Association between hospital competition and quality of prostate cancer care.

BACKGROUND: Hospitals account for approximately 6% of United States' gross domestic product. We examined the association between hospital competition and outcomes in elderly with localized prostate cancer (PCa). We also assessed if race moderated this association. METHODS: Retrospective study using Surveillance, Epidemiology, and End Results (SEER) - Medicare database. Cohort included fee-for-service, African American and white men aged ≥ 66, diagnosed with localized PCa between 1998 and 2011 and their claims between 1997 and 2016. We used Hirschman-Herfindahl index (HHI) to measure of hospital competition. Outcomes were emergency room (ER) visits, hospitalizations, Medicare expenditure and mortality assessed in acute survivorship phase (two years post-PCa diagnosis), and long-term mortality. We used Generalized Linear Models for analyzing expenditure, Poisson models for ER visits and hospitalizations, and Cox models for mortality. We used propensity score to minimize bias. RESULTS: Among 253,176 patients, percent change in incident rate of ER visit was 17% higher for one unit increase in HHI (IRR: 1.17, 95% CI: 1.15-1.19). Incident rate of ER was 24% higher for whites and 48% higher for African Americans. For one unit increase in HHI, hazard of short-term all-cause mortality was 7% higher for whites and 11% lower for African Americans. The hazard of long-term all-cause mortality was 10% higher for whites and 13% higher for African Americans. CONCLUSIONS: Lower hospital competition was associated with impaired outcomes of localized PCa care. Magnitude of impairment was higher for African Americans, compared to whites. Future research will explore process through which competition affects outcomes and racial disparity.

Telehealth: An Effective Model of Care for Renal Cancer Surveillance.

The coronavirus disease 2019 pandemic presented challenges for urology patients to receive care in the format of a traditional clinic visit. For renal cancer patients, active surveillance and postintervention surveillance are the standard components of management. Telehealth, which was defined as a televideo encounter via the BlueJeans (Verizon) platform (a telehealth platform), was used to ensure continuity of care. Telehealth using the televideo modality was shown to be an effective model of care delivery to provide an optimal patient experience with ease of use.

Continuity of care in acute survivorship phase, and short and long-term outcomes in prostate cancer patients.

Continuity of care is important for prostate cancer care due to multiple treatment options, and prolonged disease history. We examined the association between continuity of care and outcomes in Medicare beneficiaries with localized prostate cancer, and the moderating effect of race using Surveillance, Epidemiological, and End Results (SEER) - Medicare data between 2000 and 2016. Continuity of care was measured as visits dispersion (continuity of care index or COCI), and density (usual provider care index or UPCI) in acute survivorship phase. Outcomes were emergency room visits, hospitalizations, and cost during acute survivorship phase and mortality (all-cause and prostate cancer-specific) over follow-up phase. Higher continuity of care was associated with improved outcomes, and interaction between race and continuity of care was significant. Continuity of care during acute survivorship phase may lower the racial disparity in prostate cancer care. Future research can analyze the mechanism of the process.

Complication and Readmission Rates following Same-Day Discharge after Percutaneous Renal Tumor Ablation.

PURPOSE: To evaluate readmission rate and complications in patients undergoing same-day discharge following percutaneous thermal ablation of renal tumors. MATERIALS AND METHODS: Patients undergoing same-day discharge following thermal ablation of renal tumors were reviewed. The primary outcome was the rate of readmission within 30 days of same-day discharge. The secondary outcomes included the rate and clinical outcomes of periprocedural complications. RESULTS: Same-day discharge occurred in 166/174 patients (95%), of whom 2/166 (1%) required short-term readmission due to pulmonary embolism and acute-on-chronic kidney injury. Both patients recovered without permanent morbidity. Admission due to complications occurred in 8/174 (5%) cases, the majority of which were related to hemorrhage. No significant differences in rates of complications or admission were found between cryoablation and RF ablation. Major complications (Clavien-Dindo grade II or higher, SIR grade C or higher) occurred in 7/174 (4%) cases, the majority related to hemorrhage. All cases were detected in the standard 4 hour postprocedural observation period and managed conservatively. The mean hemorrhage volume was significantly larger in patients requiring admission versus those discharged the same day (289 mL vs 34 mL; P = .02). Higher-volume hemorrhage occurred in larger tumors (mean, 4.0 cm vs 3.0 cm; P = .04). There was no association between major complications and central tumor or age. CONCLUSIONS: Routine same-day discharge following percutaneous renal tumor thermal ablation can be performed with a low rate of short-term readmission. The majority of periprocedural complications can be managed conservatively, and patients can be discharged the same day.

