It's complicated: The relationship of non-narcotic medications and postoperative opioid use in radical cystectomy patients.

INTRODUCTION: The effect of individual non-narcotic analgesics in cystectomy enhanced recovery after surgery (ERAS) is unknown. Additionally, many non-narcotic medications are associated with side effects pertinent to the cystectomy population. To better understand the actual use and utility of these medications, we sought to characterize the association between non-narcotic medications and milligram morphine equivalent (MME) narcotic score during the postoperative inpatient stay. METHODS: We reviewed 260 consecutive ERAS cystectomy patients. The MME impact of non-narcotic compliance and cumulative dose of medication received was evaluated separately with general linear models. We also assessed relationship of non-narcotic compliance to patient reported pain score, length of stay (LOS), and time to return of bowel function (ROBF) and performed manual review of postoperative documentation to identify reasons for medication noncompliance. RESULTS: Compliance with postoperative acetaminophen, gabapentin, and ketorolac was low. There was an inverse relationship between ketorolac dose and MME on postoperative day 1 (-0.026 MME/mg; P = 0.004) and postoperative day 2 (-0.33 MME/mg; P < 0.001). Compliance with ketorolac was associated with lower MME on postoperative day 1 (26.1 MME v. 33.6 MME; P = 0.023). There were no such associations identified with gabapentin or acetaminophen. Gabapentin compliance was associated with earlier ROBF (3.7 days v. 4.3 days; P = 0.006). Ketorolac compliance was associated with lower pain score on POD1 (3.25 VAS v. 4.07 VAS; P = 0.019) and POD2 (3.05 VAS v. 3.85 VAS; P = 0.040) There was no association between medication compliance and LOS. The most common reasons identified for non-compliance with gabapentin and ketorolac were renal function concerns (38% and 40% respectively), bleeding concerns with ketorolac (20%) and concerns for neurologic adverse effect with gabapentin (16%). CONCLUSION: Compliance with non-narcotic medications in our ERAS cystectomy protocol was poor. There was a modest association with ketorolac and postoperative MME but no association with gabapentin or acetaminophen. Further study will clarify the role of these medications for cystectomy patients. Component specific analysis of protocolized care is valuable and may alter care pathways.

Impact of pathologic features on local recurrence in penile squamous cell carcinoma after penectomy.

BACKGROUND: Penile squamous cell carcinoma (PSCC) is a rare malignancy that may be cured in cases of local disease by resection of the primary tumor. Risk factors and patterns of local recurrence (LR) have not been well described in cases requiring partial or radical penectomy. In this study, we evaluated risk factors for LR and the impact of frozen and final margin assessment. MATERIALS AND METHODS: We evaluated 119 patients with PSCC who had undergone partial or radical penectomy from 2007 to 2023. Data regarding clinical and pathologic features were collected by retrospective chart review. The primary outcome of interest was LR. Determinants of LR were analyzed by Student's t, Fisher's exact, chi-square and logistic regression analysis. Predictive statistics of frozen margin status on final margin were assessed and LR rates for subsets of frozen and final margin interaction were defined. Finally, all cases of positive margins and LR were described to highlight patterns of LR and the importance of margin status in these cases. RESULTS: There were 8 (6.7%) cases of local recurrence. There were no significant predictors of LR, although a trend toward increased LR risk was observed among those with a positive final margin. Positive final margins were found in 15 (13%) cases. Frozen margin analysis was utilized in 79 cases, of which 10 (13%) were positive. The sensitivity, specificity, positive predictive value, and negative predictive value of frozen margin status for final margins were 44%, 92%, 40%, and 93%, respectively. There were no LR among cases in which frozen margin was not sent. Analysis of all cases with positive margin and/or LR identified three subsets of patients: CIS or focally positive margin resulting in either no LR or LR managed with minimal local intervention, bulky disease in which survival is determined by response to subsequent therapy rather than local recurrence, and clinically significant local recurrence requiring continued surveillance and intervention despite negative margins. CONCLUSIONS: LR is rare, even in cases of larger, proximal tumors requiring partial or radical penectomy. In this study, no statistically significant risk factors for local recurrence were identified; however, analysis of frozen and final margins provided insight into the importance of margin status and patterns of local recurrence. When feasible, visibly intra-operative negative margins are an excellent predictor of low risk for LR, and, in cases of CIS or focally positive margins, further resection to achieve negative margins is unlikely to reduce the risk of clinically significant LR. Additionally, in cases of bulky disease, the goals of resection should be focused toward palliation and next line therapy.

