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Introduction: While abiraterone acetate (AA) has demonstrated survival benefit in advanced prostate cancer (APC), meaningful cardiotoxicity is observed. It is unclear whether the magnitude differs based on disease indication and concurrent steroid administration. Methods: We performed a systematic review and meta-analysis of phase II/III RCTs of AA in APC published as of August 11, 2020. Primary outcomes examined were all-and high-grade (grade = 3) hypokalemia and fluid retention, and secondary outcomes included hypertension and cardiac events. We performed random effects meta-analysis comparing intervention (AA + steroid) and control (placebo ± steroid), stratified by treatment indication and whether patients received steroids. Results: Among 2,739 abstracts, we included 6 relevant studies encompassing 5901 patients. Hypokalemia and fluid retention were observed more frequently among patients receiving AA (odds ratio [OR] 3.10 [95% CI 1.69-5.67] and 1.41 [95% CI 1.19-1.66]). This was modified by whether patients in the control received steroids: trials where control patients did not demonstrated a larger association between AA and hypokalemia (OR 6.88 [95% CI 1.48-2.36] versus OR 1.86 [95% CI 4.97-9.54], P < .0001) and hypertension (OR 2.53 [95% CI 1.91-3.36] vs. OR 1.55 [95% CI 1.17-2.04], P = .1) than those where steroids were administered. We observed heterogeneity due to indication: there were greater effects on hypokalemia (P < 0001), hypertension (P = .03), and cardiac disorders (P = .01) among patients treated for mHSPC than mCRPC. Conclusions: The magnitude of cardiotoxicity with AA differs based on trial design and disease indication. These data are valuable in treatment decisions and highlight utilization of appropriate data for counseling. [ABSTRACT FROM AUTHOR]

There are several choices for the correction of complex transposition of the great arteries and double outlet right ventricle not amenable to the Rastelli-type surgery, but outcome data are limited to small series. This study aims to report results after the aortic root translocation and en bloc rotation of the outflow tract procedures. This is a retrospective, multicentric, observational study. Clinical, anatomy, procedural, and detailed follow-up data (median, 4.43 years) were collected. A total of 70 patients (62.9% male; median age, 1 year; range 4 days to 12.4 years) were included: n = 43 in the aortic root translocation group and n = 27 in the en bloc rotation group. Those in the aortic root translocation group were older (P =.01) and more likely to have had previous procedures (P <.0001), but cardiac anatomy was similar in both groups. Aortic root translocation and en bloc rotation early mortality (30 days) was similar (4.7% vs 3.7%, P =.8). Late survival and freedom from any cardiac reintervention were 92.7% and 16.9% at 15 years overall, respectively. Freedom from right ventricular outflow tract/conduit reintervention was better in the en bloc rotation group than in the aortic root translocation group (100% vs 24.5%, P =.0003), but more patients in the en bloc rotation group had moderate (or worse) aortic valve regurgitation during follow-up (16% vs 2.6%, P =.07). Both aortic root translocation and en bloc rotation are valuable surgical options for the treatment of complex transposition of the great arteries and double outlet right ventricle. In the en bloc rotation group, there was better freedom from right ventricular outflow tract reinterventions, but a higher probability of aortic valve regurgitation. Identifying the main driving forces for these observed differences requires further study of these procedures. ART and EBR of the outflow tract procedures show overall good and comparable outcomes, with some differences in patient profile, freedom from reintervention, and residual valvular lesions. [Display omitted] [ABSTRACT FROM AUTHOR]

To assess the outcomes, total healthcare utilization, and cost savings for same-day discharge (SDD) vs inpatient robotic-assisted partial nephrectomy (RAPN) and robotic-assisted radical nephrectomy (RARN). We compared 146 RAPNs and 65 RARNs consecutively performed as SDD (RAPN = 21, RARN = 9) vs inpatient (RAPN = 125, RARN = 56) from April 2015 to May 2023 at two academic medical centers. We collected baseline demographics, perioperative characteristics, and 30-day complications. We applied the Time-Driven Activity-Based Costing analysis to compare total costs of RAPN and PARN throughout the cycle of care, including inpatient vs SDD. Baseline demographics and comorbidities were similar between patients undergoing inpatient vs SDD RAPN and RARN. One Clavien-Dindo grade II complication (3.3%) requiring readmission due to wound infection for antibiotics occurred after SDD RAPN; no complications occurred after SDD RARN. Two unscheduled office or emergency department visits (6.7%) occurred after SDD RAPN for surgical-site infection and urinary retention. SDD vs inpatient RAPN and RARN demonstrated a $3091 (18%) and $4003 (25%) overall cost reduction, respectively. SDD RAPN and RARN result in cost savings of 18%-25% without a difference in complications, and thereby improves value-based care for appropriately selected patients. [ABSTRACT FROM AUTHOR]