Single instillation of mitomycin C plus bacillus Calmette-Guérin (BCG) versus BCG alone in high grade non-muscle invasive bladder cancer.

INTRODUCTION: This study sought to determine if the addition of perioperative mitomycin C (MMC) to treatment with bacillus Calmette-Guérin (BCG) after transurethral resection (TURBT) is superior to TURBT plus BCG alone in high grade non-muscle invasive bladder cancer (NMIBC). MATERIALS AND METHODS: Data for 719 patients diagnosed with NMIBC at the University of Pennsylvania Health System between 1977 and 2009 was reviewed retrospectively. Of these patients, 120 had high grade disease and were treated with either BCG alone or with a single instillation of 40 mg of MMC perioperatively in addition to BCG and were thus included in our study. The primary endpoints of this study included recurrence-free survival, overall and disease-free survival as assessed via Kaplan-Meier analysis. RESULTS: Of the 120 patients identified who received treatment for high grade NMIBC, 97 were treated with BCG alone and 23 received a single instillation of perioperative MMC in addition to BCG. There were no statistically significant differences noted in demographic or pathologic variables. Patients were followed for a median of 4.5 years and a maximum of 21.8 years, with no differences demonstrated in recurrence-free survival (p = 0.75), overall survival (p = 0.93) or disease-free survival (p = 0.76). Both lack of lymphovascular invasion and BCG maintenance therapy reached significance as independent predictors of recurrence-free survival (p = 0.19 and p = 0.28). CONCLUSIONS: While our study indicates that perioperative MMC likely offers little benefit in regards to recurrence or survival in high grade NMIBC, at this point in time, a larger scale, randomized, controlled trial is needed to adequately address this question.

Simplification of the Fuhrman grading system for renal cell carcinoma.

INTRODUCTION: The Fuhrman grading system (FGS) is the most widely utilized pathological classification and predictor of renal cell carcinoma (RCC) prognosis. The aim of this study was to test the prognostic ability of a simplified two-tier FGS. MATERIALS AND METHODS: We reviewed the data of 509 patients with clear cell RCC who underwent radical or partial nephrectomy between January 1994 and April 2007. The conventional four-tier (I, II, III, IV) FGS was compared to a simplified two-tier FGS in which grades I and II were combined (low grade) and grades III and IV were combined (high grade). Cancer-specific survival (CSS) was calculated for each patient. Univariate and multivariate analyses were used in combination with area under the curve (AUC) of receiver operating characteristic curves to compare prognostic accuracies between grading schemes. RESULTS: Median follow up was 81.6 months. Using the conventional FGS, the 5 year CSS for Fuhrman grades I, II, III, and IV were 74.1%, 76.0%, 57.3%, and 40.7%, respectively (p < 0.001). Using the simplified two-tier FGS, the 5 year CSS for low grade and high grade were 75.5% and 54.7%, respectively (p < 0.001). Both FGSs achieved independent predictor status in multivariate analyses. Prognostic accuracy of multivariate models between the two FGSs had nearly identical AUCs, with a c-statistic of 0.769 and 0.716 for the two-tier and conventional systems, respectively. CONCLUSIONS: Our findings indicate that the simplified FGS performs similarly to the conventional system. The use of this simplified system may promote greater continuity of pathological interpretation as well as provide a more simplified approach for clinician utilization.

Response of the human detrusor to stretch is regulated by TREK-1, a two-pore-domain (K2P) mechano-gated potassium channel.

