Safety and feasibility of urological procedures in Jehovah's Witness patients.

OBJECTIVES: To describe the safety and feasibility of urological transfusion-free surgeries in Jehovah's Witness patients. METHODS: An institutional review board-approved, retrospective review of Jehovah's Witness patients who underwent urological transfusion-free surgeries between 2003 and 2019 was carried out. Surgeries were stratified into low, intermediate and high risk based on complexity, invasiveness and bleeding potential. Patient demographics, perioperative data and clinical outcomes are reported. RESULTS: A total of 161 Jehovah's Witness patients (median age 63.4 years) underwent 171 transfusion-free surgeries, including 57 (33.3%) in low-, 82 (47.9%) in intermediate- and 32 (18.8%) in high-risk categories. The mean estimated blood loss increased with risk category at 48 mL (range 10-50 mL), 150 mL (range 50-200 mL) and 388 mL (range 137-500 mL), respectively (P < 0.001). Implementing blood augmentation and conservation techniques increased with each risk category (3.5% vs 29% vs 69%, respectively; P < 0.001). Average length of stay increased concordantly at 1.6 days (range 0-12 days), 2.9 days (range 1-13 days) and 5.6 days (range 2-12 days), respectively (P ≤ 0.001). However, there was no increase in complication rates and readmission rates attributed to bleeding among the risk categories at 30 days (P = 0.9 and 0.4, respectively) and 90 days (P = 0.7 and 0.7, respectively). CONCLUSIONS: Transfusion free urological surgery can be safely carried out on Jehovah's Witness patients using contemporary perioperative optimization. Additionally, these techniques can be expanded for use in the general patient population to avoid short- and long-term consequences of perioperative blood transfusion.

Validating the role of ABO blood type in risk of perioperative venous thromboembolism after radical cystectomy.

PURPOSE: To validate the relationship between ABO blood type and risk of VTE post-RC in a large retrospective database. METHODS: Patients with urothelial bladder cancer (UBC) who underwent RC (intent-to-cure) for whom ABO blood type was available between 2003 and 2015 were identified from our IRB-approved database. VTE was defined as deep vein thrombosis (DVT) or pulmonary embolism (PE) within 90 days of surgery. VTE prophylaxis consisted of immediate postoperative Coumadin (2003-2009), unfractionated heparin (UFH) during hospitalization (2009-2015), and UFH during hospitalization plus 4 weeks of enoxaparin after discharge (2013-2015). Univariable and multivariable analyses of the association of ABO blood type with postoperative, symptomatic VTE and oncologic outcomes were performed. RESULTS: Of 1341 patients, 595 (44.4%) were ABO type O and 746 (55.6%) were non-O (A, B and AB). 90 patients were diagnosed with VTE within 90 days of surgery (6.7%) (43% DVT-only, 57% PE ± DVT). On multivariable analysis non-O blood type was associated with a nearly twofold increased risk of VTE (OR = 1.94, 95% CI 1.215-3.098, p = 0.004). No difference in recurrence-free survival or overall survival was seen between ABO groups. CONCLUSION: Non-O blood type is an independent, non-modifiable risk factor for postoperative VTE after RC. More comprehensive counseling and thromboprophylaxis should be considered in this high-risk group.

The association between intraoperative fluid intake and postoperative complications in patients undergoing radical cystectomy with an enhanced recovery protocol.

PURPOSE: To evaluate the association between intraoperative fluid intake and postoperative complications in patients who underwent radical cystectomy (RC) for bladder cancer with an enhanced recovery protocol. METHODS: 287 patients underwent open RC with enhanced recovery protocol (ERAS) from 2012 to 2016. 107 were excluded; non-urothelial (30), palliative (37), had adjunct procedures or not-consented (40). We prospectively evaluated intraoperative fluid intake (crystalloid, colloid and blood) and correlated with length of stay, 30- and 90-day complications. RESULTS: 180 patients enrolled into the study with median age of 70 years (78% male). 71% underwent orthotopic diversion. Median intraoperative crystalloid and colloid intake were 4000 and 500 cc, respectively. Nineteen percent of patients received blood transfusion. Median length of stay was 4 days. The overall 30- and 90-day complication rates were 59 and 75%, respectively. Multivariate logistic regressions controlling for a subset of clinically relevant variables showed no significant association between intraoperative fluid intake and complications at 30 or 90 days (p = 0.88 and 0.62, respectively). A multivariable linear regression similarly showed no association between total intraoperative fluid intake and length of stay (p = 0.099). CONCLUSION: Higher intraoperative fluid intake was not found to independently increase the complication rate following radical cystectomy. Larger studies and prospective trials are needed to determine if fluid optimization may play a role in decreasing morbidity after this major surgery.

