Does radical cystectomy have a better prognosis than bladder conservative treatment in the real world?

PURPOSE: To compare the prognosis and quality of life between radical cystectomy and bladder conservative treatment for muscle invasive bladder cancer in the real world. MATERIALS AND METHODS: Patients treated for muscle invasive bladder cancer without metastases were retrospectively evaluated for overall survival, progression-free survival, and rehospitalization. RESULTS: Of the 141 patients, 62 underwent bladder conservative treatment and 79 underwent radical cystectomy. Patients who underwent radical cystectomy had significantly better progression-free survival (HR: 1.83, 95% CI: 1.12-3.00; p < 0.01) and overall survival (HR: 1.82, 95% CI: 0.99-3.34; p = 0.03) than those who underwent conservative treatment. However, there was no significant difference in prognosis between patients who refused to undergo radical cystectomy and those who underwent. In addition, rehospitalization rates for complications and additional treatment were significantly higher in patients who received conservative treatment (69.3% vs. 34.2%; p < 0.01), and the length of hospital stay was also prolonged compared to patients who received radical cystectomy (26 vs. 9 days; p = 0.03). CONCLUSIONS: Overall, conservative treatment had a significantly poorer prognosis than radical cystectomy, but there was no significant difference in prognosis when comparing patients who refused radical cystectomy and received conservative treatment with those who received radical cystectomy. However, hospitalization rates and length of stay were significantly worse for patients who chose conservative treatment, which may lead to a decline in quality of life.

Factors Associated with Re-Resection in T1 Bladder Cancer: Identifying Patients Who Do Not Receive Guideline-Concordant Care at the Population Level.

PURPOSE: Prior research has shown that concordance with the guideline-endorsed recommendation to re-resect patients diagnosed with primary T1 bladder cancer (BC) is suboptimal. Therefore, the aim of this population-based study was to identify factors associated with re-resection in T1 BC. MATERIALS AND METHODS: We linked province-wide BC pathology reports (January 2001 to December 2015) with health administrative data sources to derive an incident cohort of patients diagnosed with T1 BC in the province of Ontario, Canada. Re-resection was ascertained by a billing claim for transurethral resection within 2 to 8 weeks after the initial resection, accounting for system-related wait times. Multivariable logistic regression analysis accounting for the clustered nature of the data was used to identify various patient-level and surgeon-level factors associated with re-resection. P values <0.05 were considered statistically significant (2-sided). RESULTS: We identified 7,373 patients who fulfilled the inclusion criteria. Overall, 1,678 patients (23%) underwent re-resection. Patients with a more aggressive tumor profile and individuals without sufficiently sampled muscularis propria as well as younger, healthier and socioeconomically advantaged patients were more likely to receive re-resection (all p <0.05). In addition, more senior, lower volume and male surgeons were less likely to perform re-resection for their patients (all p <0.05). CONCLUSIONS: Only a minority of all patients received re-resection within 2 to 8 weeks after initial resection. To improve the access to care for potentially underserved patients, we suggest specific knowledge translation/exchange interventions that also include equity aspects besides further promotion of evidence-based instead of eminence-based medicine.

Management Trends and Outcomes of Patients Undergoing Radical Cystectomy for Urothelial Carcinoma of the Bladder: Evolution of the University of Southern California Experience over 3,347 Cases.

PURPOSE: There are conflicting reports on outcome trends following radical cystectomy (RC) for bladder cancer. MATERIALS AND METHODS: Evolution of modern bladder cancer management and its impact on outcomes was analyzed using a longitudinal cohort of 3,347 patients who underwent RC at an academic center between 1971 and 2018. Outcomes included recurrence-free survival (RFS) and overall survival (OS). Associations were assessed using univariable and multivariable models. RESULTS: In all, 70.9% of cases underwent open RC in the last decade, although trend for robot-assisted RC rose since 2009. While lymphadenectomy template remained consistent, nodal submission changed to anatomical packets in 2002 with increase in yield (p <0.001). Neoadjuvant chemotherapy (NAC) use increased with time with concomitant decrease in adjuvant chemotherapy; this was notable in the last decade (p <0.001) and coincided with improved pT0N0M0 rate (p=0.013). Median 5-year RFS and OS probabilities were 65% and 55%, respectively. Advanced stage, NAC, delay to RC, lymphovascular invasion and positive margins were associated with worse RFS (all, multivariable p <0.001). RFS remained stable over time (p=0.73) but OS improved (5-year probability, 1990-1999 51%, 2010-2018 62%; p=0.019). Among patients with extravesical and/or node-positive disease, those who received NAC had worse outcomes than those who directly underwent RC (p ≤0.001). CONCLUSIONS: Despite perioperative and surgical advances, and improved pT0N0M0 rates, there has been no overall change in RFS trend following RC, although OS rates have improved. While patients who are downstaged with NAC derive great benefit, our real-world experience highlights the importance of preemptively identifying NAC nonresponders who may have worse post-RC outcomes.