The mechanisms of mechanosensitivity underlying the response of the human bladder to stretch are poorly understood. Animal data suggest that stretch-activated two-pore-domain (K2P) K(+) channels play a critical role in bladder relaxation during the filling phase. The objective of this study was to characterize the expression and function of stretch-activated K2P channels in the human bladder and to clarify their physiological role in bladder mechanosensitivity. Gene and protein analysis of the K2P channels TREK-1, TREK-2 and TRAAK in the human bladder revealed that TREK-1 is the predominantly expressed member of the mechano-gated subfamily of K2P channels. Immunohistochemical labelling of bladder wall identified higher levels of expression of TREK-1 in detrusor smooth muscle cells in comparison to bladder mucosa. Functional characterization and biophysical properties of the predominantly expressed member of the K2P family, the TREK-1 channel, were evaluated by in vitro organ bath studies and the patch-clamp technique. Electrophysiological recordings from single smooth muscle cells confirmed direct activation of TREK-1 channels by mechanical stretch and negative pressure applied to the cell membrane. Inhibition of TREK-1 channels in the human detrusor significantly delayed relaxation of the stretched bladder smooth muscle strips and triggered small-amplitude spontaneous contractions. Application of negative pressure to cell-attached patches (-20 mmHg) caused a 19-fold increase in the open probability (NPo) of human TREK-1 channels. l-Methionine (1 mm), a specific TREK-1 inhibitor, dramatically decreased the NPo of TREK-1 channels from 0.045 ± 0.003 to 0.008 ± 0.001 (n = 8, P ≤ 0.01). Subsequent addition of arachidonic acid (10 µm), a channel opener, increased the open probability of methionine-inhibited unitary currents up to 0.43 ± 0.05 at 0 mV (n = 9, P ≤ 0.05). The results of our study provide direct evidence that the response of the human detrusor to mechanical stretch is regulated by activation of mechano-gated TREK-1 channels. Impaired mechanosensation and mechanotransduction associated with the changes in stretch-activated K2P channels may underlie myogenic bladder dysfunction in humans.

Substance use disorder and its effects on outcomes in men with advanced-stage prostate cancer.

BACKGROUND: Substance use disorder in patients with cancer has implications for outcomes. The objective of this study was to analyze the effects of the type and timing of substance use on outcomes in elderly Medicare recipients with advanced prostate cancer. METHODS: This was an observational cohort study using Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data from 2000 to 2009. Among men who were diagnosed with advanced prostate cancer between 2001 and 2004, we identified those who had a claim for substance use disorder in the year before cancer diagnosis, 1 year after cancer diagnosis, and an additional 4 years after diagnosis. The outcomes investigated were use of health services, costs, and mortality. RESULTS: The prevalence of substance use disorder was 10.6%. The category drug psychoses and related had greater odds of inpatient hospitalizations (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.9-2.8), outpatient hospital visits (OR, 2.6; 95% CI, 1.9-3.6), and emergency room visits (OR, 1.7; 95% CI, 1.2-2.4). Substance use disorder in the follow-up phase was associated with greater odds of inpatient hospitalizations (OR, 2.0; 95% CI, 1.8-2.2), outpatient hospital visits (OR, 2.0; 95% CI, 1.7-2.4), and emergency room visits (OR, 1.7; 95% CI, 1.5-2.1). Compared with men who did not have substance use disorder, those in the category drug psychoses and related had 70% higher costs, and those who had substance use disorder during the follow-up phase had 60% higher costs. The hazard of all-cause mortality was highest for patients in the drug psychoses and related category (hazard ratio, 1.3; 95% CI, 1.1-1.7) and the substance use disorder in treatment phase category (hazard ratio, 1.5; 95% CI, 1.3-1.7). CONCLUSIONS: The intersection of advanced prostate cancer and substance use disorder may adversely affect outcomes. Incorporating substance use screening and treatments into prostate cancer care guidelines and coordination of care is desirable.

Optimizing bladder cancer locoregional failure risk stratification after radical cystectomy using SWOG 8710.

