Diminished Short-Term Efficacy of Reduced-Dose Induction BCG in the Treatment of Non-Muscle Invasive Bladder Cancer.

The ongoing Bacillus Calmette-Guérin (BCG) shortage has created challenges for the treatment of non-muscle invasive bladder cancer (NMIBCa). Our objective was to evaluate the efficacy of reduced-dose induction BCG (RD-iBCG) compared to full-dose induction BCG (FD-iBCG) regarding recurrence rates. We hypothesized that patients receiving RD-iBCG may recur at a higher rate compared to those who received FD-iBCG therapy. A retrospective review of all patients with NMIBCa treated with intravesical therapy at our institution between 2015-2020 was conducted. Inclusion criteria consisted of having a diagnosis of AUA intermediate or high-risk NMIBCa with an indication for a six-week induction course of FD or RD-BCG with at least 1 year of documented follow up. The data were censored at one year. Propensity score matching for age, sex, tumor pathology, and initial vs. recurrent disease was performed. The primary endpoint was bladder cancer recurrence, reported as recurrence-free survival. A total of 254 patients were reviewed for this study. Our final cohort was 139 patients after exclusion. Thirty-nine percent of patients had HGT1 disease. 38.6% of patients receiving RD-BCG developed a recurrence of bladder cancer within a one-year follow-up as compared to 33.7% of patients receiving FD therapy. After propensity matching, this value remained statistically significant (p = 0.03). In conclusion, RD-iBCG for NMIBCa is associated with a significantly greater risk of recurrence than full-dose induction therapy, suggesting that RD-iBCG may not be equivalent or non-inferior to full-dose administration in the short term.

Spontaneous rupture of a bladder diverticulum with delayed open surgical repair.

Spontaneous rupture of a bladder diverticulum is a rare entity typically associated with tissue weakness, bladder outlet obstruction, increased intra-abdominal pressure, or inflammation. Diagnosis is most often achieved via cystogram with a reported role for pelvic ultrasound. Extraperitoneal ruptures are typically treated with catheterization and antibiosis while intraperitoneal ruptures are most frequently treated with immediate surgical intervention. In this case, an adult female presented with an intraperitoneal rupture with no clear inciting event with diagnosis confirmed by pelvic transvaginal ultrasound following a non-diagnostic cystogram. The patient was treated successfully with delayed open surgical repair.

Contemporary National Trends and Variations of Pelvic Lymph Node Dissection in Patients Undergoing Robot-Assisted Radical Prostatectomy.

INTRODUCTION: Previous studies showed suboptimal adherence to clinical practice guidelines for pelvic lymph node dissection (PLND) during radical prostatectomy (RP). Robot-assisted RP (RARP) has become the predominant surgical management for localized prostate cancer in the United States but contemporary national data on PLND adherence during RARP are still lacking. METHODS: RARPs for clinically localized (cT1-2N0M0) intermediate-risk and high-risk prostate cancer diagnosed between 2010 and 2016 in National Cancer Database were identified. Outcome of interest was PLND and multivariable logistic regressions were used to identify whether patient demographics and facility characteristics were associated with the outcome. RESULTS: We included 115,355 patients in the final cohort (intermediate-risk = 86,314, high-risk = 29,041). From 2010 to 2016, there was an increasing trend of PLND in the overall, intermediate-risk, and high-risk cohorts. In 2016, PLND was performed in 79.7% of the intermediate-risk and 93.5% of the high-risk patients. Multivariable logistic regressions showed Hispanic race/ethnicity (vs. white) (odds ratio [OR] = 0.90, P = .010), lowest socioeconomic status (vs. highest) (OR = 0.85, P < .001), rural area (vs. metro area) (OR=0.61, P < .001), and community facility (vs. academic) (OR = 0.56, P < .001) were some of the factors associated with lower PLND rate. Variations of PLND rate among reporting facility's locations were also identified. CONCLUSION: Contemporary national data showed significantly increased PLND rate in patients who underwent RARP for intermediate-risk and high-risk prostate cancer in recent years. However, there were still some variations in PLND rate among different patient populations and facilities. Continued efforts need to be made to further increase PLND rate and narrow or eliminate disparities we identified.

Surgical Delay and Pathological Outcomes for Clinically Localized High-Risk Prostate Cancer.