Objective: To measure decisional quality in patients being counseled on treatment for small renal masses and identify potential areas of improvement.Materials and Methods: A total of 73 patients diagnosed with small renal masses at the University of California, Los Angeles Health completed an instrument measuring decisional conflict, patient satisfaction with care, disease-specific knowledge, and patient impression that shared decision-making occurred in the visit after counseling by a specialist. Participant characteristics were compared between those with high and low decisional conflict using chi-square or Student t test (or Wilcoxon rank-sum test).Results: Participants were mostly older (mean age 63.5), white (84%), in a relationship (61%), and unemployed or retired (63%). Mean knowledge score was 59% correct. The mean (standard deviation) decisional conflict score was 16.4 (18.4) indicating low levels of decisional conflict but with a wide range of scores. Comparing participants with high decisional conflict with those with low decisional conflict, there were significant differences in knowledge scores (Wilcoxon P = .0069), patient satisfaction with care (P = .0011), and perceived shared decision-making (P <.0001).Conclusion: Patients with small renal masses generally have low levels of decisional conflict and can identify a preferred treatment after a physician visit. However, both groups lack overall knowledge about their disease even after counseling, and thus may be heavily influenced by paternalistic care. Those patients with decisional conflicts are less likely to perceive their care as satisfactory and are less likely to be involved in decision-making. [ABSTRACT FROM AUTHOR]

Background: By 2022, there will be 18 million predicted cancer survivors, which is an estimated 30% more than the number of survivors in 2012. In prostate cancer alone, the most common cancer in American men other than skin cancer, 1 in 7 men will be diagnosed during their lifetime. Nevertheless, only approximately 1 in 39 will actually die of the disease. Although life expectancy is often good, these men have multiple treatment management options to choose from, including active surveillance, surgery, or radiotherapy, each of which carries its own array of long-term adverse effects. The same applies to renal cancer where patient have to sift through information to decide among active surveillance, partial nephrectomy, racial nephrectomy, robotic vs. open surgery, and ablation.Basic Procedures: Ultimately, patient, providers, and stakeholders lack high-quality evidence to effectively guide treatment decisions, and these decisions become even harder to discern when considering end-of-life care, palliative care, and the ethics regarding the new End of Life Option Act. As of November 1, 2016, the number of open urologic cancer clinical trials listed on ClinicalTrials.gov was 843.Main Findings: Although we continue to make tremendous strides in urologic cancer care, our options for choosing the best treatment from a patient and provider standpoint are seemingly growing murkier. We need to continue to understand how health-related quality of life varies from patient to patient, and ultimately, incorporate patient preferences and values into the treatment decision in order to make high-quality treatment decisions.Conclusions: The remained of this articles will focus on the significant strides made in urologic oncology regarding these difficult decisions from localized disease to end-of-life care and also will detail what needs to be done as we continue to pivot forward. [ABSTRACT FROM AUTHOR]

