Risk Factors for Intravesical Recurrence after Minimally Invasive Nephroureterectomy for Upper Tract Urothelial Cancer (ROBUUST Collaboration).

PURPOSE: Intravesical recurrence (IVR) after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC) has an incidence of approximately 20%-50%. Studies to date have been composed of mixed treatment cohorts-open, laparoscopic and robotic. The objective of this study is to assess clinicopathological risk factors for intravesical recurrence after RNU for UTUC in a completely minimally invasive cohort. MATERIALS AND METHODS: We performed a multicenter, retrospective analysis of 485 patients with UTUC without prior or concurrent bladder cancer who underwent robotic or laparoscopic RNU. Patients were selected from an international cohort of 17 institutions across the United States, Europe and Asia. Univariate and multiple Cox regression models were used to identify risk factors for bladder recurrence. RESULTS: A total of 485 (396 robotic, 89 laparoscopic) patients were included in analysis. Overall, 110 (22.7%) of patients developed IVR. The average time to recurrence was 15.2 months (SD 15.5 months). Hypertension was a significant risk factor on multiple regression (HR 1.99, CI 1.06; 3.71, p=0.030). Diagnostic ureteroscopic biopsy incurred a 50% higher chance of developing IVR (HR 1.49, CI 1.00; 2.20, p=0.048). Treatment specific risk factors included positive surgical margins (HR 3.36, CI 1.36; 8.33, p=0.009) and transurethral resection for bladder cuff management (HR 2.73, CI 1.10; 6.76, p=0.031). CONCLUSIONS: IVR after minimally invasive RNU for UTUC is a relatively common event. Risk factors include a ureteroscopic biopsy, transurethral resection of the bladder cuff, and positive surgical margins. When possible, avoidance of transurethral resection of the bladder cuff and alternative strategies for obtaining biopsy tissue sample should be considered.

Comparison of AUA and phoenix definitions of biochemical failure following permanent brachytherapy for prostate cancer.

PURPOSE: To compare biochemical recurrence free survival (BCRFS) and cancer-specific survival (CSS) after brachytherapy using the AUA and the Phoenix definitions. METHODS AND MATERIALS: 2634 men with T1-T4N0M0 prostate cancer were treated with brachytherapy with or without neoadjuvant hormonal therapy or external beam radiation therapy. Five, 10, and 15- year BCRFS and CSS were estimated with Kaplan-Meier estimates with log rank. Multivariate analysis of survival was performed with Cox regression analysis. RESULTS: Median age was 66, follow-up was 8.6 years, and prostate specific antigen was 6.9. Overall, 11.1% (n = 293) of patients experienced Phoenix BCR and 17.48% (n = 457) experienced AUA BCR. The rates of AUA BCR and Phoenix BCR were significantly different at 5 and 10-years but not at 15 years. Patients treated with BED ≤ 200 Gy were more likely to experience AUA BCR (22.5% vs. 12.4%, OR 1.44, p < 0.001) and Phoenix BCR (14.3% and 8.3%, OR 1.37, p < 0.001) than patients treated with a BED > 200 Gy. CONCLUSIONS: Compared to the Phoenix definition, the AUA definition of BCR after brachytherapy is associated with significantly worse BCRFS for the first 15 years after treatment. Receiving a BED > 200, which cannot be achieved without the addition of brachytherapy, is associated with better BCRFS and CSS. Our findings reaffirm the importance of dose in the management of prostate cancer.

The effect of tumor location on overall survival for pT2-4 bladder and upper tract urothelial carcinoma following radical surgery.

INTRODUCTION: Historically, staging and treatment for upper tract urothelial carcinoma were extrapolated from bladder urothelial carcinoma literature. However, embryological, genetic, and anatomical differences exist between them. We sought to explore the relationship between location of urothelial cancer and overall survival (OS). METHODS: Data was culled from the National Cancer Database from 2004-2015. Patients with pT2-pT4 treated with definitive surgery were included; those with metastatic disease or who received neoadjuvant or adjuvant treatment were excluded. Patients were stratified by tumor location and pathological stage. The primary outcome was OS. Secondary outcomes were predictors of mortality in each pT stage stratum. RESULTS: A total of 11 330 patients with bladder, 954 patients with ureteral, and 1943 patients with renal pelvis urothelial carcinoma were analyzed. Mean followup was 43.3, 39.4, and 41.4 months for bladder, ureteral, and renal pelvis, respectively. On univariable analysis, ureteral pT2 was associated with worse OS compared to both bladder (61.3 vs. 80.4 months, p=0.007) and renal pelvis (61.3 vs. 80.5 months, p=0.014). Renal pelvis pT3 was associated with improved OS compared to both bladder (42.5 vs. 28.6 months, p=0.003) and ureteral (42.5 vs. 25.7 months, p<0.001). Renal pelvis pT4 had decreased survival compared to bladder (11.4 vs. 17.7 months, p<0.001). On multivariable Cox regression, only renal pelvis pT3 was associated with a 20% decreased risk of mortality compared to bladder pT3 (hazard ratio 0.80, 95% confidence interval 0.72-0.88, p<0.001). CONCLUSIONS: Renal pelvis pT3 is associated with lower mortality. Mutational and embryological differences may play a role in this disparity.