Importance: There is a lack of data evaluating the association of surgical delay time (SDT) with outcomes in patients with localized, high-risk prostate cancer. Objective: To investigate the association of SDT of radical prostatectomy and final pathological and survival outcomes. Design, Setting, and Participants: This cohort study used data from the US National Cancer Database (NCDB) and identified all patients with clinically localized (cT1-2cN0cM0) high-risk prostate adenocarcinoma diagnosed between 2006 and 2016 who underwent radical prostatectomy. Data analyses were performed from April 1 to April 12, 2020. Exposures: SDT was defined as the number of days between the initial cancer diagnosis and radical prostatectomy. SDT was categorized into 5 groups: 31 to 60, 61 to 90, 91 to 120, 121 to 150, and 151 to 180 days. Main Outcomes and Measures: The primary outcomes were predetermined as adverse pathological outcomes after radical prostatectomy, including pT3-T4 disease, pN-positive disease, and positive surgical margin. The adverse pathological score (APS) was defined as an accumulated score of the 3 outcomes (0-3). An APS of 2 or higher was considered a separate outcome to capture cases with more aggressive pathological features. The secondary outcome was overall survival. Results: Of the 32 184 patients included in the study, the median (interquartile range) age was 64 (59-68) years, and 25 548 (79.4%) were non-Hispanic White. Compared with an SDT of 31 to 60 days, longer SDTs were not associated with higher risks of having any adverse pathological outcomes (odds ratio [OR], 0.95; 95% CI, 0.80-1.12; P = .53), pT3-T4 disease (OR, 0.99; 95% CI, 0.83-1.17; P = .87), pN-positive disease (OR, 0.79; 95% CI, 0.59-1.06; P = .12), positive surgical margin (OR, 0.88; 95% CI, 0.74-1.05; P = .17), or APS greater than or equal to 2 (OR, 0.90; 95% CI, 0.74-1.05; P = .17). Longer SDT was also not associated with worse overall survival (for SDT of 151-180 days, hazard ratio, 1.12; 95% CI, 0.79-1.59, P = .53). Subgroup analyses performed for patients with very high-risk disease (primary Gleason score 5) and sensitivity analyses with SDT considered as a continuous variable yielded similar results. Conclusions and Relevance: In this cohort study of patients who underwent radical prostatectomy within 180 days of diagnosis for high-risk prostate cancer, radical prostatectomy for high-risk prostate cancer could be safely delayed up to 6 months after diagnosis.

Associations between Hospital Volume and Outcomes of Robot-Assisted Radical Prostatectomy.

PURPOSE: Robot-assisted radical prostatectomy has become the predominant surgical modality to manage localized prostate cancer in the U.S. However, there are few studies focusing on the associations between hospital volume and outcomes of robot-assisted radical prostatectomy. MATERIALS AND METHODS: We identified robot-assisted radical prostatectomies for clinically localized (cT1-2N0M0) prostate cancer diagnosed between 2010 and 2014 in the National Cancer Database. We categorized annual average hospital robot-assisted radical prostatectomy volume into very low, low, medium, high and very high by most closely sorting the final included patients into 5 equal-sized groups (quintiles). Outcomes included 30-day mortality, 90-day mortality, conversion (to open), prolonged length of stay (more than 2 days), 30-day (unplanned) readmission, positive surgical margin and lymph node dissection rates. RESULTS: A total of 114,957 patients were included in the study, and hospital volume was categorized into very low (3 to 45 cases per year), low (46 to 72), medium (73 to 113), high (114 to 218) and very high (219 or more). Overall 30-day mortality (0.12%), 90-day mortality (0.16%) and conversion rates (0.65%) were low. Multivariable logistic regressions showed that compared with the very low volume group, higher hospital volume was associated with lower odds of conversion to open surgery (OR 0.23, p <0.001 for very high), prolonged length of stay (OR 0.25, p <0.001 for very high), 30-day readmission (OR 0.53, p <0.001 for very high) and positive surgical margins (OR 0.61, p <0.001 for very high). Higher hospital volume was also associated with higher odds of lymph node dissection in the intermediate/high risk cohort (OR 3.23, p <0.001 for very high). CONCLUSIONS: Patients undergoing robot-assisted radical prostatectomy at higher volume hospitals are likely to have improved perioperative and superior oncologic outcomes compared to lower volume hospitals.