Urine tumor DNA detection of minimal residual disease in muscle-invasive bladder cancer treated with curative-intent radical cystectomy: A cohort study.

BACKGROUND: The standard of care treatment for muscle-invasive bladder cancer (MIBC) is radical cystectomy, which is typically preceded by neoadjuvant chemotherapy. However, the inability to assess minimal residual disease (MRD) noninvasively limits our ability to offer bladder-sparing treatment. Here, we sought to develop a liquid biopsy solution via urine tumor DNA (utDNA) analysis. METHODS AND FINDINGS: We applied urine Cancer Personalized Profiling by Deep Sequencing (uCAPP-Seq), a targeted next-generation sequencing (NGS) method for detecting utDNA, to urine cell-free DNA (cfDNA) samples acquired between April 2019 and November 2020 on the day of curative-intent radical cystectomy from 42 patients with localized bladder cancer. The average age of patients was 69 years (range: 50 to 86), of whom 76% (32/42) were male, 64% (27/42) were smokers, and 76% (32/42) had a confirmed diagnosis of MIBC. Among MIBC patients, 59% (19/32) received neoadjuvant chemotherapy. utDNA variant calling was performed noninvasively without prior sequencing of tumor tissue. The overall utDNA level for each patient was represented by the non-silent mutation with the highest variant allele fraction after removing germline variants. Urine was similarly analyzed from 15 healthy adults. utDNA analysis revealed a median utDNA level of 0% in healthy adults and 2.4% in bladder cancer patients. When patients were classified as those who had residual disease detected in their surgical sample (n = 16) compared to those who achieved a pathologic complete response (pCR; n = 26), median utDNA levels were 4.3% vs. 0%, respectively (p = 0.002). Using an optimal utDNA threshold to define MRD detection, positive utDNA MRD detection was highly correlated with the absence of pCR (p < 0.001) with a sensitivity of 81% and specificity of 81%. Leave-one-out cross-validation applied to the prediction of pathologic response based on utDNA MRD detection in our cohort yielded a highly significant accuracy of 81% (p = 0.007). Moreover, utDNA MRD-positive patients exhibited significantly worse progression-free survival (PFS; HR = 7.4; 95% CI: 1.4-38.9; p = 0.02) compared to utDNA MRD-negative patients. Concordance between urine- and tumor-derived mutations, determined in 5 MIBC patients, was 85%. Tumor mutational burden (TMB) in utDNA MRD-positive patients was inferred from the number of non-silent mutations detected in urine cfDNA by applying a linear relationship derived from The Cancer Genome Atlas (TCGA) whole exome sequencing of 409 MIBC tumors. We suggest that about 58% of these patients with high inferred TMB might have been candidates for treatment with early immune checkpoint blockade. Study limitations included an analysis restricted only to single-nucleotide variants (SNVs), survival differences diminished by surgery, and a low number of DNA damage response (DRR) mutations detected after neoadjuvant chemotherapy at the MRD time point. CONCLUSIONS: utDNA MRD detection prior to curative-intent radical cystectomy for bladder cancer correlated significantly with pathologic response, which may help select patients for bladder-sparing treatment. utDNA MRD detection also correlated significantly with PFS. Furthermore, utDNA can be used to noninvasively infer TMB, which could facilitate personalized immunotherapy for bladder cancer in the future.

Pathological and Survival Outcomes Associated with Variant Histology Bladder Cancers Managed by Cystectomy with or without Neoadjuvant Chemotherapy.

