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We sought to automate R.E.N.A.L. (for radius, exophytic/endophytic, nearness of tumor to collecting system, anterior/posterior, location relative to polar line) nephrometry scoring of preoperative computerized tomography scans and create an artificial intelligence-generated score (AI-score). Subsequently, we aimed to evaluate its ability to predict meaningful oncologic and perioperative outcomes as compared to expert human-generated nephrometry scores (H-scores).A total of 300 patients with preoperative computerized tomography were identified from a cohort of 544 consecutive patients undergoing surgical extirpation for suspected renal cancer at a single institution. A deep neural network approach was used to automatically segment kidneys and tumors, and geometric algorithms were developed to estimate components of R.E.N.A.L. nephrometry score. Tumors were independently scored by medical personnel blinded to AI-scores. AI- and H-score agreement was assessed using Lin's concordance correlation and their predictive abilities for both oncologic and perioperative outcomes were assessed using areas under the curve.Median age was 60 years (IQE 51-68), and 40% were female. Median tumor size was 4.2 cm and 91.3% had malignant tumors, including 27%, 37% and 24% with high stage, grade and necrosis, respectively. There was significant agreement between H-scores and AI-scores (Lin's ⍴=0.59). Both AI- and H-scores similarly predicted meaningful oncologic outcomes (p0.001) including presence of malignancy, necrosis, and high-grade and -stage disease (p0.003). They also predicted surgical approach (p0.004) and specific perioperative outcomes (p0.05).Fully automated AI-generated R.E.N.A.L. scores are comparable to human-generated R.E.N.A.L. scores and predict a wide variety of meaningful patient-centered outcomes. This unambiguous artificial intelligence-based scoring is intended to facilitate wider adoption of the R.E.N.A.L. score.

Concern for discordance between clinical staging and final pathology drives current management of patients deemed appropriate candidates for radical cystectomy. Therefore, we set out to prospectively investigate reliability and shortcomings of cystoscopic evaluation in radical cystectomy candidates.Patients undergoing radical cystectomy for urothelial carcinoma were enrolled in a prospective single-arm study to evaluate reliability of Systematic Endoscopic Evaluation in predicting pT0 urothelial carcinoma (NCT02968732). Systematic Endoscopic Evaluation consisted of cystoscopy and tissue sampling at the time of radical cystectomy. Systematic Endoscopic Evaluation results were compared to radical cystectomy pathology. The primary end point was the negative predictive value of Systematic Endoscopic Evaluation findings in predicting radical cystectomy pathology.A total of 61 patients underwent Systematic Endoscopic Evaluation and radical cystectomy. Indications included muscle invasive bladder cancer in 42 (68.9%) and high risk nonmuscle invasive bladder cancer in 19 (31.1%). In all, 38 (62.3%, 90.5% of patients with muscle invasive bladder cancer) received neoadjuvant chemotherapy. On Systematic Endoscopic Evaluation, 31 (50.8%) patients demonstrated no visual nor biopsy-based evidence of disease (seeT0), yet 16/31 (51.6%) harbored residual disease (pT0), including 8 (8/31, 25.8%) with residual ≥pT2 disease upon radical cystectomy. The negative predictive value of Systematic Endoscopic Evaluation predicting a pT0 bladder was 48.4% (CI 30.2-66.9), which was below our prespecified hypothesis. Therefore, the trial was stopped for futility.Approximately 1 of 4 patients with seeT0 at the time of radical cystectomy harbored residual muscle invasive bladder cancer. These prospective data definitively confirm major limitations of endoscopic assessment for pT0 bladder cancer. Future work should focus on novel imaging and biomarker strategies to optimize evaluations before radical cystectomy for improved decision making regarding bladder preservation.

INTRODUCTION AND OBJECTIVE:Concern for discordance between endoscopic evaluation and final pathology drives current clinical management of patients deemed appropriate candidates for radical cystect...