National trends and disparities of minimally invasive surgery for localized renal cancer, 2010 to 2015.

PURPOSE: To investigate national utilization trends of minimally-invasive partial nephrectomy (PN) and minimally-invasive radical nephrectomy (RN), and to identify disparities in the usage of these techniques across different sociodemographic subgroups. MATERIALS AND METHODS: A retrospective cohort study was conducted using the National Cancer Database to identify patients undergoing partial or RN for cT1N0M0 renal cancer diagnosed between 2010 and 2015. Main outcomes of interest were the utilizations of minimally-invasive (robotic and laparoscopic) PN and RN. RESULTS: A total of 46,346 and 37,712 subjects who underwent PN and RN, respectively, were analyzed. During the study interval, increased utilization of robotic surgery paralleled the decreased utilization of open surgery. Robotic PN increased from 35.2% to 63.7% and robotic RN increased from 10.3% to 26.3%. The utilization of laparoscopic surgery was decreasing for PN but stable for RN through the study period. In the PN cohort, multivariable logistic regression showed non-Hispanic black (odds ratio [OR] = 0.90 [95% CI, 0.84-0.96]) and Hispanic (OR = 0.91 [0.84-0.99]) subjects were associated with less utilization of minimally invasive surgery (MIS) (vs. non-Hispanic white). Younger (18-64 years) Medicare (OR = 0.83 [0.77-0.90]), Medicaid (OR = 0.80 [0.74-0.87]), and uninsured (OR = 0.55 [0.49-0.62]) were also associated with less utilization of MIS (vs. private insurance). Compared with low socioeconomic status (SES), upper middle (OR = 1.14 [1.07-1.21]) and high (OR = 1.24 [1.16-1.33]) SES were associated with higher utilization of MIS. Similar demographic, insurance, and SES-related disparities were identified in the RN cohort. CONCLUSIONS: Utilization of MIS for localized renal cancer has increased significantly and was mainly attributed to increased usage of robotic surgery. Racial/ethnic, insurance, and SES related disparities in MIS utilization were identified. Our findings demonstrate a targetable subgroup of patients who do not have the same access to advances in surgical technology.

Concurrent Inguinal Hernia Repair in Patients Undergoing Minimally Invasive Radical Prostatectomy: A National Surgical Quality Improvement Program Study.

OBJECTIVE: To compare perioperative 30-day outcomes between minimally invasive radical prostatectomy (MIRP) with and without concurrent inguinal hernia repair (IHR) using a national database. METHODS: The National Surgical Quality Improvement Program database was queried for MIRP from 2012 to 2015. Concurrent IHR was identified using relevant Current Procedural Terminology codes. Primary outcomes were overall complications, reoperations, unplanned readmissions, and mortality within 30 days of MIRP. Secondary outcomes included operative time (OT), length of stay (LOS), prolonged length of stay (PLOS, >2 days), and discharged to continued care (DCC). Multivariable logistic regression was performed to identify the association between concurrent IHR and outcomes. RESULTS: A total of 18,065 patients were included; 375 (2.1%) had concurrent IHR. The unadjusted comparison showed no significant difference in overall complication, reoperation, unplanned readmission, or mortality rates between MIRP+IHR and MIRP only groups. OT was longer in the MIRP+IHR group (229 vs 195 minutes, p < 0.001) but no differences were found in LOS, PLOS, or DCC rates. Multivariable logistic regression showed concurrent IHR was not associated with increased odds of overall complication (odds ratio [OR] = 0.83, 95% confidence interval [CI] = 0.49-1.40, p = 0.479), reoperation (OR = 0.57, 95% CI = 0.14-2.30, p = 0.426), unplanned readmission (OR = 0.92, 95% CI = 0.51-1.64, p = 0.771), PLOS (OR = 1.19, 95% CI = 0.86-1.63, p = 0.297), or DCC (OR = 1.94, 95% CI = 0.70-5.34, p = 0.202). CONCLUSIONS: Concurrent IHR with MIRP was associated with longer OT, but there were no increased 30-day adverse outcomes within the National Surgical Quality Improvement Program (NSQIP) database. These data support the safety of performing concurrent IHR at the time of MIRP and it should be considered to spare men an additional procedure.