Persistent opioid and benzodiazepine use after radical cystectomy in enhanced recovery after surgery (ERAS) patients.

OBJECTIVES: Opioid use, misuse, and diversion is of paramount concern in the United States. Radical cystectomy is typically managed with some component of opioid pain control. We evaluated persistent opioid and benzodiazepine use after radical cystectomy and assessed the impact of their preoperative use on this outcome. We also explored associations between preoperative use and perioperative outcomes. METHODS AND MATERIALS: We used prospectively maintained data from our enhanced recovery after surgery (ERAS) cystectomy database and the Prescription Reporting with Immediate Medication Utilization Mapping (PRIMUM) database to identify controlled substance prescriptions for radical cystectomy patients. We separated patients by frequency of preoperative opioid and/or benzodiazepine prescriptions (0, 1, 2+) and used these cohorts to explore persistent use (prescription 3-12 months after surgery) alongside perioperative outcomes. RESULTS: Our cohort included 257 patients undergoing cystectomy at a single institution from 2017 to 2021. Preoperative opioid and benzodiazepine prescriptions were documented for 120 (46.7%) and 26 (10.1%) patients, respectively. Persistent opioid use was observed in 20 (14.6%) of opioid-naive patients (no prescriptions in 9 months prior to surgery) while 13 (19.7%) patients with 1 preoperative prescription and 28 (51.9%) patients with 2 or more preoperative prescriptions demonstrated persistent use. New persistent benzodiazepine use occurred in 6 (2.6%) patients. Overall persistent benzodiazepine use was present in 11 (4.3%) patients. In a multivariable model, preoperative opioid and benzodiazepine prescriptions were associated with persistent opioid use (P < 0.001; P = 0.027 respectively). No association was identified between preoperative opioid or benzodiazepine usage and perioperative outcomes including length of stay, return of bowel function, inpatient opioid usage, inpatient or discharge complications, readmissions, or emergency department visits. Inpatient pain scores were noted to be higher in patients with ≥ 2 preoperative opioid prescriptions (P = 0.037). CONCLUSIONS: Persistent opioid use was present in 23.7% of patients, with a new persistent use rate of 14.6%. Benzodiazepine use was less frequent than opioids, with a small number demonstrating new persistent use. Preoperative opioid and benzodiazepine use is associated with persistent opioid use postoperatively. Preoperative opioid and benzodiazepine use did not affect perioperative outcomes in our cohort.

Renal Mass Biopsy Mandate Is Associated With Change in Treatment Decisions.

PURPOSE: To prevent avoidable treatment and make more informed care decisions about small renal masses, the use of renal mass biopsies has increased since the early 2000s. In April 2017, Atrium Health Carolinas Medical Center began requiring biopsies before all percutaneous thermal ablation procedures for renal masses. We aim to determine the effect of this preablation biopsy mandate on small renal mass treatment decisions. MATERIALS AND METHODS: Our study is a retrospective analysis of a prospectively managed database designed to track patients with small renal masses presented at the Kidney Tumor Program from 2000-2020. We separated patients into 2 cohorts (pre- and postmandate) based on the initial encounter date, excluding those from April 2017-April 2018 to allow for implementation of the mandate. We also excluded patients with masses >4 cm. RESULTS: Overall, we found no significant difference between the pre- and postmandate cohorts, with race as an exception. Implementation of the mandate coincided with an increase in biopsies for both ablation and nonablation treatment pathways (P < .001, P = .01). Renal mass biopsy rates increased in all socioeconomic groups except the lowest quartile. Additionally, Black/Hispanic patients had the highest biopsy rate. We found significant changes in treatment decisions between our cohorts: surgery decreased 24% (P < .001), active surveillance increased 28% (P < .001), and patients with no follow-up decreased 8% (P = .03). CONCLUSIONS: Our data indicate that a preablation renal mass biopsy mandate is associated with the wider use of biopsies for all small renal mass patients, fewer surgical interventions, and an increase in active surveillance.