PURPOSE: Although neoadjuvant chemotherapy is associated with a survival advantage in pure urothelial, muscle invasive bladder cancer, the role of neoadjuvant chemotherapy is less clear in variant histology or urothelial carcinoma with divergent differentiation. We compared chemotherapy response and survival outcomes of patients with nonpure urothelial carcinoma histology who were managed with neoadjuvant chemotherapy followed by cystectomy vs cystectomy alone. MATERIALS AND METHODS: We analyzed 768 patients with clinical muscle invasive bladder cancer (cT2-4N0M0) who were treated with cystectomy at a tertiary care center from 2007 to 2017. Patients were stratified by histology and treatment strategy. Adjusted logistic and Cox regression models were used to evaluate pathological downstaging, cancer specific survival and overall survival. RESULTS: The cohort consisted of 410 patients (53%) with pure urothelial carcinoma, 185 (24%) with urothelial carcinoma with divergent differentiation and 173 (23%) with variant histology. Overall, 314 patients (41%) received neoadjuvant chemotherapy prior to cystectomy. There were similar rates of complete (18% to 30%) and partial (37% to 46%) pathological downstaging with neoadjuvant chemotherapy across all histological subgroups (p=0.30 and p=0.40, respectively). However, while patients with pure urothelial carcinoma experienced an overall survival benefit (HR 0.71, 95% CI 0.51-0.98, p=0.0013) and those with variant histology experienced a cancer specific survival benefit (HR 0.55, 95% CI 0.30-0.99, p=0.0495) with neoadjuvant chemotherapy, patients with urothelial carcinoma with divergent differentiation did not experience overall or cancer specific survival benefits with the use of neoadjuvant chemotherapy prior to cystectomy. CONCLUSIONS: Among patients with muscle invasive bladder cancer those with nonpure urothelial carcinoma histology with variant histology achieved nearly equivalent response rates and survival benefits with the use of neoadjuvant chemotherapy as those with pure urothelial carcinoma, while patients with urothelial carcinoma with divergent differentiation experienced significantly worse survival outcomes regardless of the use of neoadjuvant chemotherapy prior to cystectomy.

Robot-assisted vs open radical cystectomy for bladder cancer in adults.

BACKGROUND: It has been suggested that, in comparison with open radical cystectomy (ORC), robot-assisted radical cystectomy (RARC) results in less blood loss, shorter convalescence and fewer complications, with equivalent short-term oncological and functional outcomes; however, uncertainty remains as to the magnitude of these benefits. OBJECTIVES: To assess the effects of RARC vs ORC in adults with bladder cancer. SEARCH METHODS: We conducted a comprehensive search, with no restrictions on language of publication or publication status, for randomized controlled trials (RCTs) that compared RARC with ORC. The date of the last search was 1 July 2018. Databases searched included the Cochrane Central Register of Controlled Trials, MEDLINE (1999 to July 2018), PubMed Embase (1999 to July 2018), Web of Science (1999 to July 2018), Cancer Research UK (www.cancerresearchuk.org/), and the Institute of Cancer Research (www.icr.ac.uk/). We also searched the following trial registers: ClinicalTrials.gov (clinicaltrials.gov/); BioMed Central International Standard Randomized Controlled Trials Number (ISRCTN) Registry (www.isrctn.com); and the World Health Organization International Clinical Trials Registry Platform. The review was based on a published protocol. Primary outcomes of the review were recurrence-free survival and major postoperative complications (Clavien grade III to V). Secondary outcomes were minor postoperative complications (Clavien grades I and II), transfusion requirement, length of hospital stay (days), quality of life, and positive surgical margins (%). Three review authors independently assessed relevant titles and abstracts of records identified by the literature search to determine which studies should be assessed further. Two review authors assessed risk of bias using the Cochrane risk-of-bias tool and rated the quality of evidence according to GRADE. We used Review Manager 5 to analyse the data. RESULTS: We included in the review five RCTs comprising a total of 541 participants. Total numbers of participants included in the ORC and RARC cohorts were 270 and 271, respectively. We found that RARC and ORC may result in a similar time to recurrence (hazard ratio 1.05, 95% confidence interval [CI] 0.77 to 1.43; two trials, low-certainty evidence). In absolute terms at 5 years of follow-up, this corresponds to 16 more recurrences per 1000 participants (95% CI 79 fewer to 123 more) with 431 recurrences per 1000 participants for ORC. We downgraded the certainty of evidence because of study limitations and imprecision. RARC and ORC may result in similar rates of major complications (risk ratio [RR] 1.06, 95% CI 0.76 to 1.48; five trials, low-certainty evidence). This corresponds to 11 more major complications per 1000 participants (95% CI 44 fewer to 89 more). We downgraded the certainty of evidence because of study limitations and imprecision. We were very uncertain whether RARC reduces minor complications (very-low-certainty evidence). We downgraded the certainty of evidence because of study limitations and very serious imprecision. RARC probably results in substantially fewer transfusions than ORC (RR 0.58, 95% CI 0.43 to 0.80; two trials, moderate-certainty evidence). This corresponds to 193 fewer transfusions per 1000 participants (95% CI 262 fewer to 92 fewer) based on 460 transfusion per 1000 participants for ORC. We downgraded the certainty of evidence because of study limitations. RARC may result in a slightly shorter hospital stay than ORC (mean difference -0.67, 95% CI -1.22 to -0.12; five trials, low-certainty evidence). We downgraded the certainty of evidence because of study limitations and imprecision. RARC and ORC may result in a similar quality of life (standardized mean difference 0.08, 95% CI 0.32 lower to 0.16 higher; three trials, low-certainty evidence). We downgraded the certainty of evidence because of study limitations and imprecision. RARC and ORC may result in similar positive surgical margin rates (RR 1.16, 95% CI 0.56 to 2.40; five trials, low-certainty evidence). This corresponds to eight more (95% CI 21 fewer to 67 more) positive surgical margins per 1000 participants, based on 48 positive surgical margins per 1000 participants for ORC. We downgraded the certainty of evidence because of study limitations and imprecision. CONCLUSIONS: We conclude that RARC and ORC may have similar outcomes with regard to time to recurrence, rates of major complications, quality of life, and positive surgical margin rates (all low-certainty evidence). We are very uncertain whether the robotic approach reduces rates of minor complications (very-low-certainty evidence), although it probably reduces the risk of blood transfusions substantially (moderate-certainty evidence) and may reduce hospital stay slightly (low-certainty evidence). We were unable to conduct any of the preplanned subgroup analyses to assess the impact of patient age, pathological stage, body habitus, or surgeon expertise on outcomes. This review did not address issues of cost-effectiveness.

