. Eligibility criteria included articles discussing specifically the AMS 700TM and Coloplast Titan® models. Further searches for studies on patient/partner satisfaction were conducted. Abstracts were reviewed to include studies focusing specifically on the models we are studying and studies on patient satisfaction using the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire. The Coloplast device demonstrated slightly greater resistance to the stimulated forces of penetration and gravity. Coloplast implants coated with vancomycin/gentamicin had the highest infection rate followed by the AMS penile prosthesis and the rifampin/gentamicin coating had the lowest infection rate. Prosthesis durability and survival were similar between both brands. Overall satisfaction was high but comparisons are inconsistent. The literature is inconclusive about which device is superior. We suggest randomized, multicenter, prospective studies to help further elucidate the highlights of each product.

Bladder cancer clusters in Florida: identifying populations at risk.

PURPOSE: Modifiable risk factors for bladder cancer have been identified, ie tobacco and chemical exposure. We identified high risk bladder cancer areas and risk factors associated with bladder cancer clusters in Florida using individual and area based data. MATERIALS AND METHODS: Spatial modeling was applied to 23,266 early and advanced bladder cancer cases diagnosed between 1998 and 2002 in Florida to identify areas of excess bladder cancer risk. Multivariable regression was used to determine whether sociodemographic indicators, smoking history and proximity to known arsenic contaminated drinking water well sites were associated with bladder cancer diagnosis in a specific area (cluster). RESULTS: A total of 25 clusters were found to have a higher than expected bladder cancer rate, including 13 and 12 of early and late stage disease, respectively. Urban white patients were more likely to live in an advanced bladder cancer cluster. Advanced bladder cancer cluster membership was associated with living in close proximity to known arsenic contaminated drinking water wells. CONCLUSIONS: There are multiple areas of early and late stage bladder cancer clusters in Florida. Individuals in an advanced bladder cancer cluster tended to live close to arsenic contaminated wells. Increased evaluation of potentially contaminated well water is warranted in these high risk areas. Targeted bladder cancer public awareness campaigns, smoking cessation support and potentially targeted screening should also be considered in communities at increased risk for bladder cancer. Our analytical approach can also be used by others to systematically identify communities at high risk for bladder and other cancers.

Barriers to Neoadjuvant Chemotherapy before Radical Cystectomy at a Single Referral Center in South Florida.

INTRODUCTION: We investigated barriers to the receipt of neoadjuvant chemotherapy by patients undergoing radical cystectomy. METHODS: After institutional review board approval we performed a retrospective chart review from January 1, 2012 to March 1, 2018 of cases of radical cystectomy with urinary diversion for bladder cancer. Patients were placed in 1 of 3 groups according to eligibility to receive neoadjuvant chemotherapy before undergoing cystectomy, as "NAC" if they received neoadjuvant chemotherapy, "No NAC - Declined" if they were eligible but declined neoadjuvant chemotherapy and "No NAC - Ineligible" if they were clinically ineligible to receive neoadjuvant chemotherapy. We performed univariate and multivariate analyses on social and pathological factors in these 3 categories. RESULTS: Of 268 patients identified 209 were eligible to be included in this study. On univariate analysis statistical differences were noted according to age and distance from treatment center. On pathological analysis stage was statistically different between the cohorts. A multivariate analysis revealed that single patients were more likely to decline neoadjuvant chemotherapy as opposed to married patients. CONCLUSIONS: Neoadjuvant chemotherapy before radical cystectomy for muscle invasive bladder cancer continues to be an underused treatment modality in South Florida. Age, marital status and distance from treatment center all appear to have an impact on patient acceptance of or referring doctor recommendations for neoadjuvant chemotherapy. We suggest larger multi-institutional studies to further assess this issue.

Does Health Insurance Modify the Association Between Race and Cancer-Specific Survival in Patients with Urinary Bladder Malignancy in the U.S.?

Background: Scientific evidence on the effect of health insurance on racial disparities in urinary bladder cancer patients' survival is scant. The objective of our study was to determine whether insurance status modifies the association between race and bladder cancer specific survival during 2007-2015. Methods: The 2015 database of the cancer surveillance program of the National Cancer Institute (n = 39,587) was used. The independent variable was race (White, Black and Asian Pacific Islanders (API)), the main outcome was cancer specific survival. Health insurance was divided into uninsured, any Medicaid and insured. An adjusted model with an interaction term for race and insurance status was computed. Unadjusted and adjusted Cox regression analysis were applied. Results: Health insurance was a statistically significant effect modifier of the association between race and survival. Whereas, API had a lower hazard of death among the patients with Medicaid insurance (HR 0.67; 95% CI 0.48-0.94 compared with White patients, no differences in survival was found between Black and White urinary bladder carcinoma patients (HR 1.24; 95% CI 0.95-1.61). This may be due a lack of power. Among the insured study participants, Blacks were 1.46 times more likely than Whites to die of bladder cancer during the 5-year follow-up (95% CI 1.30-1.64). Conclusions: While race is accepted as a poor prognostic factor in the mortality from bladder cancer, insurance status can help to explain some of the survival differences across races.