Impact of dedicated renal enhanced recovery after surgery (RERAS) program on postoperative opioid consumption and evaluation of surgeon-specific compliance to the program.

INTRODUCTION AND OBJECTIVE: Enhanced Recovery After Surgery (ERAS) protocols have been increasingly applied to urologic surgeries such as cystectomy and prostatectomy, though research defining protocols and outcomes for renal ERAS programs (RERAS) for nephrectomy remains limited. We aim to assess perioperative outcomes following implementation of our RERAS protocol modified from ERAS society cystectomy guidelines, as well as describe compliance with protocol guidelines. METHODS: We performed a retrospective cohort analysis of 400 patients who underwent partial or radical nephrectomy between October 2017 and August 2020. RERAS protocol was initiated September 30, 2018, and patients were categorized into pre- and post-RERAS implementation cohorts based on surgery date. Perioperative outcomes including complications, 30-day readmissions, length of stay, and opioid consumption were compared across pre- and post-RERAS cohorts. Protocol compliance was reported based on adherence to program recommendations. RESULTS: Among 400 patients included in analysis, the pre-RERAS cohort included 133 patients and the post-RERAS cohort included 267 patients. There were no differences in overall complications (P = 0.354) and 30-day readmissions (P = 0.078). Length of stay (P < 0.001) and postoperative opioid consumption (P < 0.001) were significantly reduced post-RERAS. We observed an increase in compliance with RERAS recommendations over time (P< 0.001). CONCLUSION: RERAS implementation was associated with decreased length of stay and opioid usage, underscoring the benefits of program adoption in an era of opioid dependence and strained hospital capacity. Successful initiation of a RERAS protocol requires intentional organization and buy in from all providers involved.

Racial and Socioeconomic Disparities in MRI-Fusion Biopsy Utilization to Assess for Prostate Cancer.

OBJECTIVE: To evaluate whether racial disparities in MRI-Bx usage persisted after correction for socioeconomic, demographic, and clinical factors. METHODS: This is a retrospective cohort study of patients who received either MRI-Bx or systematic biopsy (SB) within a single academic medical center between January 2018 - June 2020. For each patient, socioeconomic variables including household income, education, percent below poverty, and unemployment were estimated using 2015 American Community Survey census-tract level data. Chi-square analysis was used to examine differences in clinical and demographic characteristics between the two groups. The Benjamini-Hochberg procedure was used to control false discovery rate (FDR) for multiple testing. RESULTS: Eighteen percent of Black men (53/295) received MRI-Bx while 41% (228/561) of white men received MRI-Bx. Patients coming from highly impoverished areas were less likely to receive MRI-Bx, 25% vs 75%, respectively. In multivariate analysis, race remained significantly different across MRI-Bx and SB groups. Clinical factors including family history, DRE, BMI, and prostate volume were not significantly different between patients receiving MRI-Bx and SB. CONCLUSION: Black men are less likely to receive MRI-Bx than white men, even after adjusting for clinical and socioeconomic characteristics. Further work is necessary to identify and study methods to increase equity in PCa diagnostic testing.

Surgeon-administered Transversus Abdominis Plane (TAP) Block is Associated With Decreased Opioid Usage and Length of Stay Following Radical Cystectomy.

