Use and Validation of the AUA/SUO Risk Grouping for Nonmuscle Invasive Bladder Cancer in a Contemporary Cohort.

PURPOSE: We applied nonmuscle invasive bladder cancer AUA (American Urological Association)/SUO (Society of Urologic Oncology) guidelines for risk stratification and analyzed predictors of recurrence and progression. MATERIALS AND METHODS: We retrospectively reviewed the records of 398 patients with nonmuscle invasive bladder cancer treated between 2001 and 2017. Descriptive statistics were used to compare AUA/SUO risk groups. Predictors of recurrence and progression were determined by multivariable regression. Kaplan-Meier analysis was done, a Cox proportional hazards regression model was created and time dependent AUCs were calculated to determine progression-free and recurrence-free survival by risk group. RESULTS: Median followup was 37 months (95% CI 35-42). Of the patients 92% underwent bacillus Calmette-Guérin induction and 46% received at least 1 course of maintenance treatment. Of the patients 11.5% were at low, 32.5% were at intermediate and 55.8% were at high risk. In patients at low, intermediate and high risk the 5-year progression-free survival rate was 93%, 74% and 54%, and the 5-year recurrence-free survival rate was 43%, 33% and 23%, respectively. Kaplan-Meier analysis was done to stratify high grade Ta 3 cm or less tumor recurrence-free and progression-free survival in the intermediate vs the high risk group. Relative to low risk, classification as intermediate and as high risk was an independent predictor of progression (HR 9.7, 95% CI 2.23-42.0, p <0.01, and HR 36, 95% CI 8.16-159, p <0.001, respectively). Recurrence was more likely in patients at high risk than in those at low risk (HR 2.03, 95% CI 1.11-3.71, p=0.022). For recurrence and progression the 1-year AUC was 0.60 (95% CI 0.546-0.656) and 0.68 (95% CI 0.622-0.732), respectively. CONCLUSIONS: The AUA/SUO nonmuscle invasive bladder cancer risk classification system appropriately stratifies patients based on the likelihood of recurrence and progression. It should be used at diagnosis to counsel patients and guide therapy.

Kidney Transplantation in Transgender Patients.

PURPOSE OF REVIEW: Kidney transplantation and gender affirmation treatments are becoming increasingly more prevalent due to advances in technology. However, there is a paucity of data regarding kidney transplantation in transgender patients. Interesting considerations must be made in this patient population, since there are many hormonal interactions with kidney function and the transplantation process. RECENT FINDINGS: The diagnosis of estimated glomerular filtration rate (eGFR), preoperative assessment/counseling, decreased testosterone levels in a transgender male to female patient, increased estrogen/progesterone in a female to male patient, and drug side effects all have important and unique implications for kidney transplant recipients. Kidney transplantation can be safely and effectively managed in transgender patients with special considerations in eGFR calculations, mental health/lifestyle counseling, and drug interactions.

Extraperitoneal pediatric kidney transplantation of adult renal allograft using an en-bloc native liver and kidney mobilization technique.

BACKGROUND: We describe the safety and efficacy of performing pediatric kidney transplantation with a modified extraperitoneal approach that includes mobilization of the native liver and kidney. METHODS: We retrospectively identified pediatric renal transplants performed using this technique between 2015 and 2019. Data on patient demographics, surgical technique, and intraoperative details were collected. Outcomes were measured by morbidity and re-operation at 90 days, as well as serum creatinine, allograft survival, and overall survival at 1 year. RESULTS: Twenty-one patients with a median age of 5 (IQR 3-9) years, weighing 17.5 (IQR 14.5-24) kg were included. Median donor age was 24 (IQR 19-31) years. No intraoperative complications occurred. One child required a right native nephrectomy to allow sufficient space. Postoperatively, all patients had immediate graft function without urine leak or allograft thrombosis. 90-day morbidity and re-operation rates were zero. Both 1-year allograft and overall survival were 100% (on follow-up of all 21 patients through 1 year post-transplant), with a median serum creatinine of 0.58 (IQR 0.47-0.70) mg/dl at 1 year post-transplant. CONCLUSIONS: Pediatric kidney transplantation of adult renal allografts using an extraperitoneal approach with native liver and kidney mobilization has promising allograft and patient survival outcomes that eliminates peritoneal violation and may diminish the need for native nephrectomy.