Ambulatory Robotic-Assisted Partial Nephrectomy: Safety and Feasibility Study.

OBJECTIVE: To evaluate the feasibility and safety of performing robotic-assisted laparoscopic partial nephrectomy (RAPN) as outpatient surgery in patients with renal masses. MATERIALS AND METHODS: We analyzed RAPN performed by a single surgeon at an academic medical center from July 2018 to June 2019 and identified those individual patients who were discharged on the same day. These cases were then compared to a concurrent inpatient RAPN group. Relationships with outcome analyzed using Fisher's exact test and Student's t test. RESULTS: Twenty-three of 84 RAPNs (27.4%) were performed as ambulatory. Mean age was 57.4 years. Average tumor size was 2.24 cm. The mean total operative time was 99.4 minutes. Average estimated blood loss was 51.0 mL. When compared to the cohort of patients who stayed overnight, on multivariate analysis, the tumor size (2.24 ± 0.71 vs 3.65 ± 1.55 cm, P <0.001), and operative time (99.5 ± 25.1 vs 131.2 ± 30.8 minutes, P <0.001) were less in ambulatory cases. No differences were seen in regards to Charlson comorbidity index, age, gender, body mass index, estimated blood loss, or surgical approach. Within 90 days of postoperative period, the readmission rate for the entire cohort was 0. CONCLUSION: RAPN can be performed safely as ambulatory in select patients with comparable outcome without complication or hospital readmission.

Permanent prostate brachytherapy is safe in men with severe baseline lower urinary tract symptoms.

PURPOSE: To evaluate the long-term urinary outcomes of men with severe pretreatment lower urinary tract symptoms (LUTS) treated with permanent prostate brachytherapy (PPB) ± external beam radiation therapy for localized prostate cancer. METHODS AND MATERIALS: A total of 105 men with International Prostate Symptom Score (IPSS) 20-35 before PPB were categorized by IPSS change at last followup: (1) worse = IPSS rise >3; (2) no change = IPSS change within three points of baseline; (3) improved = IPSS fall by >3 points. We then evaluated patients who worsened vs. those who did not (no change or improved) with respect to incontinence outcomes, LUTS medication usage, and predictors of symptom worsening. RESULTS: Mean followup was 80.3 ± 55.8 months. Mean age was 66.3 ± 7.1 years; mean pretreatment IPSS was 23.6 ± 3.0. Overall mean improvement in IPSS was 7.6 ± 9.3. Specifically, 14.3% (15/105) worsened, 21.9% (23/105) had no significant change, and 63.8% (67/105) improved. There were no patient- or treatment-related factors significantly associated with long-term worsening of urinary symptoms. No men required anticholinergic therapy at last followup, whereas 7% (8/105) were using an alpha blocker. Only 2.9% (3/105) of men were using at least one pad daily at last followup. Alternatively, only 7.7% (8/105) reported subjective incontinence. CONCLUSIONS: PPB is an acceptable option in the setting of severe baseline LUTS in appropriately selected and counseled patients when performed by a skilled practitioner.

The role of extended venous thromboembolism prophylaxis following urologic pelvic surgery.

With the emergence of evidence that venous thromboembolisms (VTE) typically occurs following discharge after urologic pelvic surgery, the focus on extended VTE prophylaxis has intensified. Urologists should have a comprehensive understanding of various VTE risk factors in order to weigh the risk of postoperative hemorrhage with the possibility of fatal pulmonary embolus. Risk factors such as advanced age, obesity, and active malignancy are especially common in patient's undergoing urologic pelvic surgery, and thus this issue becomes particularly relevant to the practicing urologist. In previous years, guidelines on extended VTE prophylaxis have either been vague or not urology specific; however, the European Association of Urology has recently issued recommendations on VTE prophylaxis stratified by VTE risk and surgery type. Although these guidelines are a major advance, definitive answers on this question may prove elusive in the form of prospective randomized data given the low incidence of clinically significant postoperative VTE.