OBJECTIVE: To study the effect of surgeon-administered Transversus Abdominis Plane block (sTAP) on opioid usage and length of stay (LOS). METHODS: Starting in April 2018, two surgeons at our institution gradually introduced sTAP for radical cystectomy (RC) patients. We performed a retrospective observational cohort analysis of RC patients catalogued in a prospectively maintained database using the Enhanced Recovery After Surgery Interactive Auditing System. Two surgeons adopted the sTAP block technique in April 2018. We included patients undergoing RC for bladder malignancy under Enhanced Recovery After Surgery protocol between January 2017 and August 2020. Primary outcomes included LOS, and postoperative day (POD) 0-3 total opioids consumption measured by morphine milligram equivalents (MME). Multivariable linear or logistic models evaluated the association of TAP with outcomes while controlling for potential confounders. RESULTS: Among 178 patients included in analysis, 84 patients underwent sTAP block and 94 did not. Multivariable analysis demonstrated significantly lower POD 0-3 total opioid usage (106.4 vs 192.2 MME, P = .004), and mean LOS (5.6 vs 7.7 days, P <.001) among the sTAP group. CONCLUSION: sTAP appears to be an effective adjunct to RC care associated with improved LOS, and POD 0-3 opioid consumption. Further studies are needed to optimize TAP block technique and anesthetic composition.

Genomic analysis of response to bacillus Calmette-Guérin (BCG) treatment in high-grade stage 1 bladder cancer patients.

BACKGROUND: Intravesical bacillus Calmette-Guérin (BCG) therapy is standard treatment for high-risk non-muscle invasive bladder cancer (NMIBC) but overall efficacy is low, and no reliable predictive biomarkers currently exist to refine patient selection. We performed genomic analysis on high-grade (HG) T1 NMIBCs to determine if response to therapy is predicted by certain mutational and/or expressional changes. METHODS: Patients with HG T1 NMIBC treated with induction BCG were stratified by response into durable and non-durable responders. Baseline tumor samples were subjected to targeted DNA sequencing and whole-exome RNAseq. Genomic variants differing significantly between response groups were analyzed using Ingenuity Pathway Analysis (IPA) software. Variant selection was refined to target potential biomarker candidates for responsiveness to BCG. RESULTS: Among 42 patients, the median follow-up was 51.7 months and 40.5% (n=17) were durable BCG responders. Deleterious mutations in the RNA sequence of JCHAIN, S100A7, CLEC2B, and ANXA10 were more common in non-durable responders. Mutations in MCL1 and MSH6 detected on targeted sequencing were more commonly found in durable responders. Of all deleterious DNA and RNA mutations identified, only MCL1 was significantly associated with longer recurrence free survival (RFS) (P=0.031). CONCLUSIONS: Differences in the genomic profiles of HG T1 NMIBC tumors exist between those who show durable response to BCG and those who do not. Using pathway analysis, those differences imply upregulation of several interconnected inflammatory pathways among responders. Specific variants identified here, namely MCL1, are candidates for further study and, if clinically validated, may serve as useful biomarkers in the future.

Racial Disparities in Prostate Specific Antigen Screening and Referral to Urology in a Large, Integrated Health Care System: A Retrospective Cohort Study.

PURPOSE: Contemporary trends and racial disparities in prostate cancer screening and referral to urology for prostate cancer risk are not well characterized, despite consensus that Black men are at higher risk for poor prostate cancer outcomes. The objective of this study was to characterize current racial disparities in prostate cancer screening and referral from primary care to urology for prostate cancer concern within our large, integrated health care system. MATERIALS AND METHODS: This retrospective cohort study used data from Atrium Health's enterprise data warehouse, which includes patient information from more than 900 care locations across North Carolina, South Carolina and Georgia. We included all men seen in the ambulatory or outpatient setting between 2014 and 2019 who were ≥40 years old. Clinical and demographic data were collected for all men, including age and race. Racial outcomes were reported for all groups with >2% representation in the population. Between-group comparisons were determined using chi-squared analysis, Wilcoxon rank sum testing and multivariable logistic regression, with significance defined as p <0.05. RESULTS: We observed a significant decrease in prostate specific antigen testing across all age and racial groups in a cohort of 606,985 men at Atrium Health, including 87,189 Black men, with an overall relative decline of 56%. As compared to White men, Black men were more likely to undergo prostate specific antigen testing (adjusted OR 1.24, 95% CI 1.22-1.26) and be referred to urology for prostate cancer (adjusted OR 1.94, 95% CI 1.75-2.16). CONCLUSIONS: There was a continued significant decline in prostate cancer screening between 2014 and 2019. Despite having modestly elevated odds of being screened for prostate cancer compared to White men, Black men are relatively underscreened when considering that those who undergo prostate specific antigen screening are more likely to be referred by primary care to urology for additional prostate cancer diagnostic evaluation.