Understanding volume-outcome relationships in nephrectomy and cystectomy for cancer: evidence from the UK Getting it Right First Time programme.

OBJECTIVES: To investigate volume-outcome relationships in nephrectomy and cystectomy for cancer. MATERIALS AND METHODS: Data were extracted from the UK Hospital Episodes Statistics database, which records data on all National Health Service (NHS) hospital admissions in the England. Data were included for a 5-year period (April 2013-March 2018 inclusive) and data on emergency and paediatric admissions were excluded. Data were extracted on the NHS trust and surgeon undertaking the procedure, the surgical technique used (open, laparoscopic or robot-assisted) and length of hospital stay during the procedure. This dataset was supplemented by data on mortality from the UK Office for National Statistics. A number of volume thresholds and volume measures were investigated. Multilevel modelling was used to adjust for hierarchy and confounding factors. RESULTS: Data were available for 18 107 nephrectomy and 6762 cystectomy procedures for cancer. There was little evidence of trust or surgeon volume influencing readmission rates or mortality. There was some evidence of shorter length of hospital stay for high-volume surgeons, although the volume measure and threshold used were important. CONCLUSIONS: We found little evidence that further centralization of nephrectomy or cystectomy for cancer surgery will improve the patient outcomes investigated. It may be that length of stay can be optimized though training and support for lower-volume centres, rather than further centralization.

Effect of hospital volume on 90-day mortality after radical cystectomy for bladder cancer in Spain.

OBJECTIVE: To investigate 90-day mortality rate of RC for bladder cancer in a nationwide population-based study. DESIGN, SETTING, AND PARTICIPANTS: We used mandatory hospital discharge forms of all patients submitted to RC due to bladder cancer in Spain during 2011-2015 (n = 12,154 in 196 hospitals). At present, a centralization policy for RC has not been issued by the health authorities. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We calculated in-hospital, 30-, 60- and 90-day mortality. Average annual RC volume was used as a continuous variable (log-transformed) and also grouped into deciles to identify any potential non-linear relationships. Logistic regression model with mixed effect was performed adjusting for year of surgery, comorbidity, surgical approach, type of admission, age, sex, and hospital size. RESULTS AND LIMITATION: Overall 90-day mortality rate was 6.5%. Lowest mortality rates (3.3% at 90 days) are achieved in hospitals doing more than 38 cases per year. The 90-day adjusted mortality rate is associated with annual average RC volume with a 20.6% decrease per 10 extra RCs/year (95% CI 12.3-28.1% p < 0.001). High Charlson comorbidity index, advanced age, and open surgical approach were the clinical variables associated with higher mortality. CONCLUSIONS: Our study identifies an inverse association between 90-day mortality and hospital volume. High-volume hospitals achieve lower mortality rate within 90 days.

Partial cystectomy with a bipolar sealing device in seven dogs with naturally occurring bladder tumors.