We evaluated the risk of bleeding complications in patients undergoing partial nephrectomy in whom perioperative antiplatelet therapy was continued, as antiplatelet therapy is increasingly used and hemorrhage is a significant concern in partial nephrectomy.In this 2-center retrospective analysis 1,097 patients underwent partial nephrectomy between 2000 and 2014. The cohort was split into 3 groups of perioperative continuation of antiplatelet therapy (group 1-67), antiplatelet therapy stopped preoperatively (group 2-254) and no chronic antiplatelet therapy (group 3-776). Bleeding complications were defined as any transfusion, or any hospital readmission or secondary procedure performed for hemorrhage. Multivariable analysis was performed to elucidate independent risk factors for bleeding complications.Patients in group 1 were older (median age 66 years vs 64 and 57 years in groups 2/3, p0.0001), and had greater comorbidity (median ASA classification score 3 vs 2 and 2, p0.0001). Group 1 had a higher rate of bleeding complications (20.9% vs 7.1% and 6.4%, p0.0001) and transfusions (16.4% vs 5.9% and 5.4%, p=0.002). Multivariable analysis revealed continued antiplatelet therapy was an independent predictor of bleeding complications (OR 2.19, 95% CI 1.06-4.51, p=0.03). These findings appear attributable to intraoperative clopidogrel use. On multivariable analysis the use of aspirin alone was not associated with bleeding complications (OR 1.64, 95% CI 0.72-3.75, p=0.24).The risk of bleeding complications due to antiplatelet therapy use at partial nephrectomy may be due to clopidogrel. The need to continue perioperative aspirin alone does not appear to be a contraindication to the safe performance of partial nephrectomy.

The surface-intermediate-base margin score is a novel standardized reporting system of resection techniques during nephron sparing surgery. We validated the surgeon assessed surface-intermediate-base score with microscopic histopathological assessment of partial nephrectomy specimens.Between June and August 2014 data were prospectively collected from 40 consecutive patients undergoing nephron sparing surgery. The surface-intermediate-base score was assigned to all cases. The score specific areas were color coded with tissue margin ink and sectioned for histological evaluation of healthy renal margin thickness. Maximum, minimum and mean thickness of healthy renal margin for each score specific area grade (surface [S] = 0, S = 1 ; intermediate [I] or base [B] = 0, I or B = 1, I or B = 2) was reported. The Mann-Whitney U and Kruskal-Wallis tests were used to compare the thickness of healthy renal margin in S = 0 vs 1 and I or B = 0 vs 1 vs 2 grades, respectively.Maximum, minimum and mean thickness of healthy renal margin was significantly different among score specific area grades S = 0 vs 1, and I or B = 0 vs 1, 0 vs 2 and 1 vs 2 (p0.001). The main limitations of the study are the low number of the I or B = 1 and I or B = 2 samples and the assumption that each microscopic slide reflects the entire score specific area for histological analysis.The surface-intermediate-base scoring method can be readily harnessed in real-world clinical practice and accurately mirrors histopathological analysis for quantification and reporting of healthy renal margin thickness removed during tumor excision.

Hypothesizing that changing hospitals between diagnosis and definitive therapy (care transition) may delay timely treatment, we identified the association between care transitions and a treatment delay of 3 months or greater in patients with muscle invasive bladder cancer.Using the National Cancer Database we identified all patients with stage II or greater urothelial carcinoma treated from 2003 to 2010. Care transition was defined as a change in hospital from diagnosis to definitive treatment course, that is diagnosis to radical cystectomy or the start of neoadjuvant chemotherapy. Logistic regression models were used to test the association between care transition and treatment delay.Of 22,251 patients 14.2% experienced a treatment delay of 3 months or greater and this proportion increased with time (13.5% in 2003 to 2006 vs 14.8% in 2007 to 2010, p = 0.01). Of patients who underwent a care transition 19.4% experienced a delay to definitive treatment compared to 10.7% diagnosed and treated at the same hospital (p0.001). The proportion of patients with a care transition increased during the study period (37.4% in 2003 to 2006 vs 42.3% in 2007 to 2010, p0.001). After adjustment patients were more likely to experience a treatment delay when undergoing a care transition (OR 2.0, 95% CI 1.8-2.2).Patients with muscle invasive bladder cancer who underwent a care transition were more likely to experience a treatment delay of 3 months or greater. Strategies to expedite care transitions at the time of hospital referral may improve quality of care.

