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Objective: To quantify the short-term burden associated with continent diversion relative to ileal conduit creation., Methods: Bladder cancer patients who underwent radical cystectomy in 2019 and 2020 were identified in the American College of Surgeons National Surgical Improvement Program database using current procedural terminology codes and pathology reports. Patients were grouped by urinary diversion performed: ileal conduit versus continent diversion (neobladder or cutaneous reservoir). Multiple logistic regression was used to examine the association between type of urinary diversion and 30-day outcomes, including postoperative complications, all-cause readmissions, and mortality, adjusting for baseline differences., Results: Of 4,755 patients who underwent radical cystectomy, 677 underwent continent diversion (14.2%). These patients were significantly younger (median 62 vs 71 years, P <.01) and less likely to have diabetes (13.6% vs 20.1%, P <.01), COPD (3.7% vs 7.1%, P<0.01), and prior pelvic radiation (5.5% vs 13.1%, P <.01). A greater proportion of continent diversion patients experienced a postoperative complication (56.0% vs 48.9%, P <.01) and all-cause readmission (30.3% vs 20.4%, P <.0). After adjustment, continent diversion patients had 1.4 (95% CI: 1.1-1.7) and 1.7 (95% CI: 1.4-2.1) times the odds of experiencing a postoperative complication or all-cause readmission, respectively. There was no statistically significant difference in mortality (OR 1.2, 95% CI: 0.5-2.9)., Conclusion: Compared to ileal conduit creation, continent urinary diversion is associated with increased odds of postoperative complications and readmission to the hospital within 30 days of surgery. Bladder cancer patients undergoing cystectomy and seeking continent diversion should be counseled on the increased short-term morbidity associated with this specific type of diversion., (Copyright © 2022. Published by Elsevier Inc.)

Objective: To demonstrate the surgical technique for prophylactic mesh placement in the sublay position during ileal conduit creation because literature suggests that prophylactic mesh placement at the time of cystectomy may reduce the risk of parastomal hernias with low risk of mesh-related complications. Parastomal hernias are one of the most common complications following ileal conduit construction and occur in 17-65% of patients undergoing cystectomy with urinary diversion. Review of our institutions data demonstrated a high incidence of hernias associated with ileal conduits, which have substantial burden to patients, surgeons, and the healthcare system., Methods: This is a retrospective chart review of data from a single surgeon who performed cystectomy with ileal conduit for 12 patients with bladder cancer between January, 2021-March, 2022 at our institution. These dates were chosen based on the timing of availability of literature suggesting a benefit from prophylactic mesh placement. Preliminary data was analyzed determine the incidence of parastomal hernia and mesh-related complications., Results: A total of 12 patients underwent cystectomy with ileal conduit between January, 2021-March, 2022 at our institution. Eleven patients (92%) had prophylactic mesh placed during their procedure. Median follow up was 5.4 months (0.8-8 months). Two patients (17%) developed a parastomal hernia which was detected clinically and/or radiographically. The hernias occurred in patients with mesh and within 6 months of cystectomy. One patient had stomal stenosis eventually requiring surgical revision. There were no mesh infections or mesh removals., Conclusion: Parastomal hernias are a common and morbid complication of ileal conduit urinary diversion. Our early experience demonstrates that the procedure is straightforward, adds little time to the surgical procedure, and is associated with a low complication rate. Our experience is too small and follow up too short to confirm that the results of the randomized trial can be matched at our center., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To understand cystoscopic surveillance practices among patients with low-risk non-muscle-invasive bladder cancer (NMIBC) within the Department of Veterans Affairs (VA)., Methods: Using a validated natural language processing algorithm, we included patients newly diagnosed with low-risk (ie low-grade Ta) NMIBC from 2005 to 2011 in the VA. Patients were followed until cancer recurrence, death, last contact, or 2 years after diagnosis. Based on guidelines, surveillance overuse was defined as >1 cystoscopy if followed <1 year, >2 cystoscopies if followed 1 to <2 years, or >3 cystoscopies if followed for 2 years. We identified patient, provider, and facility factors associated with overuse using multilevel logistic regression., Results: Overuse occurred in 75% of patients (852/1135) - with an excess of 1846 more cystoscopies performed than recommended. Adjusting for 14 factors, overuse was associated with patient race (odds ratio [OR] 0.49, 95% confidence interval [CI]: 0.28, 0.85 unlisted race vs White), having 2 comorbidities (OR 1.60, 95% CI: 1.00, 2.55 vs no comorbidities), and earlier year of diagnosis (OR 2.50, 95% CI: 1.29, 4.83 for 2005 vs 2011, and OR 2.03, 95% CI: 1.11, 3.69 for 2006 vs 2011). On sensitivity analyses assuming all patients were diagnosed with multifocal or large low-grade tumors (ie, intermediate-risk), overuse would have still occurred in 45% of patients., Conclusion: Overuse of cystoscopy among patients with low-risk NMIBC was common, raising concerns about bladder cancer surveillance cost and quality. However, few factors were associated with overuse. Further qualitative research is needed to identify other determinants of overuse not readily captured in administrative data., (Published by Elsevier Inc.)