Hospital volume and short-term outcomes after cytoreductive nephrectomy.

PURPOSE: To investigate the impact of hospital volume on short-term outcomes after cytoreductive nephrectomy (CN) for metastatic renal cell carcinoma (mRCC). METHODS: We identified mRCC patients who underwent CN from 2006 to 2013 in the National Cancer Database. Annual hospital CN volume was categorized as high (top 20th percentile) and low. Multivariable logistic regressions were used to compare 30-day mortality, 90-day mortality, prolonged length of stay (PLOS, ≥7 days), and 30-day readmission rates. Sensitivity analyses were performed with hospital volume considered as a continuous variable. RESULTS: A total of 9789 patients were included with high-volume (n = 1916) defined as ≥8 cases and low-volume (n = 7873) as 1-7 cases annually. Multivariable logistic regression showed that high-volume was associated with lower odds of 30-day mortality (OR = 0.69, P = 0.013), 90-day mortality (OR = 0.65, P < 0.001), PLOS (OR = 0.82, P = 0.002), and 30-day readmission (OR = 0.78, P = 0.028). Sensitivity analyses showed that increasing hospital volume (per case) was associated with lower odds of 30-day mortality (OR = 0.965, P = 0.008), 90-day mortality (OR = 0.966, P < 0.001), PLOS (OR = 0.982, P = 0.001), and 30-day readmission (OR = 0.975, P = 0.012). CONCLUSION: Higher hospital volume was associated with better short-term outcomes after CN. Future studies are needed to validate our findings and explore the potential components leading to better outcomes in the higher volume hospitals.

Hospital volume and outcomes of robot-assisted partial nephrectomy.

OBJECTIVE: To evaluate the impact of hospital volume on outcomes of robot-assisted partial nephrectomy (RAPN). MATERIALS AND METHODS: Patients with renal cell carcinoma who underwent RAPN between 2010 and 2013 were identified in the National Cancer Database. Hospital yearly RAPN volume was categorized into groups by sorting patients as closely as possible into five groups of equal size (quintiles): very low; low; medium; high; and very high volume. Outcomes included 30-day mortality, 90-day mortality, open conversion, prolonged length of hospital stay (PLOS; defined as >3 days), 30-day readmission rate, and positive surgical margin (PSM) rate. Unadjusted analyses and multivariable logistic regressions were used to compare outcomes. Sensitivity analyses with hospital volume considered as a continuous variable were also performed. RESULTS: A total of 18 724 RAPN cases were included. Hospital volume quintiles were: very low volume, 1-7 cases (n = 3 693); low volume, 8-14 cases (n = 3 719); medium volume, 15-23 cases (n = 3 833); high volume, 24-43 cases (n = 3 649); and very high volume, ≥44 cases (n = 3 830). There was no significant difference in 30-day or 90-day mortality among the five groups. Multivariable logistic regression analysis (reference: very low volume) showed that higher hospital volume was associated with lower odds of conversion (low [odds ratio {OR}: 0.88; P = 0.377]; medium [OR: 0.60; P = 0.001]; high [OR: 0.57; P < 0.001]; very high [OR: 0.47; P < 0.001]), lower odds of PLOS (low [OR: 0.93; P = 0.197], medium [OR: 0.75; P < 0.001]; high [OR: 0.62; P < 0.001]; very high [OR: 0.45; P < 0.001]), and lower odds of PSMs (low [OR: 0.76; P < 0.001]; medium [OR: 0.76, P < 0.001]; high [OR: 0.59; P < 0.001]; very high [OR: 0.34; P < 0.001]). Sensitivity analyses confirmed increasing hospital volume (per 1-case increase) was associated with lower odds of conversion (OR: 0.986; P < 0.001), PLOS (OR: 0.989; P < 0.001) and PSMs (OR: 0.984; P < 0.001). A difference in 30-day readmission rate was found in unadjusted analysis but not in adjusted analyses. CONCLUSION: Undergoing RAPN at higher-volume hospitals may have better peri-operative outcomes (conversion to open and LOS) and lower PSM rates. Future studies are needed to explore the detailed components that lead to the superior outcomes in higher-volume hospitals.