Thromboprophylaxis with subcutaneous heparin or low molecular weight heparin is now an integral part of national surgical quality and safety assessment efforts, and has been incorporated into the current AUA Best Practice Statement. We evaluated familiarity and compliance with the AUA Best Practice Statement, assessed practice patterns in terms of perioperative thromboprophylaxis and specifically examined self-reported compliance in high risk patients undergoing radical cystectomy.An electronic survey was sent to AUA members with valid e-mail addresses (10,966). Associations between AUA Best Practice Statement adherence and factors such as urological specialty, graduation year and guideline familiarity were assessed using chi-square analyses and generalized estimating equations.With 1,210 survey responses the largest group of respondents was urological oncologists and/or laparoscopic/robotic specialists (26.0%). This group was more likely to use thromboprophylaxis than nonurological oncologists and/or laparoscopic/robotic specialists in high risk patients (OR 1.3, CI 1.1-1.5). Respondents aware of the AUA Best Practice Statement guidelines (50.7%) were more likely to use thromboprophylaxis (OR 1.4, CI 1.2-1.6). Although 18.1% of urological oncologists and/or laparoscopic/robotic specialists and 34.2% of nonurological oncologists and/or laparoscopic/robotic specialists avoided routine thromboprophylaxis in patients undergoing radical cystectomy, the former were more likely to use thromboprophylaxis (p0.0001) than other respondents. Urologists graduating after the year 2000 used thromboprophylaxis in high risk patients undergoing radical cystectomy more often than did earlier graduates (79.2% vs 63.4%, p0.0001).Although younger age and self-reported urological oncologist and/or laparoscopic/robotic specialist status correlated strongly with thromboprophylaxis use, self-reported adherence to AUA Best Practice Statement was low, even in high risk cases with clear AUA Best Practice Statement recommendations such as radical cystectomy. These data identify opportunities for quality improvement in patients undergoing major urological surgery.

Multiple risks compete with cancer as the primary cause of death. These factors must be considered against the benefits of treatment. We constructed a model of competing causes of death to help contextualize treatment trade-off analyses in patients with localized renal cell carcinoma.We identified 6,655 individuals 66 years old or older with localized renal cell carcinoma in the linked SEER (Surveillance, Epidemiology and End Results)-Medicare data set for 1995 to 2005. We used Fine and Gray competing risks proportional hazards regression to predict probabilities of competing mortality outcomes. Prognostic markers included race, gender, tumor size, age and the Charlson comorbidity index score.At a median followup of 43 months, age and comorbidity score strongly correlated with patient mortality and were most predictive of nonkidney cancer death, as measured by concordance statistics. Patients with localized, node negative kidney cancer had a low 3 (4.7%), 5 (7.5%) and 10-year (11.9%) probability of cancer specific death but a significantly higher overall risk of death from competing causes within 3 (10.9%), 5 (20.1%) and 10 years (44.4%) of renal cell carcinoma diagnosis, depending on comorbidity score.Informed treatment decisions regarding patients with solid tumors must integrate not only cancer related variables but also factors that predict noncancer death. We established a comorbidity based predictive model that may assist in patient counseling by allowing quantification and comparison of competing risks of death in patients 66 years old or older with localized renal cell carcinoma who elect to proceed with surgery.

We assessed whether the impact of partial nephrectomy and radical nephrectomy on overall mortality differed by patient age in a Medicare population undergoing surgery for T1a renal cell carcinoma.Using linked SEER (Surveillance, Epidemiology and End Results)-Medicare data, we identified patients older than 66 years who underwent partial nephrectomy or radical nephrectomy for T1a (4 cm or smaller) renal cell carcinoma from 1995 to 2007. The effects of procedure type on overall mortality by age were assessed using time dependent Cox proportional hazards models adjusted by propensity score based weighting.A total of 5,496 patients (mean age 74.2 ± 5.6 years, 55.9% male) who underwent partial nephrectomy (1,665; 30.3%) or radical nephrectomy (3,831; 69.7%) for 4 cm or smaller renal cell carcinoma (mean tumor size 2.8 ± 0.9 cm) were identified. After adjustment, a statistically significant survival benefit for partial nephrectomy compared to radical nephrectomy was observed at 1 year (age 68, HR 1.6, CI 1.2-2.3; age 75, HR 1.5, CI 1.1-1.9; age 85, HR 1.7, CI 1.1-2.5) and 3 years (age 68, HR 1.4, CI 1.03-2.0; age 75, HR 1.3, CI 1.1-1.6; age 85, HR 1.5, CI 1.02-2.3), while these trends became insignificant in patients younger than 68 and older than 85 years. However, the survival benefit decreased with time, and little significant benefit with partial nephrectomy was observed at 5 and 10 years after surgery regardless of age (66 years or older).Lacking strong evidence regarding a long-term survival benefit, the decision to perform partial nephrectomy in elderly patients should be individualized, and placed in the context of baseline renal function, expected surgical morbidity and competing risks to survival.