Objective: To assess geographic variation in cystoscopy rates among women vs men with suspected bladder cancer, lending insight into gender-specific differences in cystoscopic evaluation., Methods: We conducted a cross-sectional study of all fee-for-service Medicare beneficiaries within 306 Hospital Referral Regions (HRRs) who received care in 2014. For each HRR, we calculated the age- and race-adjusted cystoscopy rate for women and men as our primary outcome. The rate was the number of beneficiaries who underwent cystoscopy for bladder cancer symptoms (using procedure and ICD-9 diagnosis codes) divided by all beneficiaries in the HRR. We used the coefficient of variation to compare relative variability of cystoscopy rates., Results: Overall, 173,551 women (n = 14.8 million) and 286,090 men (n = 11.5 million) underwent cystoscopy in 2014. While women received less cystoscopies compared to men (mean 11.0 vs 23.5 per 1000, P < .001), there was greater variation in cystoscopy rates among women (coefficient of variation 27.5 vs 23.5, P = .010). When restricting to ICD-9 codes for hematuria only, women continued to demonstrate greater variation in cystoscopy rates (coefficient of variation 27.8 vs 24.2, P = .022). Findings were robust across larger HRR sizes-thereby removing some random variation seen in smaller HRRs-as well as across years 2010, 2011, 2012, and 2013., Conclusion: Cystoscopy rates are lower in women than men, likely due to their lower bladder cancer incidence. However, there is greater variation in cystoscopy rates among women with symptoms of bladder cancer. This may reflect increased provider uncertainty whether to refer and work-up women with suspected bladder cancer., (Copyright © 2018. Published by Elsevier Inc.)

Objective: To take the first step toward assembling population-based cohorts of patients with bladder cancer with longitudinal pathology data, we developed and validated a natural language processing (NLP) engine that abstracts pathology data from full-text pathology reports., Methods: Using 600 bladder pathology reports randomly selected from the Department of Veterans Affairs, we developed and validated an NLP engine to abstract data on histology, invasion (presence vs absence and depth), grade, the presence of muscularis propria, and the presence of carcinoma in situ. Our gold standard was based on an independent review of reports by 2 urologists, followed by adjudication. We assessed the NLP performance by calculating the accuracy, the positive predictive value, and the sensitivity. We subsequently applied the NLP engine to pathology reports from 10,725 patients with bladder cancer., Results: When comparing the NLP output to the gold standard, NLP achieved the highest accuracy (0.98) for the presence vs the absence of carcinoma in situ. Accuracy for histology, invasion (presence vs absence), grade, and the presence of muscularis propria ranged from 0.83 to 0.96. The most challenging variable was depth of invasion (accuracy 0.68), with an acceptable positive predictive value for lamina propria (0.82) and for muscularis propria (0.87) invasion. The validated engine was capable of abstracting pathologic characteristics for 99% of the patients with bladder cancer., Conclusion: NLP had high accuracy for 5 of 6 variables and abstracted data for the vast majority of the patients. This now allows for the assembly of population-based cohorts with longitudinal pathology data., (Published by Elsevier Inc.)

Objective: To examine discomfort, anxiety, and preferences for decision making in patients undergoing surveillance cystoscopy for non-muscle-invasive bladder cancer (NMIBC)., Methods: Veterans with a prior diagnosis of NMIBC completed validated survey instruments assessing procedural discomfort, worry, and satisfaction, and were invited to participate in semistructured focus groups about their experience and desire to be involved in surveillance decision making. Focus group transcripts were analyzed qualitatively, using (1) systematic iterative coding, (2) triangulation involving multiple perspectives from urologists and an implementation scientist, and (3) searching and accounting for disconfirming evidence., Results: Twelve patients participated in 3 focus groups. Median number of lifetime cystoscopy procedures was 6.5 (interquartile range 4-10). Based on survey responses, two-thirds of participants (64%) experienced some degree of procedural discomfort or worry, and all participants reported improvement in at least 2 dimensions of overall well-being following cystoscopy. Qualitative analysis of the focus groups indicated that participants experience preprocedural anxiety and worry about their disease. Although many participants did not perceive themselves as having a defined role in decision making surrounding their surveillance care, their preferences to be involved in decision making varied widely, ranging from acceptance of the physician's recommendation, to uncertainty, to dissatisfaction with not being involved more in determining the intensity of surveillance care., Conclusion: Many patients with NMIBC experience discomfort, anxiety, and worry related to disease progression and not only cystoscopy. Although some patients are content to defer surveillance decisions to their physicians, others prefer to be more involved. Future work should focus on defining patient-centered approaches to surveillance decision making., (Published by Elsevier Inc.)