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Background We investigated provider and regional variation in payments made to surgeons by the Centers for Medicare & Medicaid Services (CMS) by indexing payments to unique beneficiaries treated and examined the proportion of charges that resulted in payments. Understanding variation in care within CMS may prove actionable by identifying modifiable, and potentially unwarranted, variations. Methods We analyzed the Medicare Part B Provider Utilization and Payment Data released by CMS for 2012. We included Medicare B participants in the fee-for-service program. We calculated for each provider the ratio of number of services provided to individual beneficiaries, and the ratio of total submitted charges to total Medicare payments. We also categorized each provider into deciles of total Medicare payments, and calculated the means per decile of total Medicare payment for surgeons and urologists. To determine any associations with ratio of services to beneficiaries, we conducted multivariate linear regressions. Results The 20th, 40th, 60th, and 80th percentiles for the services-per-beneficiary ratios are 1.6, 2.2, 3.1, and 5.0, respectively ( n = 83,376). Greater-earning surgeons offered more services per beneficiary, with a precipitous increase from the lowest decile to the highest. Charges were consistently greater than payments by a factor of 3. In our multivariate analysis of services per beneficiary ratio, female providers had lower ratios ( P < .01), and we noted significant regional variation in the ratio of services per unique beneficiary ( P < .001 for each of the 10 Standard Federal Regions). Conclusion We found significant variation in patterns of payments for surgical care in CMS. [ABSTRACT FROM AUTHOR]

• Although neoadjuvant chemotherapy is currently standard of care for patients with muscle-invasive bladder cancer, its adoption remains far from universal, and we still lack predictive tools to better understand who may most benefit from chemotherapy, let alone from what type of therapy. • In this study, we utilized biodynamic analysis (also known as motility contrast tomography or biodynamic imaging) to help develop a classifier for predicting response to chemotherapy in muscle-invasive bladder cancer. • Biodynamic analysis provides a fast and simple quantitative analysis to help fill a large gap where targetable genetic biomarkers do not yet exist or still have unproven benefit. Biodynamic signatures (temporal patterns of microscopic motion within a 3-dimensional tumor explant) offer phenomic biomarkers that are highly predictive for therapeutic response. By utilizing motility contrast tomography, which provides a simple, fast assessment of motion patterns in living tissue, we evaluated the predictive accuracy of a biodynamic drug response classifier in muscle-invasive bladder cancer (MIBC) patients undergoing neoadjuvant chemotherapy (NAC). One hundred five consecutive bladder cancer patients suspected of having MIBC were screened in a multi-institutional prospective observational study (NCT03739177) from July 2018 to June 2020, of whom, 30 completed NAC and radical cystectomy. Biodynamic signatures from treatment-naïve fresh bladder tumor specimens obtained after transurethral resection were measured in living tumor fragments challenged by standard-of-care cytotoxins. Patients received gemcitabine and cisplatin or dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin per institutional guidelines and were followed through radical cystectomy. A 4-level classifier was developed to predict pathologic complete response (pCR) vs. incomplete response utilizing a one-left-out cross-validation protocol to minimize over-fitting. Area under the curve evaluated predictive utility. Thirty percent (9 of 30) achieved pCR. Utilizing the 4-level classifier, biodynamically "favored" (scoring ≥ 3) and "strongly favored" (scoring 4) regimens accurately predicted pCR at rates of 66.7% (4 of 6 patients) and 100% (4 of 4 patients), respectively. Biodynamically "favored" scores predicted pCR with 88% sensitivity and 95% negative predictive value, P < 0.0001. Only 5.0% (1 of 20 patients) achieved pCR from regimens scoring 1 or 2, indicating poor to no response from NAC. Area under the receiver operating curve was 96% (95% Confidence Interval: 79%–99%, P < 0.0001). Future direction involves validating this model prospectively. Biodynamic scoring accurately predicts response in MIBC patients receiving NAC and holds promise to substantially improve the scope of appropriate management intervention. [ABSTRACT FROM AUTHOR]

Purpose Cost estimates through traditional hospital accounting systems are often arbitrary and ambiguous. We used time-driven activity-based costing (TDABC) to determine the true cost of low-dose-rate (LDR) and high-dose-rate (HDR) brachytherapy for prostate cancer and demonstrate opportunities for cost containment at an academic referral center. Methods and Materials We implemented TDABC for patients treated with I-125, preplanned LDR and computed tomography based HDR brachytherapy with two implants from initial consultation through 12-month followup. We constructed detailed process maps for provision of both HDR and LDR. Personnel, space, equipment, and material costs of each step were identified and used to derive capacity cost rates, defined as price per minute. Each capacity cost rate was then multiplied by the relevant process time and products were summed to determine total cost of care. Results The calculated cost to deliver HDR was greater than LDR by $2,668.86 ($9,538 vs. $6,869). The first and second HDR treatment day cost $3,999.67 and $3,955.67, whereas LDR was delivered on one treatment day and cost $3,887.55. The greatest overall cost driver for both LDR and HDR was personnel at 65.6% ($4,506.82) and 67.0% ($6,387.27) of the total cost. After personnel costs, disposable materials contributed the second most for LDR ($1,920.66, 28.0%) and for HDR ($2,295.94, 24.0%). Conclusions With TDABC, the true costs to deliver LDR and HDR from the health system perspective were derived. Analysis by physicians and hospital administrators regarding the cost of care afforded redesign opportunities including delivering HDR as one implant. Our work underscores the need to assess clinical outcomes to understand the true difference in value between these modalities. [ABSTRACT FROM AUTHOR]