OBJECTIVE: To describe the use of a bipolar sealing device (BSD) for partial cystectomy in dogs undergoing excision of bladder tumors. STUDY DESIGN: Multicenter, prospective, clinical pilot study. SAMPLE POPULATION: Seven client-owned dogs with nontrigonal urinary bladder lesions. METHODS: Dogs underwent a sealed partial cystectomy with a BSD, with or without cystoscopic guidance of the resection. The sealed cystectomy site was oversewn with a single-layer simple continuous pattern with monofilament absorbable suture. RESULTS: Sealed partial cystectomy was successfully performed in all dogs, with a median surgical duration of 69 minutes (range, 50-120). Lesions were located at the apex in six dogs and on the ventral midbody of the bladder in one dog. No urine leakage from the BSD luminal seal was visible prior to suture closure in three dogs, while varying amounts of urine leaked from the sealed site in four dogs. Suture was placed over the seal in grossly normal bladder tissue in six dogs and in the BSD peripheral thermal effect zone in one dog; in this latter dog, revision cystorrhaphy was required 3 days later because of uroabdomen. The other six dogs had no clinical evidence of urinary bladder healing complications. CONCLUSION: The integrity of the seal generated by the BSD tested here on partial cystectomies varied between dogs and was unpredictable. CLINICAL SIGNIFICANCE: Sealed partial cystectomy with a BSD may reduce exposure of urinary bladder luminal contents to the surgical site. However, the placement of sutures over the seal and through grossly normal bladder tissue is recommended to prevent postoperative uroabdomen.

Impact of adjuvant chemotherapy in patients with adverse features and variant histology at radical cystectomy for muscle-invasive carcinoma of the bladder: Does histologic subtype matter?

BACKGROUND: The use of adjuvant chemotherapy (AC) in pure urothelial carcinoma of the bladder is established. Regarding variant histology, there is a gap in knowledge concerning the optimal treatment after radical cystectomy (RC). The objective of this study was to assess the effect of AC on overall survival (OS) in patients who had pure urothelial carcinoma, urothelial carcinoma with concomitant variant histology, or another pure variant histology. METHODS: Within the National Cancer Data Base, 15,397 patients who underwent RC for nonmetastatic, localized carcinoma of the bladder and had positive lymph nodes (T2N+) or locally advanced stage (≥T3N0/N+) were identified, excluding those who had previously received neoadjuvant chemotherapy. Multivariable Cox regression models were used to examine the specific effect of AC on OS stratified by each distinct histologic subtype, including pure urothelial carcinoma, micropapillary or sarcomatoid differentiation, squamous cell carcinoma, adenocarcinoma, and neuroendocrine tumors. To account for immortal time bias, Cox regression analyses and Kaplan-Meier analyses were conducted with a landmark at 3 months. RESULTS: In multivariable landmark analyses, AC compared with initial observation was associated with an OS benefit for patients who had pure urothelial carcinoma (hazard ratio, 0.87; 95% confidence interval, 0.82-0.91), whereas no differences were observed with regard to those who had variant histology. CONCLUSIONS: Multivariable Cox regression landmark analysis revealed a survival benefit from AC for patients with a pure urothelial carcinoma. However, a survival benefit of AC for patients who had urothelial carcinoma with concomitant variant histology or other pure variant histology was not demonstrated.

Hospital Quality Metrics for Radical Cystectomy: Disease Specific and Correlated to Mortality Outcomes.

PURPOSE: Measuring quality is a high priority for health care systems globally. Despite the high perioperative morbidity, mortality, expenditures and performance variation of radical cystectomy there is a paucity of validated bladder cancer quality metrics. We aimed to create a hospital quality scoring system for radical cystectomy which is disease specific and associated with patient centered outcomes. MATERIALS AND METHODS: We used the National Cancer Database to identify hospitals where radical cystectomy was performed from 2004 to 2014. Mixed effects models were constructed to assess variation in hospital performance across 7 quality indicators. Indirect standardization was used to case mix adjust hospital performance. We assessed associations between quality indicators as well as the novel BC-QS (Bladder Cancer Quality Score) composite hospital quality metric with 30-day, 90-day and overall mortality using logistic and Cox regression, respectively. RESULTS: At 1,200 facilities radical cystectomy was performed in a total of 48,341 patients from 2004 to 2014. Mixed effects models demonstrated significant between hospital variation across all quality indicators after case mix adjustment. The composite BC-QS metric was composed of the hospital positive margin rate, the lymph node dissection rate and the neoadjuvant chemotherapy rate. Better BC-QS performance was associated with lower 30-day and 90-day mortality (adjusted OR 0.78, 95% CI 0.64-0.96, and OR 0.84, 95% CI 0.72-0.97, respectively) and overall mortality (HR 0.86, 95% CI 0.81-0.92). Hospitals with a higher BC-QS had higher volume and more were affiliated with an academic institution than hospitals with a lower BC-QS (p <0.0001). CONCLUSIONS: The BC-QS captures variations in the hospital performance of radical cystectomy and it shows an association of higher quality with lower patient mortality. Our validation of this quality metric provides support for its potential use by policy makers and payers in efforts to measure hospital quality for high cost surgeries.

Long-Term Outcomes Following Partial Versus Complete Cystectomy in Advanced Colorectal Cancer with Regarding to the Extent of Bladder Invasion.