Objective: To evaluate trends in prostate biopsy and cancer diagnosis at a center with conservative screening practices in the pre- and post-2012 era. More restrictive prostate-specific antigen (PSA) screening guidelines have led to lower rates of screening, biopsy, and diagnosis of prostate cancer. It is not clear, however, how regions with low baseline screening rates (the Lebanon, New Hampshire hospital referral region centered on Dartmouth-Hitchcock Medical Center had the lowest rate of screening among Medicare patients in 2012) have responded to these guidelines., Methods: We retrospectively analyzed patients who underwent prostate biopsy from January 2011 to March 2016. Demographic and clinical characteristics were analyzed by time. Multivariable analysis assessed for factors associated with higher grade cancer., Results: There were 614 prostate biopsies were performed. PSA at biopsy increased with time (7.2 in 2011 vs 10.1 in 2015, P = .0085); age did not. There was a stable proportion of benign findings; proportions of low-grade disease decreased, whereas intermediate- and high-grade disease increased (2011 vs 2015: 21.1% vs 10.8% Gleason 3 + 3, 32.9% vs 43.3% ≥ Gleason 3 + 4, P = .0454). Factors predictive of higher grade disease included abnormal digital examination (odds ratio [OR] 2.19, P = .0076), higher PSA (OR 1.09, P = .0040), and later biopsy date (OR 1.01, P = .0469)., Conclusion: In an environment of conservative baseline screening practices, there has been a shift in prostate biopsy criteria and outcomes, namely a rising PSA threshold for biopsy and a 50% decrease in the diagnosis of low-grade disease. Additional study is needed to ensure these trends are favorably impacting the quality of care., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To assess a large national sample of bladder cancer pathology reports to determine if they contained the components necessary for clinical decision-making., Methods: We examined a random sample of 507 bladder cancer pathology reports from the national Department of Veterans Affairs Corporate Data Warehouse to assess whether each included information on the 4 report components explicitly recommended by the College of American Pathologists' protocol for the examination of such specimens: histology, grade, presence vs absence of muscularis propria in the specimen, and microscopic extent. We then assessed variation in the proportion of reports lacking at least 1 component across Department of Veterans Affairs facilities., Results: One hundred eight of 507 reports (21%) lacked at least 1 of the 4 components, with microscopic extent and presence vs absence of muscularis propria in the specimen most commonly missing (each in 11% of reports). There was wide variation across facilities in the proportion of reports lacking at least 1 component, ranging from 0% to 80%., Conclusion: One-fifth of bladder cancer pathology reports lack information needed for clinical decision-making. The wide variation in incomplete report rates across facilities implies that some facilities already have implemented best practices assuring complete reporting whereas others have room for improvement. Future work to better understand barriers and facilitators of complete reporting may lead to interventions that improve bladder cancer care., (Published by Elsevier Inc.)

Objectives: To describe the costs associated with the learning curve of robotic-assisted prostatectomy (RAP)., Methods: A theoretical model of the cost of operative time during the learning curve for RAP was constructed. Within the theoretical model varying rates of improvement were considered, and once the learning curve was complete, the total cost of operative time was calculated. This cost was then compared with an actual series of RAP, whose operative time and associated costs during the learning curve were also calculated., Results: In the theoretical model, surgeons improved at rates of 1, 5, or 10 minutes per case, and began the learning curve that required 8 or 9 hours to perform a single RAP. At the end of the learning curve it took either 3 or 4 hours. The most expensive learning curve was 360 cases long and cost $1.3 million; the least expensive learning curve was 24 cases and cost $95,000. The literature search involved 8 series, with a range of learning curves from 13 to 200 cases. The least expensive learning curve was $49,613 and the most expensive learning curve was $554,694. The average learning curve was 77 cases and cost $217,034., Conclusions: Costs associated with operative time while learning RAP are substantial, and should be considered when deciding whether to implement RAP at an individual institution. RAP may best be suited to high volume prostatectomy centers, in which the learning curve can be rapidly traversed, and associated costs minimized.

We report the first case of an adenocarcinoma developing in a continent ileocolonic urinary reservoir. The tumor presented 7 years after the urinary diversion and more than 6 years after the resection of a Dukes' B lesion of the left colon. This report demonstrates that the colonic segment used for urinary diversion retains its malignant potential and that surveillance pouchoscopy should be performed in these patients.