A high-performance liquid chromatographic assay with diode-array detection has been developed for the in-process control of zolpidem synthesis and for the analysis of the drug and its synthetic intermediates.The separation uses a 4.6mm i.d. reversed-phase Kromasil C18 (150mm) column, 5μm particle size with a gradient elution mode of acetonitrile and 0.02M NH4OAc (adjusted to pH 8.0) as the mobile phase (flow rate 1.0mlmin-1).The analysis is performed in 12min. The method is simple, rapid and highly specific. [Copyright &y& Elsevier]

A high-performance liquid chromatographic assay coupled with UV detection (239 nm) has been developed for the determination of midazolam and its synthesis precursors. The separation of the analytes was performed on a Kromasil C8 column (15 cm×4.6 mm i.d., 5 μm) at 30 °C. The mobile phase [ammonium chloride (pH 5.5, 1 g l−1)–methanol–acetonitrile (45:22:33, v/v/v)] was pumped at a flow-rate of 1.5 ml min−1. This method is rapid (less than 11 min), sensitive (limit of detection (LOD) ranged between 0.05 and 0.5 mg l−1) and selective for the determination of midazolam, and it could be used for monitoring different synthetic routes. [Copyright &y& Elsevier]

A high-performance liquid chromatographic assay coupled with UV detection (215 nm) was developed for the determination of sultamicillin and its synthesis precursors. The separation of the analytes was performed on a Kromasil C18 column (15 cm×4.6 mm i.d., 5 μm) at 20 °C. The mobile phase (25 mM phosphate buffer, pH 7.0 and acetonitrile 48%) was pumped at a flow rate of 1.0 ml min−1. This method is sensitive (limits of detection ranged between 0.4 and 1.2 mg l−1) and selective for the determination of sultamicillin and could be used for monitoring different synthetic routes. [Copyright &y& Elsevier]

Introduction and Objective: The timing of radiotherapy (RT) after prostatectomy is controversial, and its effect on sexual, urinary, and bowel function is unknown. This study seeks to compare patient-reported functional outcomes after radical prostatectomy (RP) and postprostatectomy radiation as well as elucidate the timing of radiation to allow optimal recovery of function.Methods: The Comparative Effectiveness Analysis of Surgery and Radiation (CEASAR) study is a prospective, population-based, observational study of men with localized prostate cancer. Patient-reported sexual, urinary, and bowel functional outcomes were measured using the 26-item Expanded Prostate Index Composite at baseline and at 6, 12, 36, and 60 months after enrollment. Functional outcomes were compared among men undergoing RP alone, post-RP adjuvant radiation (RP + aRT), and post-RP salvage radiation (RP + sRT) using multivariable models controlling for baseline clinical, demographic, and functional characteristics.Results: Among 1,482 CEASAR participants initially treated with RP for clinically localized prostate cancer, 11.5% (N = 170) received adjuvant (aRT, N = 57) or salvage (sRT, N = 113) radiation. Men who received post-RP RT had worse scores in all domains (sexual function [-9.0, 95% confidence interval {-14.5, -3.6}, P < 0.001], incontinence [-8.8, {-14.0, -3.6}, P < 0.001], irritative voiding [-5.9, {-9.0, -2.8}, P < 0.001], bowel irritative [-3.5, {-5.8, -1.2}, P = 0.002], and hormonal function [-4.5, {-7.2, -1.7}, P = 0.001]) compared to RP alone at 5 years of follow-up. Compared to men treated with RP alone in an adjusted linear model, sRT was associated with significantly worse scores in all functional domains. aRT was associated with significantly worse incontinence, urinary irritation, and hormonal function domain scores compared to RP alone at 5 years of follow-up. On multivariable modeling, RT administered approximately 24 months after RP was associated with the smallest decline in sexual domain score, with an adjusted mean decrease of 8.85 points (95% confidence interval [-19.8, 2.1]) from post-RP, pre-RT baseline.Conclusions: In men with localized prostate cancer, post-RP RT was associated with significantly worse sexual, urinary, and bowel function domain scores at 5 years compared to RP alone. Radiation delayed for approximately 24 months after RP may be optimal for preserving erectile function compared to radiation administered closer to the time of RP. [ABSTRACT FROM AUTHOR]