BACKGROUND: Two procedures widely performed to treat locally advanced colorectal cancer adherent to the urinary bladder are total cystectomy (as part of pelvic exenteration) and partial cystectomy; however, little is known about outcomes following partial cystectomy. METHODS: A retrospective database of patients with colorectal cancer involving the urinary bladder who underwent R0 or R1 resection at our institution from 2001 to 2015 was constructed. The histological extent of bladder invasion and long-term outcomes were examined. RESULTS: Of the 89 consecutive patients, 49 underwent partial cystectomy and all had negative margins of the bladder. Tumor invasion to the urinary bladder was confirmed histologically in 19 of 49 patients (coincidence rate of diagnosis, 39%): invasion only to the bladder serosa (n = 3), invasion to the bladder muscle (n = 4), and invasion beyond the bladder muscle without (n = 1) and with (n = 11) exposure to the bladder lumen. The 5-year recurrence-free and overall survival rates were 63.2% and 70.2% in the partial cystectomy group, and 66.2% and 72.7% in the total cystectomy group (p = 0.567 and 0.648), respectively. Except for the remnant bladder, recurrence sites were very similar to sites observed in patients who underwent total cystectomy. Intravesical recurrence occurred in four patients 3-13 months after the initial surgery, all of whom showed bladder lumen exposure to the tumor. CONCLUSIONS: With regard to long-term outcomes and low diagnostic concordance rates of clinical and pathological bladder invasion, partial cystectomy seems a generally acceptable treatment option. However, when the bladder lumen is exposed to a colorectal tumor, surgeons should be cognizant of possible intravesical recurrence and act accordingly.

Characterising 'bounce-back' readmissions after radical cystectomy.

OBJECTIVE: To examine predictors of early readmissions after radical cystectomy (RC). Factors associated with preventable readmissions may be most evident in readmissions that occur within 3 days of discharge, commonly termed 'bounce-back' readmissions, and identifying such factors may inform efforts to reduce surgical readmissions. PATIENTS AND METHODS: We utilised the Healthcare Cost and Utilization Project's State Inpatient Databases to examine 1867 patients undergoing RC in 2009 and 2010, and identified all patients readmitted within 30 days of discharge. We assessed differences between patients experiencing bounce-back readmission compared to those readmitted 8-30 days after discharge using logistic regression models and also calculated abbreviated LACE scores to assess the utility of common readmissions risk stratification algorithms. RESULTS: The 30-day and bounce-back readmission rates were 28.4% and 5.6%, respectively. Although no patient or index hospitalisation characteristics were significantly associated with bounce-back readmissions in adjusted analyses, bounce-back patients did have higher rates of gastrointestinal (14.3% vs 6.7%, P = 0.02) and wound (9.5% vs 3.0%, P < 0.01) diagnoses, as well as increased index and readmission length of stay (5 vs 4 days, P = 0.01). Overall, the median abbreviated LACE score was 7, which fell into the moderate readmission risk category, and no difference was observed between readmitted and non-readmitted patients. CONCLUSION: One in five readmissions after RC occurs within 3 days of initial discharge, probably due to factors present at discharge. However, sociodemographic and clinical factors, as well as traditional readmission risk tools were not predictive of this bounce-back. Effective strategies to reduce bounce-back readmission must identify actionable clinical factors prior to discharge.

Period-specific mean annual hospital volume of radical cystectomy is associated with outcome and perioperative quality of care: a nationwide population-based study.

OBJECTIVE: To investigate the association between hospital volume and overall survival (OS), cancer-specific survival (CSS), and quality of care of patients with bladder cancer who undergo radical cystectomy (RC), defined as the use of extended lymphadenectomy (eLND), continent reconstruction, neoadjuvant chemotherapy (NAC), and treatment delay of <3 months. PATIENTS AND METHODS: We used the Bladder Cancer Data Base Sweden (BladderBaSe) to study survival and indicators of perioperative quality of care in all 3172 patients who underwent RC for primary invasive bladder cancer stage T1-T3 in Sweden between 1997 and 2014. The period-specific mean annual hospital volume (PSMAV) during the 3 years preceding surgery was applied as an exposure and analysed using univariate and multivariate mixed models, adjusting for tumour and nodal stage, age, gender, comorbidity, educational level, and NAC. PSMAV was either categorised in tertiles, dichotomised (at ≥25 RCs annually), or used as a continuous variable for every increase of 10 RCs annually. RESULTS: PSMAV in the highest tertile (≥25 RCs annually) was associated with improved OS (hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.75-1.0), whereas the corresponding HR for CSS was 0.87 (95% CI 0.73-1.04). With PSMAV as a continuous variable, OS was improved for every increase of 10 RCs annually (HR 0.95, 95% CI 0.90-0.99). Moreover, higher PSMAV was associated with increased use of eLND, continent reconstruction and NAC, but also more frequently with a treatment delay of >3 months after diagnosis. CONCLUSIONS: The current study supports centralisation of RC for bladder cancer, but also underpins the need for monitoring treatment delays associated with referral.