Propensity matched comparative analysis of survival following chemoradiation or radical cystectomy for muscle-invasive bladder cancer.

OBJECTIVE: To compare survival outcome between chemoradiation therapy (CRT) and radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC). PATIENTS AND METHODS: We conducted a retrospective analysis of patients with MIBC (≥cT2, N0, M0) in the National Cancer Database (2004-2013). CRT was defined as a radiation dose of ≥40 Gy and chemotherapy within 90 days of radiation. Descriptive statistics were used to compare groups. RC and CRT patients were propensity matched. Kaplan-Meier analysis was used to compare overall survival (OS). Multivariable Cox regression was used to determine predictors of survival. RESULTS: In all, 8 379 (6 606 RC and 1 773 CRT) patients met the inclusion criteria and 1 683 patients in each group were propensity matched. On multivariable extended Cox analysis, significant predictors of decreased OS were age, Charlson-Deyo Comorbidity score of 1, Charlson-Deyo Comorbidity score of 2, stage cT3-4, and urothelial histology. CRT was associated with decreased mortality at year 1 (hazard ratio [HR] 0.84, 95% confidence interval [CI] 0.74-0.96; P = 0.01), but at 2 years (HR 1.4, 95% CI 1.2-1.6; P < 0.001) and 3 years onward (HR 1.5, 95% CI 1.2-1.8; P < 0.001) CRT was associated with increased mortality. The 5-year OS was greater for RC than for CRT (38% vs 30%, P = 0.004). CONCLUSIONS: Initially after treatment for MIBC the risk of mortality is lower with CRT compared to RC. However, at ≥2 years after treatment the mortality risk favours RC. Patients who are suitable surgical candidates, with a low risk of morbidity, may be better served by RC.

Racial disparity and survival outcomes between African-American and Caucasian American men with penile cancer.

OBJECTIVE: To determine whether there is a survival difference for African-American men (AAM) versus Caucasian American men (CM) with penile squamous cell carcinoma (pSCC), particularly in locally advanced and metastatic cases where disease mortality is highest. PATIENTS AND METHODS: Using the Florida Cancer Data System, we identified men with pSCC from 2005 to 2013. We compared age, follow-up, stage, race, and treatment type between AAM and CM. We performed Kaplan-Meier analysis for overall survival (OS) between AAM and CM for all stages, and for those with locally advanced and metastatic disease. A multivariable model was developed to determine significant predictors of OS. RESULTS: In all, 653 men (94 AAM and 559 CM) had pSCC and 198 (30%) had locally advanced and/or metastatic disease. A higher proportion of AAM had locally advanced and/or metastatic disease compared to CM (38 [40%] vs 160 [29%], P = 0.03). The median (interquartile range) follow-up for the entire cohort was 12.6 (5.4-32.0) months. For all stages, AAM had a significantly lower median OS compared to CM (26 vs 36 months, P = 0.03). For locally advanced and metastatic disease, there was a consistent trend toward disparity in median OS between AAM and CM (17 vs 22 months, P = 0.06). After adjusting for age, stage, grade, and treatment type, AAM with pSCC had a greater likelihood of death compared to CM (hazard ratio 1.64, P = 0.014). CONCLUSIONS: AAM have worse OS compared to CM with pSCC and this may partly be due to advanced stage at presentation. Treatment disparity may also contribute to lessened survival in AAM, but we were unable to demonstrate a significant difference in treatment utilisation between the groups.

Comparison of readmission and short-term mortality rates between different types of urinary diversion in patients undergoing radical cystectomy.