BACKGROUND: Clinical trials of radiation after radical cystectomy (RC) and chemotherapy for bladder cancer are in development, but inclusion and stratification factors have not been clearly established. In this study, the authors evaluated and refined a published risk stratification for locoregional failure (LF) by applying it to a multicenter patient cohort. METHODS: The original stratification, which was developed using a single-institution series, produced 3 subgroups with significantly different LF risk based on pathologic tumor (pT) classification and the number of lymph nodes identified. This model was then applied to patients in Southwest Oncology Group (SWOG) 8710, a randomized trial of RC with or without chemotherapy. LF was defined as any pelvic failure before or within 3 months of distant failure. RESULTS: Patients in the development cohort and the SWOG cohort had significantly different baseline characteristics. The original risk model was not fully validated in the SWOG cohort, because lymph node yield was not as strongly associated with LF as in the development cohort. Regression analysis indicated that margin status could improve the model. A revised stratification using pT classification, margin status, and the number of lymph nodes identified produced 3 subgroups with significantly different LF risk in both cohorts: low risk (≤pT2), intermediate risk (≥pT3 with negative margins AND ≥10 lymph nodes identified), and high risk (≥pT3 with positive margins OR <10 lymph nodes identified) with 5-year LF rates of 8%, 20%, and 41%, respectively, in the SWOG cohort and 8%, 19%, and 41%, respectively, in the development cohort. CONCLUSIONS: A model incorporating pT classification, margin status, and the number of lymph nodes identified stratified LF risk in 2 different RC populations and may inform the design of future trials.

Factors influencing the length of stay after radical cystectomy: implications for cancer care and perioperative management.

INTRODUCTION: Although radical cystectomy (RC) is the gold standard treatment for muscle invasive bladder cancer it is associated with perioperative complications, readmissions, and a prolonged length of hospital stay (PLOS). We explored the perioperative factors associated with a PLOS after RC and subsequent long-term outcomes. MATERIAL AND METHODS: Consecutive patients with urothelial bladder cancer undergoing RC with curative intent at our institution were classified into two groups: LOS <12 days and PLOS ≥12 days. Clinicopathological variables were compared on univariate and multivariable analysis. Complications, re-admissions, adjuvant chemotherapy use, recurrence free survival (RFS), and overall survival (OS) were compared between the two groups. Competing risk analysis was performed for bladder cancer specific mortality (BCSM). RESULTS: 330 patients were included in the analysis (median LOS = 9 days [IQR = 8-11]) of which, 274 patients (83 %) had a LOS <12 days (median = 8 days [IQR = 7-10]) and 56 patients (17 %) had a PLOS ≥12 days (median = 16 days [IQR = 13-21.5]). Only female gender, older age, and perioperative complications were associated with a PLOS. 90 day readmission rates were similar (p = 0.75). No difference was seen for BCSM, RFS, or adjuvant chemotherapy usage between the two groups. However, OS was significantly worse for PLOS (median OS = 27.7 vs. 45.6 months [p = 0.046]; HR = 1.53 [95 % CI = 1.01-2.33]). CONCLUSION: Both female and elderly patients should receive preoperative counseling about their increased risk of a PLOS after RC. Patients who experience a PLOS are at greater risk for subsequent all-cause mortality. These patient groups may benefit from proactive interventions.

Does quantification of smoking history correlate with initial bladder tumor grade and stage?

The causal association between cigarette smoking and urothelial bladder cancer has been firmly established for several decades. However, the impact of smoking intensity on initial tumor aggressiveness is less established and is reviewed in this manuscript. Particular attention is given to the relation between smoking history with both muscle-invasive bladder cancer (MIBC) and non-muscle-invasive bladder cancer (NMIBC). This article also briefly reviews the epidemiologic evidence, smoking-associated carcinogenesis, and the limitations of quantifying smoking history. There is evidence to suggest that smokers have a three-fold increased risk of developing invasive bladder cancer compared to non-smokers, and smoking cessation can reduce this risk. Continued efforts should be made to raise awareness of bladder cancer in smokers and to advocate further for smoking cessation.

Re-examination of the natural history of high-grade T1 bladder cancer using a large contemporary cohort.