Safety of decreasing ureteral stent duration following radical cystectomy.

PURPOSE: We aim to assess the safety of decreasing ureteral stenting duration following Radical Cystectomy with Urinary Diversion (RCUD). MATERIALS AND METHODS: We analyzed a prospectively and retrospectively collected dataset for cystectomy patients at our tertiary center. Adult patient who underwent RCUD for malignancy from January 2013 to February 2018 were included. Patients with a history of abdominal/pelvic radiation and continent diversions were excluded. The patient population was divided to late stent removal group (LSR-POD 14) and early stent removal group (ESR-POD5). Our endpoints were total stent duration, 90-day readmission, 90-day total-UTI, 90-day urinary-readmissions, complications and Ureteroenteric Stricture (UES) rates. Statistical methods included t test, Chi-squared test and multivariate logistic regression. RESULTS: One hundred and seventy-eight patients were included in the final analysis after inclusion/exclusion criteria were applied. The LSR (n = 74) and ESR (n = 104) groups were similar in preoperative characteristics except higher intracorporeal ileal conduit formation in ESR. The duration of stenting decreased significantly from approximately 15.5-5 days (P < 0.001). The LSR had higher 90-day overall readmission rates (OR = 2.57, 95% CI 1.19-5.53, P = 0.016) and total-UTIs (OR = 2.36, 95%CI 1.11-5.04, P = 0.026). With a median follow-up of 9.8 months, UES was similar between the two groups. CONCLUSION: Shorter ureteral stent duration is a safe and non-inferior option following RCUD. It allows for stent removal prior to discharge and less outpatient visits. In addition, decreasing stent duration was linked decreased readmissions and total-UTIs without increased risk of UES. However, future studies are needed to establish causality and promote stent duration change.

Clinical Utility of Postneoadjuvant Chemotherapy Computerized Tomography for Muscle Invasive Urothelial Bladder Cancer.

INTRODUCTION: For muscle invasive bladder cancer, computerized tomography scans are often used before cystectomy to optimize surgical decision planning. The aim of this study is to evaluate the clinical value of postneoadjuvant chemotherapy computerized tomography in patients with localized bladder cancer before cystectomy. METHODS: All T2-3N0 patients with urothelial bladder cancer who completed cisplatin based neoadjuvant chemotherapy were retrospectively analyzed. On postneoadjuvant chemotherapy computerized tomography patients with tumor progression, nodal involvement, metastatic disease and noncancer findings were determined, and subsequent surgical decision making was evaluated. RESULTS: Of 79 cases 21.5% had a new finding on postneoadjuvant chemotherapy scan of which false-positive rates for nodal and metastatic disease were 100%. The frequency of novel findings on postneoadjuvant computerized tomography were 4 (5.1%) with tumor progression, 6 (7.6%) newly discovered enlarged nodes, 8 (10.1%) suspicious for distant metastases and 3 (3.8%) noncancer related conditions. Only 3.8% (3) had alterations in original cystectomy plans exclusively due to tumor progression and 100% of the cohort underwent cystectomy. Overall survival was not associated with new findings (3-year OS 77.4% vs 74%, p=0.473). Median time from postneoadjuvant chemotherapy scan to cystectomy was statistically delayed for patients with new radiographic findings vs those with consistent preneoadjuvant chemotherapy scans (29.5 vs 51 days; p=0.014). CONCLUSIONS: Compared to the preneoadjuvant chemotherapy scans, our data suggests that postneoadjuvant chemotherapy computerized tomography scans discover new findings in approximately 21.5% of cases, but this rarely changes preoperative plans, is not associated with overall survival and is frequently associated with false-positive results.

Association of 5-Alpha Reductase Inhibitor Use with Prostate Specific Antigen Level at the Time of Urology Referral in a Retrospective Cohort at a Large, Integrated Health Care System.