Objectives: To assess the prostate cancer diagnostic yield, complications, and costs of transperineal prostate biopsies when performed with local anesthesia versus sedation.Methods: Data were prospectively collected for men undergoing transperineal MRI-targeted biopsy at the outpatient clinic and tertiary hospital of a single center between October 2017 to February 2020. These data included demographic, procedural, and pathologic variables and complications. Time-driven activity-based costing was performed to compare procedural costs.Results: 126 men were included. Age, BMI and PSA were similar for local (n = 45) vs sedation (n = 81), all P>0.05. Detection of clinically significant prostate cancer (CSPC) on combined systematic and targeted biopsy was similar for local vs sedation (24% vs 36%; P = 0.2). Local had lower detection on targeted biopsies alone (8.9% vs 25%; P = 0.03). However, fewer targeted cores were obtained per region of interest with local vs sedation (median 3 vs 4 cores; P<0.01). For local vs sedation, the complication rate was 2.6% and 6.1% (P = 0.6). The median visual analog pain score for local vs sedation was 3/10 vs 0/10 (P<0.01). The mean procedure time for local vs sedation was 22.5 vs 17.5 minutes (48.3 minutes when including anesthesia time). Time-driven activity-based costs for local vs sedation were $961.64 vs $2208.16 (P<0.01).Conclusion: Transperineal biopsy with local anesthesia is safe with comparable outcomes to sedation. While the number of cores taken differed, there was no statistical difference in the detection of clinically significant cancer. [ABSTRACT FROM AUTHOR]

Objective: To examine the relationship between hospital volume and the management of bladder cancer variant histology. Variant histologies of bladder cancer are rare which limits the ability for providers to develop expertise however there is a clear hospital and/or surgeon-volume relationship for management of rare or complex surgical and/or medical diseases.Methods: We queried the National Cancer Database from 2004-2016 for all cases of bladder cancer, identifying cases of variant histology. Our primary outcome was overall survival while secondary outcomes included identifying treatment patterns. Hospitals were stratified into those that managed ≤2, >2-4, >4-6, and ≥6 cases per year of variant histology.Results: We identified 23,284 patients with bladder cancer of variant histology who were treated at 1301 hospitals. Few institutions had high volume experience with this disease: 18.5% (n = 241) treated >2 patients annually and 5.7% (n = 76) treated >4 cases annually. Hospital volume positively correlated with utilization of early radical cystectomy (RC) in non-muscle invasive disease and neoadjuvant chemotherapy in muscle-invasive disease. On multivariable analysis, increased hospital volume was associated with improved survival. After stratifying by sub-type, hospital volume continued to be associated with improved survival for squamous, small cell, and sarcomatoid cancers.Conclusion: Management of variant histology urothelial carcinoma at high-volume centers is associated with improved overall survival. The mechanisms of this are multifactorial, and future research should focus on improvement opportunities for low-volume hospitals, centralization of care, and/or increased access to care at high-volume centers. [ABSTRACT FROM AUTHOR]