Insurance status as a modifier of the association between race and stage of prostate cancer diagnosis in Florida during 1995 and 2013.

BACKGROUND: Cancer stage at diagnosis is a critical prognostic factor regarding a patient's health outcomes. It has yet to be shown whether insurance status across different race has any implications on the stage of disease at the time of diagnosis. This study aimed to investigate whether insurance status was a modifier of the association between race and stage of previously undetected prostate cancer at the time of diagnosis in Florida between 1995 and 2013. METHODS: Secondary data analysis of a cross-sectional survey using information from the Florida Cancer Data System (n = 224,819). Study participants included black and white males diagnosed with prostate cancer in Florida between 1995 and 2013. The main outcome variable was stage of prostate cancer at diagnosis. The main independent variable was race (black vs white). Adjusted logistic regression models were used to explore the association between race, insurance status and stage at diagnosis. Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated. RESULTS: Black males were more likely to be diagnosed with late stage prostate cancer (OR 1.31; 95% CI 1.27-1.35). Being uninsured (OR 2.28; 95% CI 2.13-2.45) or having Medicaid (OR 1.84; 95% CI 1.70-1.98) was associated with a diagnosis of late stage cancer. Stratified analysis for health insurance revealed that blacks had an increased risk for late stage cancer if uninsured (OR 1.29; 95% CI 1.07-1.55) and if having Medicare (OR 1.39; 95% CI 1.31-1.48). CONCLUSION: Insurance status may modify the effect of race on late stage prostate cancer in black patients.

Radiation therapy for prostate cancer increases subsequent risk of bladder and rectal cancer: a population based cohort study.

PURPOSE: Pre-prostate specific antigen era series demonstrated an increased risk of bladder cancer and rectal cancer in men who received radiotherapy for prostate cancer. We estimated the risk of secondary bladder cancer and rectal cancer after prostate radiotherapy using a contemporary population based cohort. MATERIALS AND METHODS: We identified 243,082 men in the Surveillance, Epidemiology and End Results database who underwent radical prostatectomy or radiotherapy for prostate cancer between 1988 and 2003. We estimated the incidence rate, standardized incidence ratio and age adjusted incidence rate ratio of subsequent bladder cancer and rectal cancer associated with radical prostatectomy, external beam radiotherapy, brachytherapy, and a combination of external beam radiotherapy and brachytherapy. RESULTS: The relative risk of bladder cancer developing after external beam radiotherapy, brachytherapy and external beam radiotherapy-brachytherapy compared to radical prostatectomy was 1.88, 1.52 and 1.85, respectively. Compared to the general United States population the standardized incidence ratio for bladder cancer developing after radical prostatectomy, external beam radiotherapy, brachytherapy and external beam radiotherapy-brachytherapy was 0.99, 1.42, 1.10 and 1.39, respectively. The relative risk of rectal cancer developing after external beam radiotherapy, brachytherapy and external beam radiotherapy-brachytherapy compared to radical prostatectomy was 1.26, 1.08 and 1.21, respectively. The standardized incidence ratio for rectal cancer developing after radical prostatectomy, external beam radiotherapy, brachytherapy and external beam radiotherapy-brachytherapy was 0.91, 0.99, 0.68 and 0.86, respectively. CONCLUSIONS: Men who receive radiotherapy for localized prostate cancer have an increased risk of bladder cancer compared to patients undergoing radical prostatectomy and compared to the general population. The risk of rectal cancer is increased in patients who receive external beam radiotherapy compared to radical prostatectomy. Patients should be counseled appropriately regarding these risks.

Florida bladder cancer trends 1981 to 2004: minimal progress in decreasing advanced disease.