Patients undergoing serial cross-sectional abdominal imaging to evaluate abdominal symptomatology may have a renal tumor develop during followup of an unrelated disease process. Evaluation of such patients provides an opportunity to further define the radiographic inception, natural history and growth patterns of renal tumors.Renal tumor databases from 2 institutions were reviewed for patients in whom an enhancing renal tumor developed despite a prior normal cross-sectional radiographic examination of the kidneys. Variables evaluated included age, gender, tumor size at presentation, calculated tumor growth rate from negative scan to radiographic presentation and pathology in patients undergoing definitive treatment.We identified 36 patients with an average age of 65 years (range 44 to 82). Mean tumor size on presentation was 2.3 cm (range 1.0 to 5.0). The presumed absolute growth rate based on the timing of the initial negative imaging study and tumor diameter at presentation was significantly greater than the observed absolute growth rate after tumor detection (0.71 vs 0.039 cm per year, p = 0.028). No difference was noted between presumed and observed tumor growth based on absolute change in tumor volume (1.44 vs 5.37 cm(3) per year, p = 0.203). Presumed relative growth rates based on tumor diameter (665% vs 23% per year) and volume (1,397% vs 169% per year) were significantly greater than observed relative growth rates (p = 0.005 and p = 0.013, respectively).The presumed growth rate of the tumors was significantly greater than the observed growth rate, suggesting that tumor growth rates do not follow a linear pattern throughout their development and progression.

We compared outcomes in patients undergoing robotic vs open partial nephrectomy stratified by moderately and highly complex tumor nephrometry scores.Patients treated with partial nephrectomy from 2007 to 2010 were grouped by tumor characteristics into low-nephrotomy score 4 to 6, moderate-7 to 9 and high-10 to 12 anatomical complexity cohorts. Lesions with low complexity were excluded from study. Demographic, surgical and pathological outcomes were compared between patients undergoing robotic vs open partial nephrectomy in the moderately and highly complex cohorts.A total of 281 patients, of whom 63.3% were male, with a mean±SD age of 58.1±11.7 years and a mean followup of 21.3±16.3 months underwent partial nephrectomy. Moderately complex lesions were noted in 81 robotic and 136 open partial nephrectomy cases with a mean tumor size of 3.8±2.2 cm. Highly complex lesions were noted in 10 robotic and 54 open partial nephrectomy cases with a mean tumor size of 4.8±3.0 cm. There were no differences between the groups in patient age, race, gender, body mass index or American Society of Anesthesiologists classification. Cases treated with open partial nephrectomy for moderately or highly complex lesions were of higher pathological stage (p=0.02 and 0.01, respectively). The percent change in creatinine and the glomerular filtration rate were similar for robotic and open partial nephrectomy in the moderately and highly complex tumor groups. In patients undergoing robotic vs open partial nephrectomy for moderately complex lesions we noted differences in pathological tumor size (mean 3.2±1.8 vs 4.1±2.3 cm, p0.0001) and operative time (205.9±52.5 vs 189.5±52.0 minutes, p0.01) while decreased estimated blood loss (131.3±127.8 vs 256.5±291.3 ml) and hospital length of stay (3.7±1.6 vs 5.6±3.9 days, each p0.001) were observed in the robotic group. Comparison of highly complex lesions revealed decreased hospital length of stay (2.9±1.4 vs 6.1±4.1 days, p0.0001) in the robotic partial nephrectomy group.In our large institutional series of patients with moderate and highly complex solid renal tumors classified by the nephrometry score robotic partial nephrectomy offered comparable perioperative and functional outcomes with the added benefit of decreased hospital length of stay.

President Woodrow Wilson was never able to gain ratification of the Treaty of Versailles, the peace accord to end World War I. Before he could convince the American people of the importance of ratification, Wilson suffered a stroke followed by life threatening urinary sepsis due to urinary retention, and was treated by the father of modern urology, Hugh Hampton Young. The effects of these health problems are examined in the context of their implications on international affairs.Biographical sources and primary documentation of Wilson's physicians were reviewed to determine the effect of Wilson's stroke on his voiding habits. Hugh Hampton Young's evaluation and decision making is examined in depth.In the fall of 1919 President Wilson was recovering from a stroke. Shortly after the stroke his preexisting voiding dysfunction progressed to urinary retention from which urinary sepsis developed. Hugh Hampton Young advised on Wilson's case and counseled patience over surgery. The President began voiding spontaneously and recovered from sepsis. The illness left him severely weakened and unable to mount an aggressive campaign to persuade the U.S. Senate of the importance of ratifying the Treaty of Versailles. His personal physician, Admiral Cary T. Grayson, stated that the President was mentally never the same after the sepsis.Wilson's voiding dysfunction contributed to his inability to win approval for the Treaty of Versailles and the League of Nations. As a result, the United States returned to a policy of isolationism and Europe plunged into 2 decades of upheaval, leading to World War II.