Short- and long-term survival has improved after radical cystectomy for bladder cancer in Québec during the years 2000-2015.

BACKGROUND AND OBJECTIVES: We evaluated the short- and long-term outcome in bladder cancer (BC) patients treated with radical cystectomy (RC) in Québec (Canada). METHODS: Data were collected from provincial registries on all BC patients who underwent RC in Québec province in 2000-2015. Outcomes were hospitalization rates and survival. Survival analyses were conducted using log-rank tests and Cox proportional hazards models. RESULTS: In total, 4450 patients were included in our analysis. RC was increasingly conducted by higher-volume surgeons in larger, higher-volume, academic hospitals. Comparing patients treated in 2010-2015 to 2000-2009, recently treated patients had shorter postoperative hospital stays (absolute difference, 0.9 days, P < 0.001) but also a higher readmission rate (25.0% vs 21.1% in the 30 days following discharge, P = 0.003). Overall (5-year rates 50.9% vs 42.7%, P < 0.001) and BC-specific survival (61.3% vs 55.5%, P < 0.001) had significantly improved. In multivariable analyses, overall survival was significantly better in recently treated patients (hazard ratio [HR], 0.66; 95% confidence interval [CI], 0.60-0.73), younger patients (HR, 1.16; 95% CI, 1.14-1.19), patients residing closer to the hospital (HR, 1.03; 95% CI, 1.01-1.06), and patients treated by high-volume surgeons (HR, 0.88; 95% CI, 0.82-0.94). CONCLUSIONS: Survival in BC patients after RC has improved in recent years. Other predictors for survival are younger age, shorter distance between patients' residences and hospitals, and higher surgeon's RC loads.

Live Birth Rate after Surgical and Expectant Management of Endometriomas after In Vitro Fertilization: A Systematic Review, Meta-Analysis, and Critical Appraisal of Current Guidelines and Previous Meta-Analyses.

Controversy exists regarding surgical management of endometriomas in infertile women before in vitro fertilization (IVF) because growing evidence indicates that surgery may impair the ovarian response. The objective of the present systematic review and meta-analysis was to compare surgical and expectant management of endometriomas regarding IVF outcomes. Prospective and retrospective controlled studies were found via the Cochrane Library, Embase, and MEDLINE databases. Thirteen studies (1 randomized controlled trial and 12 observational studies, N = 2878) were pooled, and similar live birth rates were observed in the surgically and expectantly managed groups (odds ratio = 0.83; 95% confidence interval [CI], 0.56-1.22; p = .98). The clinical pregnancy rates (odds ratio = 0.83; 95% CI, 0.66-1.05; p = .86), the number of mature oocytes retrieved, and the miscarriage rates were not statistically different between study groups. However, the total number of oocytes retrieved was lower in the surgery group (mean difference = -1.51; 95% CI, -2.60 to -0.43; p = .02). Findings suggest that surgical management of endometriomas before IVF therapy yields similar live birth rates as expectant management. However, future properly designed randomized controlled trials are warranted.

Characterization of a learning curve for robotic cystectomy with intracorporeal urinary diversion at two institutions using the cumulative sum (CUSUM) method.

INTRODUCTION: Robotic cystectomy with intracorporeal urinary diversion (RCID) is a technically challenging procedure. It is understood that this approach has a learning curve; however, limited studies have characterized this learning curve. The cumulative sum (CUSUM) method plots the learning curve. The aim of this study was to use the CUSUM approach to investigate the number of cases required to reach a consistent, desired performance level for RCID. MATERIALS AND METHODS: Retrospective study of the first 27 and 28 RCID cases performed by two new fellowship trained faculty at two separate institutions from November 2014 to January 2018. Total operating time was calculated and the CUSUM method was used to describe the learning curve, the number of cases needed for a consistent performance level. RESULTS: Twenty-seven and 28 patients were reviewed from two institutions (A and B), with 8 and 7 females, 19 and 21 males and an average age of 66.7 and 67.6 years, respectively. Twelve and ten cases, respectively, had final pathology of stage T3 bladder cancer or higher. The CUSUM curve demonstrated a learning curve of 10 and 11 cases, respectively, when the curve transitioned from steady improvement in OR times (upward slope of curve) to a relative steady state of OR times (plateau of curve). The average lymph node yield, rate of ureteral stricture, and positive margins were also examined with no learning curve noted. CONCLUSION: In RCID, approximately 10 cases were required by robotically trained new faculty to reach a steady-state level of performance.