PURPOSE: To analyze the impact of urinary diversion type following radical cystectomy (RC) on readmission and short-term mortality rates. METHODS: Patients who underwent RC for bladder cancer in the National Cancer Data Base were grouped based on the type of urinary diversion performed: non-continent [ileal conduit (IC)] or two continent techniques [continent pouch (CP) and orthotopic neobladder (NB)]. We used propensity score matching and multivariable logistic regression models to compare 30-day readmission and 30- and 90-day mortality between the different types of urinary diversion. RESULTS: Among 11,933 patients who underwent RC, we identified 10,197 (85.5%) IC, 1044 (8.7%) CP, and 692 (5.8%) NB. Patients who received IC were significantly older and had more comorbidities (p < 0.0001). Continent diversions were more likely to be performed at an academic center (p < 0.0001). Surgery performed at a non-academic center was an independent predictor of 30-day readmission (OR 1.19, p = 0.010) and 30-day mortality (OR 1.27, p = 0.043). Patients undergoing NB had an increased likelihood of being readmitted (OR 1.41, p = 0.010). There was no significant difference in short-term mortality between groups. CONCLUSIONS: Patients undergoing NB had marginally increased rates of readmission compared to IC. Surgery performed at a non-academic center was associated with higher readmission and 30-day mortality. Similar short-term mortality rates were observed among the different types of urinary diversion.

Evolution of the Application of Techniques Derived from Abdominal Transplant Surgery in Urologic Oncology.

PURPOSE OF REVIEW: The techniques derived from abdominal transplant surgery have become a major actor in recent surgical evolution by providing a more optimal solution for urologic malignancies hosted in the upper abdomen. To describe in detail the objectives, rationale, relevant milestones, and surgical maneuvers of the so-called transplant techniques as applied to complex urologic oncology cases. RECENT FINDINGS: The transplant-based surgical approach aims to decrease perioperative complications by improving tumor accessibility and field visibility through an enhanced exposure (via the use of a transverse incision, a specific retractor, and specific surgical maneuvers). A sequence of milestones inspired these advances, which finally brought the technique into maturation. The transplant-based approach has demonstrated its safety and usefulness even in the low-volume practice of more complicated urologic oncology, offering protection against the occurrence of perioperative adverse events and placing us at the gates of a new stage of surgical innovation.

Kidney Autotransplantation: Between the Past and the Future.

PURPOSE OF REVIEW: The practice of kidney autotransplantation (KAT) has become an increasingly favorable approach in the treatment of certain renovascular, ureteral, and malignant pathologies. Current KAT literature describes conventional open procedures, which are associated with substantial risks. We sought to compare previously reported outcomes, evaluate common surgical indications, and assess associated risks and benefits of current KAT methods. A thorough evaluation and review of the literature was performed with the keywords "autologous transplantation" and "kidney." RECENT FINDINGS: Early outcomes of robotic KAT are encouraging and have been associated with fewer complications and shorter hospital stay, but require robotic technique proficiency. KAT is an important method to manage selected complex urological pathologies. Robotic KAT is promising. Nevertheless, future studies should utilize larger patient cohorts to better assess the risks and benefits of KAT and to further validate this approach.

Sociodemographic and survival disparities for histologic variants of bladder cancer.