Purpose: Financial toxicity is an underappreciated component of cancer survivorship. Treatment-specific out-of-pocket costs for patients undergoing localized prostate cancer treatment have not, to date, been described and may influence patient's decision making.Methods: We performed a retrospective cohort study among commercially-insured patients in the United States with incident prostate cancer from 2013 to 2018. We captured out-of-pocket and total costs in the year following diagnosis and compared these between patients receiving radical prostatectomy, radiotherapy, and no local treatment using propensity-score weighting adjusting for patient demographics and pre-diagnosis health utilization costs.Results: Among 30,360 included men [median age 59 years, 83% Charlson score 0], 15,854 underwent surgery, 5,265 radiotherapy, and 9,241 no local therapy in the year following diagnosis. In the 6-months preceding diagnosis, median overall and out-of-pocket health care costs were $2022 (interquartile range $3778) and $466 (interquartile range $781), respectively. Following propensity-score weighting, out-of-pocket costs were significantly lower for patients who received no active treatment (adjusted cost $1746, 95% confidence interval [CI] $1704-1788), followed by those who underwent surgery ($2983, 95% CI $2832-3142, P < 0.001), and those who underwent radiation ($3139, 95% CI $2939-3353, P < 0.001) in the 6-months following diagnosis. Similar patterns were seen with out-of-pocket costs 6 to 12 months following index, with overall costs, and with costs attributable to inpatient, outpatient medical, and outpatient pharmacy services.Conclusions: Among commercially insured men with incident prostate cancer, active treatment with surgery or radiotherapy was associated with significantly higher out-of-pocket costs versus those who received no treatment, with little difference observed between treatment approaches. [ABSTRACT FROM AUTHOR]

Objectives: To examine the effect of hospital volume on short and long-term outcomes for radical nephroureterectomy (RNUx). Upper tract urothelial carcinoma is a rare malignancy that few surgeons have experience with. The hospital volume-outcome relationship has been well established for other cancers but not RNUx.Methods: The National Cancer Database was queried for all cases of upper tract urothelial carcinoma that underwent RNUx from 2004 to 2016. Average annual hospital volume for radical nephroureterectomy was stratified into tertiles. The upper tertile, defined as 6 or more RNUx per year, was considered high volume while low volume was less than 6 RNUx per year. Kaplan-Meier and Cox proportional hazards regression were used to identify independent predictors of overall survival, and logistic regression was used to identify predictors of perioperative outcomes.Results: We identified 37,479 RNUx performed across 1290 hospitals. There were no differences in baseline health or cancer staging between patients who presented at low- versus high-volume centers. Both peri-operative survival (30- and 90-day mortality) and long-term overall survival were improved in patients treated at high-volume centers. On multivariable survival analysis, treatment at a high-volume center was associated with improved hazards of survival. This relationship for long-term survival remained consistent on landmark analysis where patients who died within 90 days of surgery were removed.Conclusions: Treatment at a high-volume hospital was associated not only with improved short-term perioperative outcomes but also with improved overall long-term survival. The mechanism behind this is likely multifactorial with surgeon volume, and ancillary support services all playing critical roles. [ABSTRACT FROM AUTHOR]

Sepsis following transrectal prostate biopsy occurs in 2%-5% of cases and the risk is increasing. We performed a comprehensive literature search for the cost of post-prostate biopsy sepsis to define the potential cost savings of reducing infectious complications. Reporting of cost is varied and presents a challenge to interpretation. Length of hospitalization ranged from 1.1 to 14 days and the percent admitted to an ICU ranged from 1.1% to 25%. The estimated cost of sepsis post-prostate biopsy, adjusted for inflation, ranged from $8,672 to $19,100. Healthcare costs of treating post-biopsy infection are substantial. Our findings should guide payers and policymakers, especially in value-based care models. [ABSTRACT FROM AUTHOR]