INTRODUCTION: High-grade T1 (HGT1) bladder cancer represents a clinical challenge in that the urologist must balance the risk of disease progression against the morbidity and potential mortality of early radical cystectomy and urinary diversion. Using two non-muscle invasive bladder cancer (NMIBC) databases, we re-examined the rate of progression of HG T1 bladder cancer in our bladder cancer populations. MATERIALS AND METHODS: We queried the NMIBC databases that have been established independently at the Atlanta Veterans Affairs Medical Center (AVAMC) and the University of Pennsylvania to identify patients initially diagnosed with HGT1 bladder cancer. Demographic, clinical, and pathologic variables were examined as well as rates of recurrence and progression. RESULTS: A total of 222 patients were identified; 198 (89.1%) and 199 (89.6%) of whom were male and non-African American, respectively. Mean patient age was 66.5 years. 191 (86.0%) of the patients presented with isolated HG T1 disease while 31 (14.0%) patients presented with HGT1 disease and CIS. Induction BCG was utilized in 175 (78.8%) patients. Recurrence occurred in 112 (50.5%) patients with progression occurring in only 19 (8.6%) patients. At a mean follow-up of 51 months, overall survival was 76.6%. Fifty two patients died, of whom only 13 (25%) patient deaths were bladder cancer related. CONCLUSIONS: In our large cohort of patients, we found that the risk of progression at approximately four years was only 8.6%. While limited by its retrospective nature, this study could potentially serve as a starting point in re-examining the treatment algorithm for patients with HG T1 bladder cancer.

Oncologic control and predictors of urologic reconstruction after Mohs micrographic surgery for low-risk penile malignancy.

PURPOSE: Mohs micrographic surgery (MMS) is a low-risk penile cancer management option. However, contemporary patients' short-term oncologic control and preoperative characteristics predicting reconstruction needs are undefined. This study assesses MMS's oncologic efficacy for low-risk penile cancer and identifies baseline predictors of post-resection reconstruction referral. METHODS: We retrospectively reviewed 73 adult males with 78 penile cutaneous malignancies treated with MMS from 2005 to 2019. Patients underwent MMS with or without surgical reconstruction. Demographic information, MMS operative details, lesion pathology, and short-term outcomes were recorded. Descriptive statistics for all variables were calculated, and logistic regression identified predictive factors for urologic referral for complex reconstruction. RESULTS: Seventy-three men with 78 lesions, all staged ≤ cT1a prior to MMS, were identified. Twenty-one men were found to have invasive SCC. Median follow-up was 2.0 years (IQR 0.8-5.2 years). MMS was able to clear the disease in 90.4% of cases. One patient had disease related death following progression. Dermatology closed primarily in 68% of patients. Twenty percent of patients had a complication, most commonly poor wound healing. On univariate and multivariate linear regression analysis, lesion size > 3 cm and involvement of the glans independently predicted the need for referral to a reconstructive surgeon. CONCLUSIONS: MMS for penile cancer appears to provide sound oncologic control in the properly selected patient. Involvement of a reconstructive surgeon may be needed for glandular and large lesions, necessitating early referral to a comprehensive multidisciplinary care team.

Prostate-Specific Antigen Screening in Smokers: A Comprehensive Analysis Using a National Behavioral Survey.

INTRODUCTION: Cigarette smoking is associated with higher-risk prostate cancer at the time of diagnosis and increased overall and prostate cancer‒specific mortality. Previous studies indicate smokers are less likely to undergo PSA screening. Herein we investigate the association between smoking and PSA screening using a nationally representative US survey. We hypothesize that smokers are less likely to undergo guideline-concordant PSA screening. METHODS: We performed a cross-sectional analysis of men aged 55 to 69 who responded to the cigarette smoking and PSA screening questions of the 2018 Behavioral Risk Factor Surveillance System survey. Adjusted prevalence and adjusted risk differences were calculated using complex weighted multivariable Poisson regression modeling. RESULTS: We identified 58,996 individuals who qualified for analysis. PSA screening prevalence was 39% (95% CI: 39%-40%) nationally, 42% (95% CI: 41%-44%) for never smokers, 42% (95% CI: 39%-40%) for former smokers, and 27% (95% CI: 25%-29%) for current smokers, including 27% (95% CI: 24%-29%) for daily smokers and 29% (95% CI: 24%-33%) for nondaily smokers. Compared to never smokers, the adjusted relative risk for undergoing PSA screening was 0.81 for current smokers (95% CI: 0.75-0.88, P < .01) and 0.99 for former smokers (95% CI: 0.94-1.03, P = .53). CONCLUSIONS: Current smokers are less likely to undergo recommended PSA screening, but former smokers are screened at similar rates as never smokers. As delays in diagnosis may substantially contribute to worse prostate cancer outcomes, targeted interventions to increase screening in this population may yield significant effects.