Urinary tract infections following radical cystectomy and urinary diversion: a review of 1133 patients.

OBJECTIVE: To investigate the incidence and microbiology of urinary tract infection (UTI) within 90 days following radical cystectomy (RC) and urinary diversion. METHODS: We reviewed 1133 patients who underwent RC for bladder cancer at our institution between 2003 and 2013; 815 patients (72%) underwent orthotopic diversion, 274 (24%) ileal conduit, and 44 (4%) continent cutaneous diversion. 90-day postoperative UTI incidence, culture results, antibiotic sensitivity/resistance and treatment were recorded through retrospective review. Fisher's exact test, Kruskal-Wallis test, and multivariable analysis were performed. RESULTS: A total of 151 urinary tract infections were recorded in 123 patients (11%) during the first 90 days postoperatively. 21/123 (17%) had multiple infections and 25 (20%) had urosepsis in this time span. Gram-negative rods were the most common etiology (54% of positive cultures). 52% of UTI episodes led to readmission. There was no significant difference in UTI rate, etiologic microbiology (Gram-negative rods, Gram-positive cocci, fungi), or antibiotic sensitivity and resistance patterns between diversion groups. Resistance to quinolones was evident in 87.5% of Gram-positive and 35% of Gram-negative bacteria. In multivariable analysis, Charlson Comorbidity Index > 2 was associated with higher 90-day UTI rate (OR = 1.8, 95% CI 1.1-2.9, p = 0.05) and Candida UTI (OR 5.6, 95% CI 1.6-26.5, p = 0.04). CONCLUSIONS: UTI is a common complication and cause of readmission following radical cystectomy and urinary diversion. These infections are commonly caused by Gram-negative rods. High comorbidity index is an independent risk factor for postoperative UTI, but diversion type is not.

90-Day complication rate in patients undergoing radical cystectomy with enhanced recovery protocol: a prospective cohort study.

PURPOSE: To report 90-day complication rates following radical cystectomy (RC) with enhanced recovery after surgery (ERAS) protocol. METHODS: All consecutive patients who underwent open RC with ERAS protocol from 2012 to 2014 were included. The protocol includes no bowel preparation or NGT, early feeding, predominantly non-narcotic pain management and µ-opioid antagonists. Non-consenting and lost to follow-up patients were excluded. All patients were closely followed up, and 90-day complication (Clavien-Dindo grading), readmission and emergency room (ER) visits were prospectively recorded. RESULTS: One hundred and sixty-nine cases with a median age of 71 years were included in the study. 90-Day major and minor complication rates were 24.3 and 53.9 %, respectively. The most common complications were infectious and gastrointestinal. The 90-day ER visit rate was 37.9 %, whereas the readmission rate was 29.6 %. The most common cause of hospital readmission and ER visits was infections. CONCLUSION: Radical cystectomy and urinary diversion with enhanced recovery protocol is a morbid surgery. The most common complication, cause of ER visit and readmission is yet infections. Further studies on methods to decrease these rates are underway.

Prospective Evaluation of Continence Following Radical Cystectomy and Orthotopic Urinary Diversion Using a Validated Questionnaire.