INTRODUCTION: To investigate the impact of perioperative factors on overall survival among patients with histologic variants of bladder cancer treated with radical cystectomy. MATERIALS AND METHODS: The National Cancer Data Base was utilized to identify patients diagnosed with muscle-invasive bladder cancer (cT2-4, N0, M0) from 2004-2013. Variant histology bladder cancers (non-mucinous adenocarcinoma, mucinous/signet ring adenocarcinoma, micropapillary urothelial carcinoma, small cell carcinoma, and squamous cell carcinoma) were compared to urothelial carcinoma with respect to overall survival. Adjusted hazard ratios (aHR) and 95% confidence intervals (95% CI) were calculated from a multivariable Cox regression model to examine factors affecting overall survival, T upstaging, N upstaging, and positive surgical margins. Median survival was calculated using Kaplan-Meier analysis. RESULTS: A total of 5,856 patients were included in this study. Significant predictors of worse overall survival included: African-American ancestry (aHR = 1.24, 95%CI: 1.03-1.48, p = 0.021), age (1.03, 1.02-1.03, p < 0.001), comorbidity (1.30, 1.20-1.40, p < 0.001), cT3 stage (1.41, 1.26-1.57, p < 0.001), and cT4 stage (1.59, 1.38-1.84, p < 0.001). Small cell carcinoma (2.10, 1.44-3.06, p < 0.001) and non-mucinous adenocarcinoma (1.59, 1.15-2.20, p = 0.005) were significant predictors of worse overall survival compared to urothelial carcinoma. Small cell carcinoma had the worst 5 year overall survival (15.5%, 95% CI: 5.2%-30.9%) compared to urothelial carcinoma (48.7%, 95% CI: 47.2%-50.2%). Micropapillary urothelial carcinoma was a significant predictor of increased progression to node positivity and positive margin status after radical cystectomy compared to urothelial carcinoma (6.01, 3.11-11.63, p < 0.001; 4.38, 2.05-9.38; p < 0.001). CONCLUSIONS: Among bladder cancer patients with equal treatment and staging, small cell carcinoma and non-mucinous adenocarcinoma variant histologies were predictive of worse overall survival compared to urothelial carcinoma. Patient demographics such as African-American ancestry and age were also predictive of worse overall survival among variant histology bladder cancer and urothelial carcinoma.

Effect of prescription medications on erectile dysfunction.

Erectile dysfunction (ED) affects about 50% of men in the USA and is primarily attributed to physiological (organic) and psychological causes. However, a substantial portion of men suffer from ED due to iatrogenic causes. Common medications such as antihypertensives, non-steroidal anti-inflammatory drugs and antacids may cause ED. Physicians should be aware of the various prescription medications that may cause ED to properly screen and counsel patients on an issue that many may feel too uncomfortable to discuss. In this review, we discuss the physiology, data and alternative therapies for the ED caused by medications.

A nationwide analysis of re-exploration after liver transplant.

BACKGROUND: A retrospective review to investigate rate and outcomes of re-exploration following liver transplantation in the United States. METHODS: The NIS database was used to examine outcomes of patients who underwent re-exploration following liver transplantation from 2002 to 2012. Multivariate regression analysis was performed to compare outcomes of patients with and without reoperation. RESULTS: We sampled a total of 12,075 patients who underwent liver transplantation. Of these, 1505 (12.5%) had re-exploration during the same hospitalization. Hemorrhagic (67.9%) and biliary tract anastomosis complication (14.8%) were the most common reasons for reoperation. Patients with reoperation had a significantly higher mortality than those who did not (11.6% vs. 3.8%, AOR: 3.01, P < 0.01). Preoperative coagulopathy (AOR: 1.71, P < 0.01) and renal failure (AOR: 1.57, P < 0.01) were associated with hemorrhagic complications. Peripheral vascular disorders (AOR: 2.15, P < 0.01) and coagulopathy (AOR: 1.32, P < 0.01) were significantly associated with vascular complications. Risk of wound disruption was significantly higher in patients with chronic pulmonary disease (AOR: 1.50, P < 0.01). CONCLUSION: Re-exploration after liver transplantation is relatively common (12.5%), with hemorrhagic complication as the most common reason for reoperation. Preoperative coagulation disorders significantly increase hemorrhagic and vascular complications. Further clinical trails should investigate prophylactic strategies in high risk patients to prevent unplanned reoperation.

Overcoming Understaging and Undergrading in Upper Tract Urothelial Carcinoma. Comment on Ghoreifi et al. Modern Kidney-Sparing Management of Upper Tract Urothelial Carcinoma. Cancers 2023, 15, 4495.

Kidney-sparing management for upper tract urothelial carcinoma (UTUC) has become more common but is still most limited by inaccurate histopathologic diagnosis [...].