Introduction: Postprostatectomy incontinence significantly impairs quality of life. Although bladder neck intussusception has been reported to accelerate urinary recovery after open radical retropubic prostatectomy, its adaption to robotic surgery has not been assessed. Accordingly, we describe our technique and compare outcomes between men treated with and without bladder neck intussusception during robot-assisted laparoscopic prostatectomy.Materials and Methods: We performed a comparative trial of 48 men undergoing robot-assisted laparoscopic prostatectomy alternating between bladder neck intussusception (n = 24) and nonintussusception (n = 24). Intussusception was completed using 3-0 polyglycolic acid horizontal mattress sutures anterior and posterior to the bladder neck. We assessed baseline characteristics and clinicopathologic outcomes. Adjusting for age, body mass index, race, and D׳Amico risk classification, we prospectively compared urinary function at 2 days, 2 weeks, 2 months, and last follow-up using the urinary domain of the Expanded Prostate Cancer Index-Short Form.Results: Baseline patient characteristics and clinicopathologic outcomes were similar between treatment groups (P>0.05). Median catheter duration (8 vs. 8d, P = 0.125) and rates of major postoperative complications (4.2% vs. 4.2%, P = 1.000) did not differ. In adjusted analyses, Expanded Prostate Cancer Index-Short Form urinary scores were significantly higher for the intussusception arm at 2 weeks (65.4 vs. 46.6, P = 0.019) before converging at 2 months (69.1 vs. 68.3, P = 0.929) after catheter removal and at last follow-up (median = 7mo, 80.5 vs. 77.0; P = 0.665).Conclusions: Bladder neck intussusception during robot-assisted laparoscopic prostatectomy is feasible and safe. Although the long-term effects appear limited, intussusception may improve urinary function during the early recovery period. [ABSTRACT FROM AUTHOR]

Background: Immune checkpoint-inhibitor (ICI)-based therapy is the standard of care for first-line treatment of metastatic renal cell carcinoma (mRCC). It is unclear whether prior removal of the primary tumor influences the efficacy of these treatments. We performed a systematic review and meta-analysis of studies of first-line ICI in mRCC to determine whether the efficacy of ICI-therapy, compared to sunitinib, is altered based on receipt of prior nephrectomy.Methods: We systematically reviewed studies indexed in MEDLINE (PubMed), Embase, and Scopus and conference abstracts from relevant medical societies as of August 2020 to identify randomized clinical trials assessing first-line immunotherapy-based regimes in mRCC. Studies were included if overall survival (OS) and progression-free survival (PFS) outcomes were reported with data stratified by nephrectomy status. We pooled hazard ratios (HRs) stratified by nephrectomy status and performed random effects meta-analysis to assess the null hypothesis of no difference in the survival advantage of immunotherapy-based regimes based on nephrectomy status, while accounting for study level correlations.Results: Among 6 randomized clinical trials involving 5,121 patients, 3,968 (77%) had undergone prior nephrectomy. We found an overall survival benefit for immunotherapy-based regimes, compared to sunitinib, among both patients who had undergone nephrectomy (HR 0.75, 95% CI 0.63 -0.88) and those who had not (HR 0.74, 95% CI 0.59 -0.92), without evidence of difference based on nephrectomy history (P = 0.70; I2 = 36%). Results assessing PFS were similar (P = 0.45, I2 = 0%).Conclusions: These clinical data suggest that prior nephrectomy does not affect the efficacy of ICI-based regimens in mRCC relative to sunitinib. [ABSTRACT FROM AUTHOR]

Objective: To examine factors associated with radical cystectomy operative time among Medicare beneficiaries.Material and Methods: Using linked Surveillance, Epidemiology, and End Results-Medicare data, we identified 4,975 patients who underwent a radical cystectomy during 1991 to 2007. Using a validated method of using anesthesia administrative data to quantify operative time, we used generalized estimating equations to examine the association of patient, provider, and hospital factors on radical cystectomy operative time.Results: We found that mean operative time decreased by 5 minutes per year (Δ = -5.3min/y, P<0.001). Longer operative times were found in academic centers (Δ =+39.0min vs. nonacademic), continent diversion (Δ =+34.9min vs. ileal conduit), surgical excision of≥11 lymph nodes (Δ =+24.9min vs. 1-5), female (Δ =+32.3min vs. male sex), and perioperative anesthesia procedures such as placement of central venous catheters or arterial lines (Δ =+47.2min vs. no procedures), respectively (all P<0.01). In adjusted analysis, higher surgeon volume (Δ =-22.0min vs. lowest volume) was associated with shorter operative times (P = 0.002).Conclusions: Operative times for cystectomy have been steadily decreasing annually. There is notable variation based on academic affiliation, diversion type and extent of lymphadenectomy, surgeon and hospital volumes, as well as use of anesthetic procedures. Efforts to improve operative time by selective referral to high-volume surgeons or hospitals or both, or judicious use of perioperative procedures may have a positive effect on health care costs and overall quality of care for patients undergoing radical cystectomy for bladder cancer. [ABSTRACT FROM AUTHOR]