PURPOSE: We evaluated continence outcomes in male patients undergoing orthotopic neobladder diversion after radical cystectomy using a validated questionnaire. MATERIALS AND METHODS: Using our institutional review board approved bladder cancer database we identified 1,269 patients who underwent open radical cystectomy from 2002 to 2015. Orthotopic neobladder was constructed in 935 (74%) patients, of whom 798 (85%) were male. Beginning in 2012 the patients completed a validated pictorial pad use questionnaire at each followup visit. The questionnaire assessed pad number, size and wetness as well as catheter use. Continence was defined as use of no pads or pads that are almost dry. Questionnaires were stratified into distinct postoperative intervals for analysis. Female patients, or patients with artificial urinary sphincters or prior radiotherapy were excluded from the study. RESULTS: A total of 188 male patients with available questionnaires were followed from September 2012 to August 2015. Overall 447 questionnaires were collected, with 351 interval distinct questionnaires separated into intervals of less than 3, 3 to 6, more than 6 to 12, more than 12 to 18, more than 18 to 36 and more than 36 months after surgery (64, 61, 58, 49, 61 and 58 questionnaires, respectively). Daytime continence increased from 59% at less than 3 months postoperatively to 92% by more than 12 to 18 months. Nighttime continence increased from 28% at less than 3 months postoperatively to 51% by more than 18 to 36 months. Nearly 50% of patients reported daytime and nighttime continence by 18 to 36 months. CONCLUSIONS: After orthotopic neobladder diversion in male patients, continence improves significantly by 6 months and subsequently plateaus with 92% daytime continence by more than 12 to 18 months. Orthotopic neobladder represents an excellent functional option for urinary diversion.

Personalized 3D printed model of kidney and tumor anatomy: a useful tool for patient education.

PURPOSE: To assess the impact of 3D printed models of renal tumor on patient's understanding of their conditions. Patient understanding of their medical condition and treatment satisfaction has gained increasing attention in medicine. Novel technologies such as additive manufacturing [also termed three-dimensional (3D) printing] may play a role in patient education. METHODS: A prospective pilot study was conducted, and seven patients with a primary diagnosis of kidney tumor who were being considered for partial nephrectomy were included after informed consent. All patients underwent four-phase multi-detector computerized tomography (MDCT) scanning from which renal volume data were extracted to create life-size patient-specific 3D printed models. Patient knowledge and understanding were evaluated before and after 3D model presentation. Patients' satisfaction with their specific 3D printed model was also assessed through a visual scale. RESULTS: After viewing their personal 3D kidney model, patients demonstrated an improvement in understanding of basic kidney physiology by 16.7 % (p = 0.018), kidney anatomy by 50 % (p = 0.026), tumor characteristics by 39.3 % (p = 0.068) and the planned surgical procedure by 44.6 % (p = 0.026). CONCLUSION: Presented herein is the initial clinical experience with 3D printing to facilitate patient's pre-surgical understanding of their kidney tumor and surgery.

Postoperative Pain Management after Radical Cystectomy: Comparing Traditional versus Enhanced Recovery Protocol Pathway.

PURPOSE: Opioids have traditionally been the mainstay of pain management after radical cystectomy for bladder cancer but they have many side effects. The efficacy of opioid sparing analgesics after cystectomy as part of a protocol of enhanced recovery after surgery has yet to be proved. We compared opioid use, pain score and postoperative ileus in consecutive patients on a protocol of enhanced recovery after surgery and those on a traditional protocol after radical cystectomy. MATERIALS AND METHODS: Using our institutional review board approved bladder cancer database we retrospectively reviewed the records of patients who underwent open radical cystectomy using a traditional protocol or a protocol of enhanced recovery after surgery for pain management. A total of 205 patients were ultimately enrolled in study, including 81 on a traditional protocol and 124 on the enhanced protocol. Opioid use and pain scores were analyzed and compared up to postoperative day 4. All routes of opioid use were recorded and converted to the morphine equivalent dose for comparison. Postoperative pain was recorded using a visual analog scale. Postoperative records were reviewed for the incidence of ileus. RESULTS: Patients on the enhanced recovery after surgery protocol and those on a traditional protocol were similar demographically. When analyzing data up to the median hospital stay on the case group, patients on enhanced recovery used significantly less opioids per day (4.9 mg vs 20.67 mg morphine equivalents, p <0.001) and reported more pain (visual analog scale 3.1 vs 1.14, p <0.001). They also experienced a significantly lesser incidence of postoperative ileus (7.3% vs 22.2%, p = 0.003) and had a significantly shorter median length of hospital stay (4 vs 8 days, p <0.001). CONCLUSIONS: Patients on the protocol of enhanced recovery after surgery used significantly less opioid analgesics, possibly contributing to decreased postoperative ileus and shorter length of hospital stay.

Imaging in benign prostatic hyperplasia: what is new?