INTRODUCTION: 5-Alpha reductase inhibitor (5-ARI) use leads to a 50% decline in serum prostate specific antigen (PSA) without a concomitant decrease in prostate cancer (PCa) risk. We hypothesize that failure to account for the effect of 5-ARI use on serum PSA leads to increased PCa risk at urology referral among 5-ARI users. METHODS: This is a retrospective cohort study for the years 2018-2019. Atrium Health is a large, vertically integrated health system with over 900 care locations in North Carolina and South Carolina. Men ≥40 years old during 2018-2019 who had a PSA test performed were included. We determined differences in corrected serum PSA level at the time of referral to urology. 5-ARI users and nonusers were compared using the chi-square test, Student's t-test and gamma regression. RESULTS: From 2018-2019, there were 91,368 men who underwent PSA testing, including 2,939 5-ARI users. At referral, 5-ARI users had similar uncorrected median PSA (5.8 vs 5.6 ng/ml, p=0.05). After correcting for the effect of 5-ARIs on PSA, 5-ARI users had a median PSA of 11.6 ng/ml at urology referral, compared to 5.6 ng/ml in nonusers. CONCLUSIONS: Men taking 5-ARIs have higher corrected serum PSA at time of referral to urology. As the unadjusted PSA at referral to urology for PCa risk was similar between 5-ARI users and nonusers, this indicates that the effect of 5-ARI use on serum PSA levels is not routinely accounted for when assessing PCa risk.

Epidemiology and survival outcome of adult kidney, bladder, and prostate rhabdomyosarcoma: A SEER database analysis.

Rhabdomyosarcoma (RMS) is rare in adulthood, accounting for 2%-5% of adult soft tissue tumors, and less than 20% occur in genitourinary organs. Given its rarity, survival data on adult kidney, bladder, and prostate RMSs is limited. In this population-based analysis, we performed an analysis of all adult RMS cases reported in Surveillance, Epidemiology, and End Results (SEER) database to understand prognostic factors among kidney, bladder, and prostate RMS. A query of the SEER database was performed from 1973 to 2016 for patients >18 of age with RMS. The final cohort consisted of 14 kidney, 35 bladder, and 21 prostate RMS cases in the adult population. Demographic, treatment, and survival data were obtained. Analysis was performed using Fisher's exact test, survival analysis, and model. The median (range) age of diagnosis for adult bladder RMS was 65 years old (19-84) compared to 52.5 (28-68) and 42 (19-87) for kidney and prostate (p = 0.007). About 78.6% of patients underwent surgical intervention. Five-year overall survival (OS) for adult kidney, bladder, and prostate RMS are 17.1% (2.9-41.6%), 22.2% (9.4-38.4%), and 33.0 (12.8-55.0%), respectively. OS was not statistically associated with primary site (p = 0.209). On multivariable analysis, compared to adult bladder RMS, kidney RMS had a higher incidence of mortality (HR: 2.16, 95% CI 1.03-4.53, p = 0.041). Incidence of mortality from prostate RMS was not significantly different from bladder RMS (HR: 0.70, 95% CI 0.30-1.65, p = 0.411). Extent of disease (HR: 5.17, 95% CI 2.09-12.79, p < 0.001) and older age (HR 1.03, 95% CI 1.01-1.04, p = 0.002) were adverse prognostic factors for OS. Overall survival at 5 years for adult kidney, bladder, and prostate RMS is poor. Localized disease and younger age are prognostic factors for improved outcomes in adult RMS. Hence, early diagnosis and intervention appear paramount to improved survival for this rare malignancy in adulthood.

Safety and effectiveness of percutaneous renal cryoablation with conscious sedation.