The TERE1 protein interacts with mitochondrial TBL2: regulation of trans-membrane potential, ROS/RNS and SXR target genes.

We originally discovered TERE1 as a potential tumor suppressor protein based upon reduced expression in bladder and prostate cancer specimens and growth inhibition of tumor cell lines/xenografts upon ectopic expression. Analysis of TERE1 (aka UBIAD1) has shown it is a prenyltransferase enzyme in the natural bio-synthetic pathways for both vitamin K-2 and COQ10 production and exhibits multiple subcellular localizations including mitochondria, endoplasmic reticulum, and golgi. Vitamin K-2 is involved in mitochondrial electron transport, SXR nuclear hormone receptor signaling and redox cycling: together these functions may form the basis for tumor suppressor function. To gain further insight into mechanisms of growth suppression and enzymatic regulation of TERE1 we isolated TERE1 associated proteins and identified the WD40 repeat, mitochondrial protein TBL2. We examined whether disease specific mutations in TERE1 affected interactions with TBL2 and the role of each protein in altering mitochondrial function, ROS/RNS production and SXR target gene regulation. Biochemical binding assays demonstrated a direct, high affinity interaction between TERE1 and TBL2 proteins; TERE1 was localized to both mitochondrial and non-mitochondrial membranes whereas TBL2 was predominantly mitochondrial; multiple independent single amino acid substitutions in TERE1 which cause a human hereditary corneal disease reduced binding to TBL2 strongly suggesting the relevance of this interaction. Ectopic TERE1 expression elevated mitochondrial trans-membrane potential, oxidative stress, NO production, and activated SXR targets. A TERE1-TBL2 complex likely functions in oxidative/nitrosative stress, lipid metabolism, and SXR signaling pathways in its role as a tumor suppressor.

Toremifene to reduce fracture risk in men receiving androgen deprivation therapy for prostate cancer.

PURPOSE: Androgen deprivation therapy is associated with fracture risk in men with prostate cancer. We assessed the effects of toremifene, a selective estrogen receptor modulator, on fracture incidence in men receiving androgen deprivation therapy during a 2-year period. MATERIALS AND METHODS: In this double-blind, placebo controlled phase III study 646 men receiving androgen deprivation therapy for prostate cancer were assigned to toremifene (80 mg by mouth daily) and 638 were assigned to placebo. Subjects were followed for 2 years. The primary study end point was new vertebral fractures. Secondary end points included fragility fractures, bone mineral density and lipid changes. RESULTS: The 2-year incidence of new vertebral fractures was 4.9% in the placebo group vs 2.5% in the toremifene group, a significant relative risk reduction of 50% (95% CI -1.5 to 75.0, p = 0.05). Toremifene significantly increased bone mineral density at the lumbar spine, hip and femoral neck vs placebo (p <0.0001 for all comparisons). There was a concomitant decrease in markers of bone turnover (p <0.05 for all comparisons). Toremifene also significantly improved lipid profiles. Venous thromboembolic events occurred more frequently with toremifene than placebo with 7 subjects (1.1%) in the placebo group experiencing a venous thromboembolic event vs 17 (2.6%) in the toremifene group. Other adverse events were similar between the groups. CONCLUSIONS: Toremifene significantly decreased the incidence of new vertebral fractures in men receiving androgen deprivation therapy for prostate cancer. It also significantly improved bone mineral density, bone turnover markers and serum lipid profiles.

Bladder preservation in the treatment of muscle-invasive bladder cancer (MIBC): a review of the literature and a practical approach to therapy.