PURPOSE OF REVIEW: This article discusses the new imaging techniques in diagnosis and treatment of benign prostatic hyperplasia by reviewing the most recent publications. RECENT FINDINGS: Imaging study for the evaluation of patients with lower urinary tract symptoms is not suggested by American Urology Association guidelines; however, European Association of Urology recommends the assessment of the upper urinary tract by modalities like ultrasound. Several new imaging indices like resistive index of capsular artery, presumed circle area ratio, prostatic urethral angle, intraprostatic protrusion, and detrusor wall thickness are used to find a noninvasive way for bladder outlet obstruction diagnosis. In addition to them, 3D transrectal ultrasound, near infrared spectroscopy, and MRI are used to add more practical findings in patient management. SUMMARY: Urologists have requested more imaging studies than expected for benign prostatic hyperplasia patients in recent years, and several studies have been done to find a noninvasive way to diagnose bladder outlet obstruction. However, none of them could play the urodynamic studies role in bladder outlet obstruction diagnosis.

Perioperative outcomes of goal-directed versus conventional fluid therapy in radical cystectomy with enhanced recovery protocol.

PURPOSE: The aim of this study is to evaluate the intra/perioperative fluid management and early postoperative outcomes of patients who underwent radical cystectomy with Enhanced Recovery After Surgery protocol, using goal-directed fluid therapy compared to conventional fluid therapy. METHODS: This cohort study included patients who underwent open RC for urothelial bladder carcinoma with intent to cure and Enhanced Recovery After Surgery protocol between May 2012 and August 2019. Patients who had palliative or salvage cystectomy and/or adjunct procedures, as well as those with missing detailed perioperative data were excluded. Data were compared between patients who received goal-directed fluid therapy using stroke volume variation by FloTrac™/Vigileo system (n = 119) and conventional fluid therapy based on the anesthesiologist discretion (n = 192). Primary outcome variable was 90-day complications and secondary outcome measures included in-hospital GFR trend, length of stay, and 90-day readmission. RESULTS: The goal-directed fluid therapy group received less total and net intra/perioperative fluid, yet early postoperative glomerular filtration rate trends were similar between both groups (p = 0.7). Estimated blood loss, blood transfusion, index hospital stay, 90-day complication and readmission rates were also comparable between the two groups. Multivariable logistic regression showed no significant association between perioperative fluid management method and 90-day complication rate (OR 1.4, 95% CI 0.8-2.4, p = 0.2). CONCLUSION: Stroke volume variation guided goal-directed fluid therapy is safe in radical cystectomy without compromising the renal function. It is associated with less intra- and perioperative fluid infusion; however, no association with hospital stay, 90-day complication or readmission rates were noted.

Frailty as a predictor of complications after radical cystectomy: A prospective study of various preoperative assessments.

PURPOSE: Frailty has been correlated with worse postoperative outcomes. Prospective studies examining frailty and bladder cancer are lacking. We aimed to determine whether a prospective frailty assessment or traditional risk indices can identify patients undergoing radical cystectomy (RC) at risk for complications. MATERIALS AND METHODS: Patients ≥65 years undergoing RC were preoperatively assessed using Fried Frailty Criteria (FFC; grip strength, gait speed, exhaustion, physical activity, shrinking), Charlson Comorbidity Index, American Society of Anesthesiologists score, Katz Index of Independence in Activities of Daily Living, Karnofsky Performance Scale, Eastern Cooperative Oncology Group performance status, and Center for Epidemiological Studies Depression scale. Thirty-day and 90-day postoperative complications were recorded. Univariate and multivariate analyses were performed. RESULTS: One hundred and twenty three patients were assessed with median age of 74 years. Fifty-nine patients (48.0%) had ≥1 complication within 30 days and 72 (58.5%) within 90 days. Center for Epidemiological Studies Depression scale (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.01-1.17, P = 0.027) and shrinking (OR 3.79, 95% CI 1.64-9.26, P = 0.0024) were significant for any 30-day complication, while physical activity was protective (OR 0.84, 95% CI 0.69-1.00, P = 0.072) for any 90-day complication. Being intermediately frail or frail was associated with high-grade 30-day (OR 4.87, 95% CI 1.39-22.77, P = 0.022) and 90-day complications (OR 3.01, 95% CI 1.05-9.37, P = 0.045), along with Eastern Cooperative Oncology Group score ≥3 (OR 45.00, 95% CI 6.92-437.69, P = 0.0010 and OR 17.85, 95% CI 3.21-143.26, P = 0.0079, respectively). CONCLUSIONS: Fried Frailty Criteria were predictive of high-grade complications, while individual components were predictive of having any complication. Elderly patients should be routinely assessed prior to RC to guide postoperative care.