Concurrent adrenalectomy during renal surgery for renal cell carcinoma was once routine. More recent data suggest that adrenalectomy should be reserved for tumors 7 cm or greater, particularly those involving the upper pole. We evaluated the radiographic and pathological incidence of adrenal involvement in patients undergoing renal surgery for renal cell carcinoma 7 cm or greater.Patients who underwent renal surgery for tumors 7 cm or greater between 1999 and 2008 were identified from our kidney cancer registry. We used Fisher's exact test to determine whether radiographic tumor site predicted adrenal involvement. The Kaplan-Meier method and Cox proportional hazard regression models were used to analyze the impact of adrenal resection on outcome.Of 1,650 patients we identified 179 patients who underwent surgery for renal cell carcinoma 7 cm or greater. Of these patients 91 underwent concurrent total ipsilateral adrenalectomy at renal surgery with pathological adrenal involvement confirmed in 4 (4.4%). Upper pole site did not predict involvement (p = 0.83). Preoperative adrenal imaging was 100% sensitive and 92% specific to detect adrenal involvement by renal cell carcinoma with 100% negative predictive value. No survival advantage was noted on multivariate analysis when comparing patients who underwent adrenal resection to 88 in whom the adrenal gland was spared (p = 0.38).Synchronous ipsilateral adrenal involvement with renal cell carcinoma is rare even in cases of large and/or upper pole tumors, making routine adrenalectomy unnecessary. Preoperative adrenal imaging is highly sensitive and should inform the decision to perform adrenalectomy more than tumor size or site.

Treatment decisions for renal malignancies depend largely on qualitative data, including a description of tumor anatomy and the experience of the treating surgeon. Currently characterization of renal tumor anatomical elements is descriptive and lacks standardization. Surgical decision making and data set comparisons would be significantly enhanced by a consistent, reproducible system that quantitates the pertinent characteristics of localized renal lesions. We have developed and propose a standardized nephrometry scoring system (R.E.N.A.L. Nephrometry Score) to quantify the anatomical characteristics of renal masses on computerized tomography/magnetic resonance imaging.The nephrometry score is based on 5 critical and reproducible anatomical features of solid renal masses. Of the 5 components 4 are scored on a 1, 2 or 3-point scale with the 5th indicating the anterior or posterior location of the mass relative to the coronal plane of the kidney. We applied the R.E.N.A.L. Nephrometry Score to 50 consecutive masses resected at Fox Chase Cancer Center.The R.E.N.A.L. Nephrometry Score consists of (R)adius (tumor size as maximal diameter), (E)xophytic/endophytic properties of the tumor, (N)earness of tumor deepest portion to the collecting system or sinus, (A)nterior (a)/posterior (p) descriptor and the (L)ocation relative to the polar line. The suffix h (hilar) is assigned to tumors that abut the main renal artery or vein. The nephrometry scoring system accurately classified the complexity of 50 consecutive tumors undergoing excision at our institution.Standardized reporting of renal tumor size, location and depth is essential for decision making and effective comparisons. The R.E.N.A.L. Nephrometry Score is a reproducible standardized classification system that quantitates the salient anatomy of renal masses. This novel approach for the systematic characterization of renal tumors provides a tool for meaningful comparisons of renal masses in clinical practice and in the urological literature.

Laparoscopic transvesical ureteral reimplantation with or without robotic assisted surgical devices is being developed as an alternative to open surgery. We review our experience with laparoscopic transvesical ureteral reimplantation.A total of 32 patients underwent laparoscopic transvesical reimplantation by the same surgeon. Of the patients 5 had primary obstructing megaureters and 27 had vesicoureteral reflux. Transvesical laparoscopic cross-trigonal ureteral reimplantation was performed in patients with reflux, and a Glenn-Anderson reimplantation was used in patients with a primary obstructing megaureter. A pure laparoscopic approach using two 3 mm working ports and a 5 mm camera port was used.The operative success rates were 92.6% and 80% for vesicoureteral reflux and primary obstructing megaureter cases, respectively. Complications included a postoperative urinary leak in 4 patients (12.5%) and ureteral stricture at the neoureterovesical anastomosis in 2 (6.3%). All but 1 complication occurred in patients 2 years or younger with bladder capacity less than 130 cc.Laparoscopic intravesical reimplantation is in its infancy and appears to have higher complication rates in young patients with small bladder capacity.