Practice pattern of non-muscle invasive bladder cancer in Japan, Korea and Taiwan: A Web-based survey.

OBJECTIVES: To investigate the treatment pattern of non-muscle invasive bladder cancer patients among urologists in Japan, Korea and Taiwan, with emphasis on compliance with important treatment guidelines. METHODS: A Web-based questionnaire survey was conceived by representative members of each country's urological oncology society and was open from June 2016 to February 2017 to each society's members. Descriptive statistics and multinomial logistic regression analysis were used. RESULTS: A total of 2334 urologists were invited and 701 responded to the survey with a response rate of 30.0%. Instruments used during transurethral resection of bladder cancer varied significantly between countries and depended on their availability. The re-transurethral resection rate for pT1 or high-grade disease >50% of the time was significantly higher in Japan than in the other two countries, but the collective rate was just 49%. The frequency of intravesical therapy in intermediate- to high-risk disease was generally consistent across countries. However, the choice of agent between chemotherapy and bacillus Calmette-Guérin was significantly different between countries. Maintenance bacillus Calmette-Guérin was used <10% of the time by 45% of respondents, the most important reasons being fear of side-effects, followed by a lack of efficacy and shortage of drug supply. CONCLUSIONS: There are significant differences between Japan, Korea and Taiwan in the management of intermediate- to high-risk non-muscle invasive bladder cancer. The results of this survey can serve as the basis for joint efforts to develop common clinical guidelines.

Robot-Assisted Radical Cystectomy with Intracorporeal Orthotopic Ileal Neobladder: A Safe Strategy in Elderly Patients? Results of Propensity Score Matching in a Single High-Volume Center.

AIM: To compare surgical, functional and early survival outcomes for robot-assisted radical cystectomy (RARC) with intracorporeal orthotopic neobladder (ONB) reconstruction in patients age = 75 y to those in patients age < 75 y using Propensity Score Matching. METHODS: We collected data from 15 patients age = 75 y from among 60 consecutive RARC with ONB reconstruction performed at our institution from January 2015 to July 2018. All procedures were performed by a single surgeon after modular training under the supervision of a skilled surgeon. Demographic, surgical, functional and survival data were prospectively collected and compared to the corresponding data from 15 patients from the same series age < 75 y, matched according to the ASA score, body mass index, clinical stage and associated carcinoma in situ using Propensity Score Matching. RESULTS: There were no significant differences between the two groups with regard to preoperative parameters, such as ASA score, BMI and preoperative stage. The same homogeneity was found for intraoperative parameters, such as operation time, number of nodes retrieved and ONB time. The only statistically significant difference noted was in the percentage of nerve-sparing procedures, which was higher in the younger patient group (p < 0.001). The percentages of early and late postoperative complications were higher in the older patients, but the differences were not statistically significant. Moreover, there were no differences among the two populations in terms of functional outcomes (daytime and nighttime continence, potency), or in either cancer-specific or overall mortality. CONCLUSIONS: RARC with totally intracorporeal ONB diversion can be offered to older patients with an expectation of good surgical, functional and early survival outcomes, although further studies with a larger sample size will be needed to confirm these results.

[Evaluation of the learning curve of laparoscopic radical cystectomy for cancer: Morbidity and oncological results]. / Évaluation de la courbe d'apprentissage de la cystectomie radicale laparoscopique pour cancer : morbidité et résultats oncologiques.

INTRODUCTION: The objective of this work was to evaluate the impact of the laparoscopic radical cystectomy learning curve on perioperative and oncological outcomes. PATIENT AND METHODS: This is a retrospective and single-center study of all patients who underwent laparoscopic radical cystectomy for bladder cancer from February 2007 to March 2016, (93 patients) Perioperative and oncological data were collected. We used mixed statistical models to predict the number of patients needed in the learning phase. We compared the perioperative parameters of the patients in the learning phase with those of the rest of the patients. Overall survival was estimated using the Kaplan-Meier method. RESULTS: Thirty-six patients are required for the learning phase (P1). The expertise phase begins after the 36th LRC (P2). In both phases, there was no significant difference in age, ASA score, and tumor stage (P=0.237, P=0.577, P=0.998). Mean operative time was 328.3min and 262.4min in P1 and P2 (P=0.0001), mean blood loss was 333.7mL and 194.3mL in P1 and P2 respectively (P=0.0003). The rate of major complications was high in the learning phase (P=0.042). There was no significant difference in lymph node yield, positive surgical margins and overall survival (P=0.068, P=0.194, P=0.703). CONCLUSION: This learning experience was evaluated without compromising oncological results, but with a significantly higher rate of major complications. LEVEL OF EVIDENCE: 3.