OBJECTIVE: To investigate complications and treatment failure rates of percutaneous renal cryoablation (PRC) for small renal masses under local anaesthesia and conscious sedation (LACS), to assess the safety and effectiveness of this approach, as PRC is typically performed under general anaesthesia (GA). PATIENTS AND METHODS: We retrospectively reviewed PRC under LACS from 2003 to 2017. We analysed perioperative parameters between patients who successfully underwent PRC under LACS and patients with post-procedural complications or treatment failure (renal mass enhancement after successful intraoperative tumour ablation). Two-sided non-parametric and Fisher's exact tests were performed to compare uncomplicated or disease-free PRC with the complication or treatment failure group, respectively. RESULTS: A total of 100 PRCs under LACS were performed during the study period. Of these patients, six patients had at least one postoperative complication (6%), and treatment failure was diagnosed in nine patients (9%) after PRC [mean (SD) follow-up of 42.7 (26.6) months]. The procedural failure rate was 1%. No ablations were converted to GA. The mean tumour size was smaller in patients who had no complications during PRC compared to those who did, at a mean (SD) of 2.2 (0.6) cm vs 3.0 (1.0) cm (P = 0.039). The use of more intraoperative probes during the PRC was also associated with complications, at a mean (SD) 3.0 (1.4) vs 1.8 (0.8) (P = 0.021). CONCLUSIONS: PRC under LACS is an effective and safe procedural approach for managing small renal masses with low complication, treatment failure, and procedural failure rates. Larger renal masses and intraoperative use of multiple probes is associated with an increased risk of PRC complications. ABBREVIATIONS: BMI: body mass index; CCI: Charlson Comorbidity Index; GA: general anaesthesia; LACS: local anaesthesia and conscious sedation; PRC: percutaneous renal cryoablation; R.E.N.A.L.: Radius, Exophytic/Endophytic, Nearness, Anterior/Posterior, Location.

Implementation of a Dedicated Enhanced Recovery after Surgery (ERAS) Program for Radical Cystectomy Patients is Associated With Decreased Postoperative Inpatient Opioid Usage and Pain Scores.

OBJECTIVE: To measure differences in post-operative opioid usage and pain scores between pre- and post-Enhanced Recovery after Surgery (ERAS) radical cystectomy (RC) patients in an effort to optimize outcomes. STUDY DESIGN: We performed a retrospective cohort study from a single institution from January 1, 2015 to July 31, 2018 among 86 and 108 pre- and post-ERAS RC patients. The primary endpoints were total mean opioid usage (morphine equivalent daily dosing or MEDD) and mean pain scores (Visual Analog Scale) on postoperative days (POD) 1-3. Secondary endpoints were number of opioid pills prescribed at discharge and within 30 days of discharge. Multivariable model selection was carried out with forward selection and backward elimination to identify variables associated with key outcomes. RESULTS: Total mean usage of opioids and mean pain scores were significantly lower in post-ERAS vs pre-ERAS patients across POD 1-3, respectively (32.90 MEDD vs 99.86 MEDD, P ≤ .001; 3.51 vs 4.17, P = .003). The median number of opioid pills prescribed at discharge was significantly lower in the post-ERAS group compared to pre-ERAS (30 pills vs 45 pills, P = .046) as well as the median number opioid pills prescribed within 30 days of discharge (40 pills vs 50 pills, P = .001). CONCLUSION: Our study suggests that a dedicated ERAS protocol following RC might be superior to traditional, non-ERAS methods in reducing postoperative opioid use and pain scores.

Chemoradiation for organ preservation in the treatment of muscle-invasive bladder cancer.

INTRODUCTION: Standard therapy for muscle invasive bladder cancer includes neoadjuvant chemotherapy followed by radical cystectomy with urinary diversion. Three decades of interest in primary radiation and chemotherapy for bladder preservation have yielded mature that deserve closer examination. METHODS: We reviewed the literature with an emphasis on outcomes from major clinical trials and prospective studies, while highlighting important aspects of effective treatment delivery and unanswered questions surrounding this approach. RESULTS: There are no randomized trials comparing radical cystectomy to primary chemotherapy and radiation for bladder preservation, and future phase III comparisons are unlikely to be planned. Mature results from single institution protocols and phase II cooperative group trials demonstrate favorable disease-specific survival and bladder preservation rates. Here we review the results of relevant clinical trials, including cancer-related and patient functional outcomes. We outline multi-modal treatment specifics with respect to radiation delivery, incorporation of transurethral resection and chemotherapy selection, and future directions for optimizing results of non-operative strategies. CONCLUSIONS: Combination chemotherapy and radiation can be used as an alternative to conserve the native bladder in appropriately selected patients, mirroring successful non-operative treatment paradigms used for organ-preservation for other cancer sites.