Association between precystectomy epithelial tumor marker response to neoadjuvant chemotherapy and oncological outcomes in urothelial bladder cancer.

INTRODUCTION AND OBJECTIVES: We previously reported that elevated precystectomy serum levels of epithelial tumor markers predict worse oncological outcome in patients with invasive bladder cancer (BC). Herein, we evaluated the effect of neoadjuvant chemotherapy (NAC) on elevated tumor marker levels and their association with oncological outcomes. METHODS: Under IRB approval, serum levels of Carbohydrate Antigen 125 (CA-125), Carbohydrate Antigen 19-9 (CA 19-9) and Carcinoembryonic Antigen (CEA) were prospectively measured in 480 patients with invasive BC from August 2011 through December 2016. In the subgroup undergoing NAC, markers were measured prior to the first and after the last cycle of chemotherapy (prior to cystectomy). RESULTS: Three hundred and thirty-seven patients were eligible for the study, with a median age was 71 years (range 34-93) and 81% (272) male. Elevated precystectomy level of any tumor markers (31% of patients) was independently associated with worse recurrence-free survival (hazard ratio [HR] = 2.81; P < 0.001) and overall survival (HR = 3.97; P < 0.001). One hundred and twenty-five (37%) patients underwent NAC, of whom 59 had a complete tumor marker profile and 30 (51%) had an elevated pre-NAC tumor marker. Following completion of chemotherapy, 10/30 (33%) patients normalized their tumor markers, while 20/30 (67%) had one or more persistently elevated markers. There was no difference in clinical or pathological stage between groups (P = 0.54 and P = 0.09, respectively). Further analysis showed a significantly lower rate and longer median time to recurrence/progression in the responder group (50% in responders vs. 90% in nonresponders at a median time of 22 vs. 4.8 months, respectively; P = 0.015). There was also significant difference in mortality rates and median overall survival between the study groups (30% in responders vs. 70% in nonresponders at a median time of 27.3 vs. 11.6 months respectively; P = 0.037). Two of the three patients that died in the normalized tumor marker group had tumor marker relapse at recurrence prior to their death. CONCLUSIONS: To our knowledge, this is the first study showing tumor marker response to NAC. Patients with persistently elevated markers following NAC have a very poor prognosis following cystectomy, which may help identifying chemotherapy-resistant tumors. A larger, controlled study with longer follow up is needed to determine their role in predicting survival.

Long term oncologic outcome in patients with bladder cancer after radical cystectomy: Impact of carcinoma in situ in the era of neoadjuvant chemotherapy.

PURPOSE: To assess the impact of carcinoma in situ (CIS) on oncologic outcomes in patients who underwent radical cystectomy, with a focus on those who received neoadjuvant chemotherapy (NAC) including patients with down-staging to ≤ pT1cancer after chemotherapy. MATERIALS AND METHODS: All patients who underwent radical cystectomy for urothelial cancer with curative intent from 1985 to 2011 were included. The impact of CIS on recurrence free and overall survival (OS) was assessed in the whole cohort and a subgroup who received NAC as well as those with response to chemotherapy and down-staging to ≤ pT1. RESULTS: A total of 2518 patients with a median follow-up period of 9 years were included. Among all, 1397 (55.5%) had concomitant CIS on final pathology. CIS was associated with high risk pathologic features including high-grade disease, multifocality, and nodal involvement as well as worse recurrence free survival (RFS) with no impact on OS. We did not find a significant association between CIS and oncologic outcomes in a subset of patients who received NAC including those with down-staging to ≤ pT1 disease. In multivariate analysis, CIS had no association with either recurrence free or OS. CONCLUSIONS: Concomitant CIS in radical cystectomy specimens is associated with decreased RFS; however, in multivariate analysis, it was not an independent predicting factor of oncologic outcomes. Moreover, the impact of CIS on oncologic outcomes in a subset of patients who received NAC was insignificant.