PURPOSE: There are no accepted screening recommendations for bladder cancer, although the greatest risk factors for bladder cancer are identifiable and modifiable, ie tobacco exposure. Bladder cancer survival correlates highly with disease stage. We ascertained whether there have been any demographic changes in the stage at presentation and mortality of bladder cancer in Florida during the last 25 years. MATERIALS AND METHODS: Data from Florida Cancer Data Registry were evaluated on all bladder cancer cases between 1981 and 2004. Cases were coded and analyzed as local, in situ or advanced (regional and distant) disease. Cases were stratified by demographic groups. RESULTS: The overall incidence of bladder cancer decreased slightly in the last 25 years from 24.3 to 20.5 cases per 100,000 population. Overall white and Hispanic males had an almost 3 and 2-fold incidence of bladder cancer, respectively, compared to that in black males. White females had an almost 2-fold increased incidence compared to black and Hispanic females. Advanced stage bladder cancer decreased minimally in the 25 years. White and black females had the smallest decrease in the annual percent change of advanced bladder cancer. There was only a minimal decrease in bladder cancer mortality rates in black and white but not Hispanic individuals. CONCLUSIONS: Despite knowledge of the main risk factors for bladder cancer there were only small decreases in the percent of patients presenting with advanced disease in Florida in the last 25 years. Thus, bladder cancer may be an appropriate cancer for increased public awareness campaigns and potentially targeted screening of high risk populations.

Factors affecting erectile function after radical retropubic prostatectomy: results from 1620 consecutive patients.

OBJECTIVE: To report the return of erectile function in 1620 consecutive men after radical retropubic prostatectomy (RRP), chosen by half of men diagnosed with clinically localized prostate cancer, and the goal of which is to completely excise the tumour while preserving continence and erectile function. PATIENTS AND METHODS: From January 1992 to October 2006, one surgeon performed RRP with a nerve-sparing technique where feasible. Men with erectile dysfunction before surgery, salvage RRPs, those not having a nerve-sparing procedure, neoadjuvant or adjuvant therapy within 6 months of RRP and a follow-up of <6 months were excluded from the analyses. Erectile function was evaluated by the surgeon when possible or by an annual questionnaire. Potency was defined as erectile function sufficient for intercourse with or without a phosphodiesterase-5 inhibitor. RESULTS: Of 619 men who had a bilateral and of 178 who had a unilateral nerve-sparing RRP, 72% and 53%, respectively, were potent. When stratifying by age groups (or=70 years) potency rates were 86%, 76%, 58% and 37%, respectively. Potency was more common after bilateral than unilateral nerve-sparing RRP in all age groups (P < 0.001). Age, bilateral nerve-sparing (odds ratio 2.9) and surgeon experience were associated with potency in a multivariate analysis. CONCLUSION: Careful patient selection and meticulous surgical technique are essential to achieve the right balance between cancer control and morbidity. The patient's age, nerve-sparing RRP and the surgeon's experience were the significant predictors of return of potency after RRP.

Alexis Wound Retractor for Radical Cystectomy: A Safe and Effective Method for Retraction.

Surgical site infection rates remain a common postoperative problem that continues to affect patients undergoing urologic surgery. Our study seeks to evaluate the difference in surgical site infection rates in patients undergoing open radical cystectomy when comparing the Bookwalter vs. the Alexis wound retractors. After institutional review board approval, we performed a retrospective chart review from February 2010 through August 2017 of patients undergoing open radical cystectomy with urinary diversion for bladder cancer. We then stratified the groups according to whether or not the surgery was performed with the Alexis or standard Bookwalter retractor. Baseline characteristics and operative outcomes were then compared between the two groups, with the main measure being incidence of surgical site infection as defined by the CDC. We evaluated those presenting with surgical site infections within or greater than 30 postoperatively. Of 237 patients who underwent radical cystectomy with either the Alexis or Bookwalter retractor, 168 patients were eligible to be included in our analysis. There was no statistical difference noted regarding surgical site infections (SSIs) between the two groups; however, the trend was in favor of the Alexis (3%) vs. the Bookwalter (11%) at less than 30 days surgery. The Alexis wound retractor likely poses an advantage in reducing the incidence in surgical site infections in patients undergoing radical cystectomy; however, multicenter studies with larger sample sizes are suggested for further elucidation.

The role of the surgeon and transurethral resection in the treatment of superficial bladder cancer.

Non-muscle invasive bladder cancers are a heterogeneous group of cancers whose spectrum includes low grade Ta lesions and high-grade T1 lesions. Accurate staging and grading during initial evaluation and TUR ensures appropriate treatment and prevents the risk of understaging. TUR should be ideally performed under spinal anesthesia, with a continuous flow video resectoscope to maintain a stable bladder capacity, and a video monitor. The entire bladder must be visualized, with both 30- and 70-degree lenses, and all abnormal areas must be resected, with separate biopsies from each tumor's base. Repeat TUR is recommended for all high grade tumors and T1 tumors, especially if muscle was not present in the initial specimen. Immediate instillation of single dose chemotherapy agents following TUR is highly recommended to reduce the risk of tumor recurrences.