Postchemotherapy surgery for germ cell tumors--what have we learned in 35 years?

Postchemotherapy surgery for advanced testicular cancer has evolved over the last couple of decades. Patients with nonseminomatous germ cell tumors and residual retroperitoneal mass ≥1 cm should undergo postchemotherapy retroperitoneal lymph node dissection (RPLND). For seminoma, RPLND is considered in those patients with masses ≥3 cm that are also positron emission tomography positive. Masses that occur outside of the retroperitoneum should be completely resected with the possible exception of bilateral lung masses when resection of the first mass shows necrosis. The role of surgery in patients with extragonadal germ cell tumors is most vital in those with primary mediastinal nonseminomatous germ cell tumors. Importantly, patient selection, surgical planning, and consideration of referral to centers with this expertise are important to optimize success.

Neoadjuvant and adjuvant chemotherapy approaches for invasive bladder cancer.

Deeply invasive bladder cancer, representing approximately 20% of incident cases, is cured by radical cystectomy or radiotherapy in less than 50% of cases. In an effort to improve cure rates, based on objective response rates in metastatic disease of 40%-70% from combination chemotherapy regimens, systemic chemotherapy has been incorporated into programs of definitive treatment for this disease. Several randomized trials and a meta-analysis have confirmed a survival benefit from neoadjuvant chemotherapy followed by definitive local treatment, reflecting both median survival figures and cure rates. Despite several promising phase II trials, no randomized trial of classical adjuvant chemotherapy for bladder cancer has demonstrated an overall survival benefit, despite increments in disease-free survival. Molecular prognostication has been studied in an effort to improve the utility of systemic therapy for invasive non-metastatic bladder cancer, but randomized trials have not shown associated survival benefit. Despite level 1 evidence of a survival benefit from neoadjuvant MVAC (methotrexate, vinblastine, doxorubicin [Adriamycin], cisplatin) or cisplatin, methotrexate, and vinblastine (CMV) chemotherapy, more than 50% of incident cases do not receive such treatment.

Robot assisted extended pelvic lymphadenectomy at radical cystectomy: lymph node yield compared with second look open dissection.

PURPOSE: Robot assisted radical cystectomy outcomes show feasibility and potential benefits for patient recovery. However, it is difficult to judge the completeness of extended robot assisted vs open pelvic lymph node dissection using only the lymph node count and template description. We performed a prospective protocol in which radical cystectomy and pelvic lymph node dissection done in robot assisted fashion were followed by second look open pelvic lymph node dissection. Our primary objective was to determine the fraction of lymph nodes yielded by robot assisted pelvic lymph node dissection. MATERIALS AND METHODS: Patients with pure transitional cell carcinoma and no locally advanced features were selected for robot assisted radical cystectomy. A team of 2 urological oncologists performed radical cystectomy and pelvic lymph node dissection in robot assisted fashion, followed by second look open pelvic lymph node dissection. Lymph nodes from robot assisted dissection were submitted in up to 8 separate specimens by anatomical location. Any additional specimens retrieved at open dissection were submitted separately. RESULTS: The protocol was completed in 11 patients from October 2007 to June 2009. The median yield of robot assisted and second look open pelvic lymph node dissection was 43 (range 19 to 63) and 4 (range 0 to 8), respectively, for an overall robot assisted yield of 93%. Of second look open pelvic lymph node dissections 67% were clear of residual tissue, 13% had tissue without lymph nodes and 20% had 1 or more lymph nodes. Median operative time for robot assisted pelvic lymph node dissection was 117 minutes. Concurrently open radical cystectomy without required multiple lymph node specimen submission yielded a median 24 nodes. CONCLUSIONS: Our data showing a robot assisted pelvic lymph node dissection yield of 93% of that of open surgery should allay concern that the robot assisted technique limits the completeness of pelvic lymph node dissection.