Optimizing Diagnosis of Urothelial Bladder Cancer with Blue Light Cystoscopy via Recognition of False-Positive Lesions.

Introduction: Blue light cystoscopy (BLC) using hexaminolevulinate (Cysview®) improves the detection of nonmuscle invasive bladder cancer (NMIBC).1-3 BLC results in lower recurrence rate and a better recurrence-free survival, as well as a progression benefit.4 However, false-positive (FP) fluorescence can occur for various reasons and can vary among different series. Studies have shown that FP rates are not significantly different from white light (WL) cystoscopy. We evaluated different scenarios producing FP in BLC. Methods: Under institutional review board approval, we prospectively enrolled consecutive patients undergoing transurethral resection of bladder lesions into a BLC registry between April 2014 and December 2016. Several cases are highlighted in the video demonstrating cystoscopic view under WL and blue light in specific circumstances increasing the chance of detecting an FP lesion. Results: BLC with Cysview is demonstrated in several challenging cases for the detection of NMIBC. Possible FP scenarios include tangential views of the bladder neck or side walls (1) trigone, trabeculations, or diverticula; (2) in setting of inflammation like cystitis; (3) postintravesical therapy, that is, <6 weeks interval from prior bacillus Calmette-Guérin (BCG); (4) prior resection within 6 weeks; (5) bright tiny spots; and (6) site of ureterectomy/bladder cuff resection, early fading lesions (after irrigation). Unnecessary biopsy of these lesions can be avoided through simple techniques such as changing the angle of the cystoscopic view, several rounds of irrigation, and avoiding BLC too early after BCG instillation or prior resection. Conclusions: Use of BLC with Cysview can help with the detection of NMIBC as well as carcinoma in situ in patients undergoing transurethral resection of bladder tumor for bladder cancer. The reported FP rates of BLC will decrease with experience and recognition of the mentioned scenarios. Prior presentation: None. No competing financial interests exist. Runtime of video: 7 mins 16 secs.

Gastrointestinal Complications Following Radical Cystectomy Using Enhanced Recovery Protocol.

BACKGROUND: The development of enhanced recovery after surgery (ERAS) protocols for patients undergoing radical cystectomy (RC) represents a significant advance in perioperative care. OBJECTIVE: To evaluate gastrointestinal (GI) complications following RC and urinary diversion (UD) using our institutional ERAS protocol. DESIGN, SETTING, AND PARTICIPANTS: We identified 377 consecutive cases of open RC and UD for which our ERAS protocol was used from May 2012 to December 2015. Exclusion criteria were consent refusal; non-bladder primary disease; palliative, salvage, or additional surgery; and prolonged postoperative intubation. A matched cohort of 144 patients for whom a traditional postoperative protocol (pre-ERAS) was used between 2003 and 2012 was selected for comparison. RESULTS AND LIMITATIONS: A total of 292 ERAS patients with median age of 70 yr were included in the study, 65% of whom received an orthotopic neobladder. The median time to first flatus and bowel movement was 2 d. The median length of stay was 4 d. GI complications occurred in 45 patients (15.4%) during the first 30 d following RC, 93% of which were of minor grade. The most common GI complication was postoperative ileus (POI) in 34 cases (11.6%). Some 22 patients (7.5%) required a nasogastric tube, and parenteral nutrition was required in three patients. The rate of 30-d GI complications was significantly lower in the ERAS cohort than in the control group (13% vs 27%; p=0.003), as was the rate of POI (7% vs 23%; p<0.001). This effect was independent of other variables (hazard ratio 0.38, 95% confidence interval 0.18-0.82; p=0.01). CONCLUSIONS: Our institutional ERAS protocol for RC is associated with significantly improved perioperative GI recovery and lower rates of GI complications. This protocol can be tested in multi-institutional studies to reduce GI morbidity associated with RC. PATIENT SUMMARY: In this study, we showed that an enhanced recovery protocol for patients undergoing radical cystectomy for bladder cancer was associated with a significantly shorter length of hospital stay and lower rates of gastrointestinal complications, especially postoperative ileus.

Blue light cystoscopy for the diagnosis of bladder cancer: Results from the US prospective multicenter registry.