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Bladder preservation therapies for muscle-invasive bladder cancer (MIBC) have been developed to address the needs of two cohorts: patients with severe medical co-morbidities for whom radical cystectomy is too high risk and patients with limited disease who wish to avoid aggressive surgery. There are multiple bladder preservation options, although the trimodal approach of maximal transurethral resection with chemoradiotherapy is the most strongly supported. While outcomes are worse for patients unfit for surgery than those otherwise fit for surgery, bladder preservation approaches still offer curative potential. We present a comprehensive review of the literature and outline a practical approach to bladder preservation therapy for MIBC. This review aims to help urologists easily navigate through the decision tree of therapeutic options. Radical cystectomy (RC) is associated with considerable morbidity. Aside from the perioperative period, RC with urinary diversion poses great potential for long-term complications and morbidity. Bladder preservation therapies for muscle-invasive bladder cancer (MIBC) have been developed to address the needs of two cohorts: patients with severe medical co-morbidities for whom a radical surgery is too high risk and patients with limited disease who wish to avoid radical surgery. The goal of achieving complete response to treatment while maintaining bladder form and function has led to the development of multimodal approaches to this disease. There are multiple bladder preservation options, although the trimodal approach of maximal transurethral resection with chemoradiotherapy is the most strongly supported. In medically operable patients ('fit' for surgery), there is abundant evidence to support trimodal therapy as an acceptable treatment option for highly selected patients with MIBC with favourable pathological parameters. While outcomes are worse for medically inoperable patients ('unfit' for surgery), bladder preservation approaches still offer curative potential. However, prospective trials comparing the above regimens to RC are still needed to better define their role in the treatment of MIBC. We present a comprehensive review of the literature and outline a practical approach to bladder preservation therapy for MIBC.

Percutaneous computed tomography-guided renal mass radiofrequency ablation versus cryoablation: doses of sedation medication used.

PURPOSE: To compare the amount of sedation medication administered during radiofrequency (RF) ablation versus cryoablation of small renal masses. MATERIALS AND METHODS: Records were retrospectively reviewed in patients who underwent percutaneous computed tomography-guided RF ablation and cryoablation of small renal masses from January 2002 to June 2011 for patient and tumor characteristics, amount of medications used for moderate sedation, and complications. Sedation was performed by giving patients titrated doses of midazolam and fentanyl. Additional medications were given if the desired level of sedation was not achieved. RESULTS: There were 116 patients who underwent 136 ablation procedures; 71 patients underwent RF ablation, and 65 patients underwent cryoablation. RF ablation was associated with a significantly higher mean dose of fentanyl (mean dose for RF ablation, 236.43 µg; mean dose for cryoablation, 172.27 µg; P<.001). RF ablation was also associated with a higher mean dose of midazolam (mean dose for RF ablation, 4.5 mg; mean dose for cryoablation, 3.27 mg; P<.001). In the RF ablation group, two patients required additional sedation with droperidol. As a result of oversedation, two patients in the RF ablation cohort required sedation reversal with naloxone and flumazenil. None of the patients who underwent cryoablation required sedation reversal. No other sedation-related complications occurred. CONCLUSIONS: Cryoablation of small renal masses was performed with less sedation medication than RF ablation. This finding suggests renal cryoablation is less painful than RF ablation; however, prospective studies with validated pain scales are needed to confirm these results.

Racial Disparity in Outcomes Among Prostate Cancer Patients in the Post-Affordable Care Act Period.

INTRODUCTION: Our objective was to assess whether Medicaid expansion is associated with reduced racial disparity in quality of care measured as 30-day mortality, 90-day mortality, and 30-day readmission in prostate cancer patients receiving surgery. METHODS: We used the National Cancer Database to extract a cohort of African American and White men diagnosed with prostate cancer between 2004 and 2015 and surgically treated. We used 2004-2009 data to observe preexisting racial disparity in outcomes. We used 2010-2015 data to assess racial disparity in outcomes and the interaction of race and Medicaid expansion status. RESULTS: Between 2004 and 2009, 179,762 men met our criteria. In this period, African American patients reported higher hazard of 30- and 90-day mortality and higher odds of 30-day readmission compared to White patients. Between 2010 and 2015, 174,985 men met our criteria. Of these 84% were White and 16% were African American. Main effects models showed that compared to White men, African American men had higher odds of 30-day mortality (OR=1.96, 95% CI = 1.46, 2.67), 90-day mortality (OR=1.40, 95% CI = 1.11, 1.77), and 30-day readmission (OR=1.28, 95% CI = 1.19, 1.38).The interactions between race and Medicaid expansion were not significant (P = .1306, .9499, and .5080, respectively). CONCLUSIONS: Improved access to care via Medicaid expansion may not translate into reduced racial disparity in quality-of-care outcomes in prostate cancer patients treated surgically. System-level factors such as availability of and referrals to care, and complex socioeconomic structure may also play a role in improving quality of care and reducing disparities.