INTRODUCTION: Blue light cystoscopy (BLC) using hexaminolevulinate (HAL/Cysview/Hexvix) has been previously shown to improve detection of non-muscle-invasive bladder cancer (NMIBC). Herein, we evaluated the detection of malignant lesions in a heterogenous group of patients in the real world setting and documented the change in risk category due to upstaging or upgrading. METHODS: Prospective enrollment during April 2014 to December 2016 of consecutive adult patients with suspected or known non-muscle-invasive bladder cancer based on prior cystoscopy or imaging, undergoing transurethral resection of bladder tumor at 9 different referral medical centers. HAL was instilled in the bladder for 1 to 3 hours before evacuation and inspection. Sensitivity and specificity of BLC, white light cystoscopy (WLC), and the combination of both BLC and WLC for detection of any malignancy was reported on final pathology. Number of patients with a change in American Urological Association (AUA) risk category based on BLC findings leading to a possible change in management and adverse events were recorded. RESULTS: Overall, 1,632 separate samples from bladder resection or biopsy were identified from 641 BLC procedures on 533 patients: 85 (16%) underwent repeat BLC (range: 2-5). Sensitivity of WLC, BLC, and the combination for diagnosis of any malignant lesion was 76%, 91%, and 98.5%, respectively. Addition of BLC to standard WLC increased detection rate by 12% for any papillary lesion and 43% for carcinoma in-situ. Within the WLC negative group, an additional 206 lesions in 133 (25%) patients were detected exclusively with BLC. In multifocal disease, BLC resulted in AUA risk-group migration occurred in 33 (6%) patients and a change in recommended management in 74 (14%). False-positive rate was 25% for WLC and 30% for BLC. One mild dermatologic hypersensitivity reaction (0.2%). CONCLUSIONS: BLC increases detection rates of carcinoma in-situ and papillary lesions over WLC alone and can change management in 14% of cases. Repeat use of HAL for BLC is safe.

Midline Extraperitoneal Approach to Retroperitoneal Lymph Node Dissection in Testicular Cancer: Minimizing Surgical Morbidity.

BACKGROUND: Retroperitoneal lymph node dissection (RPLND) is an important component of the management of testicular germ cell tumor (GCT) but carries significant surgical morbidity. OBJECTIVE: To describe our experience with a midline extraperitoneal (EP) approach to RPLND for seminomatous and nonseminomatous GCT. DESIGN, SETTING, AND PARTICIPANTS: From 2010 to 2015, 122 consecutive patients underwent RPLND from a prospective database. Patients requiring aortic resection or retrocrural dissection or with intraperitoneal disease were excluded. The remaining 69 patients underwent midline EP-RPLND. SURGICAL PROCEDURE: Open midline EP-RPLND was performed using a standardized technique. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Perioperative and long-term outcomes were analyzed. Complications were graded using the Clavien-Dindo classification. A descriptive analysis using SAS software was performed. RESULTS AND LIMITATIONS: A total of 68 patients underwent midline EP-RPLND successfully (98.6%). The median age was 28 yr (range 17-55). On preoperative imaging the size of the retroperitoneal mass or lymphadenopathy was <2cm in 29 patients, 2-4.9cm in 15 patients, and >5cm in 24 patients, of which 19 were >10cm. The median estimated blood loss was 325ml (interquartile range [IQR] 200-612.5). The median number of lymph nodes resected was 36 (IQR 24.5-49); the median number of positive nodes was one (IQR 0-4). The median time for return of bowel function was 2 d (IQR 1-2) and hospital stay 3 d (IQR 3-4). There were no cases of ileus. Eleven patients had 12 (17.6%) 90-d complications. Of these, six (55%) were Clavien grade 1, five (45%) were grade 2, and one was grade 3b (1.5%). Antegrade ejaculation rates were 91.6% in the primary group and 96.8% in the post-chemotherapy group. CONCLUSIONS: Midline EP-RPLND can be performed safely without compromising the completeness of the resection. This approach is associated with rapid return of bowel function, minimal rates of ileus, and short hospital stay. PATIENT SUMMARY: A midline extraperitoneal approach for retroperitoneal lymph node dissection in testicular cancer is safe and effective and leads to faster return of bowel function and earlier discharge.