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PURPOSE: Prior studies of mixed insurance populations have demonstrated poor adherence to surgical standard of care (SOC) for penile cancer. We used data from the Surveillance, Epidemiology and End Results (SEER) cancer registry linked to Medicare to calculate SOC adherence to surgical treatment of penile cancer in insured men over the age of 65, focusing on potential social and racial disparities. METHODS: This is an observational analysis of patients with T2–4 penile cancer of any histologic subtype without metastasis in the SEER-Medicare database (2004–2015). SOC was defined as penectomy (partial or radical) with bilateral inguinal lymph node dissection (ILND) based on the National Comprehensive Cancer Network guidelines. We calculated proportions of those receiving SOC and constructed multivariate models to identify factors associated with receiving SOC. RESULTS: A total of 447 men were included. Of these men, 22.1% (99/447) received SOC while 18.8% (84/447) received no treatment at all. Only 23.3% (104/447) had ILND while 80.9% (362/447) underwent total or partial penectomy. Race and socioeconomic status (SES) were not associated with decreased SOC. Increasing age (OR 0.93, 95%CI:0.89–0.96), Charlson Comorbidity Index score ≥ 2 (OR 0.53, 95%CI:0.29–0.97), and T3-T4 disease (OR 0.34, 95%CI:0.18–0.65) were associated with not receiving SOC on adjusted analysis. CONCLUSIONS: Rates of SOC are low among insured men 65 years of age or older with invasive penile cancer, regardless of race or SES. This finding is largely driven by low rates of ILND. Strategies are needed to overcome barriers to SOC treatment for men with invasive penile cancer.

Introduction:Low grade upper tract urothelial cancer is an uncommon urothelial tumor for which treatment involves multiple ureteroscopic interventions and potentially radical nephroureterec...

Introduction:No consensus exists on outcomes that define high quality care in female stress urinary incontinence management. A working group of surgeons from diverse health care settings in...

Introduction:The overprescribing of opioids after urological surgery places patients at risk for opioid overuse and dependency. However, few guidelines exist to help urologists consistently...

Introduction:Understanding best practices in perioperative care is critical for quality of care for our urology patients. We compiled a single, concise resource that provides recommendation...

Introduction:Postoperative kidney cancer surveillance is predominantly based on imaging and laboratory evaluation rather than physical exam. We sought to characterize the burden of kidney c...

OBJECTIVE The aims of this study are to determine how long it takes female patients with overactive bladder (OAB) to receive third-line treatment after starting OAB medications and identify factors associated with increased time. METHODS This was a retrospective observational cohort study of adult female patients with OAB who received third-line treatment between 2013 and 2015 using insurance claims databases. Primary outcome was time between first OAB medication and first third-line treatment. Additional variables were patient demographics, diagnostic tests, and medical comorbidities. RESULTS Of 3232 patients included in this study, 48.8% underwent sacral neuromodulation, 31.6% percutaneous tibial nerve stimulation, and 23% intradetrusor onabotulinumtoxin A injections. Twenty-one percent of patients filled medication prescriptions for 3 or more antimuscarinic medications, 30.4% took mirabegron, and 32.3% had advanced diagnostic tests suggestive of a specialist evaluation prior to starting medications. Median time to third-line treatment was 37.7 (interquartile range, 14.9, 16.3) months. Adjusted linear regression model revealed 2 predominant predictors of time to third-line treatments: each antimuscarinic medication trial was associated with 5.3 (95% confidence interval, 4.4-6.3) more months before third-line treatment (P < 0.001), and advanced diagnostic evaluations prior to starting medications were associated with 28.2 (95% confidence interval, 21-35) fewer months before third-line treatment (P < 0.001). CONCLUSIONS Women with OAB who undergo third-line therapy do so on average more than 3 years after starting medications. Time to third-line treatment is largely driven by the number of antimuscarinic medications tried and timing of diagnostic evaluation by a specialist. Based on these results, we suggest providers consider limiting antimuscarinic trials to 2 medications prior to moving on to other treatment options.

The BCAN (Bladder Cancer Advocacy Network) Patient Survey Network identified pain during intravesical procedures as a research priority for patients. Although intraurethral lidocaine is the standard of care in this setting, evidence of its use is equivocal. We systematically reviewed studies of interventions to reduce discomfort during cystoscopy and intravesical therapy of bladder cancer. We performed a meta-analysis of interventions using available randomized, controlled trials.Search terms derived from the key questions were incorporated into the literature search constructed by a research librarian and the English medical literature from 1990 to 2017 was accessed. The initial search yielded 626 potential studies and the final review incorporated 62. We combined 12 trials into a meta-analysis with a random effects model of the efficacy of intraurethral lidocaine vs plain lubricant to reduce pain during flexible cystoscopy as measured on a 10-point visual analogue scale.Data from 12 randomized controlled trials in a total of 1,549 patients were included in the final intraurethral lidocaine meta-analysis. The standardized mean difference between visual analogue scale pain scores in patients who underwent flexible cystoscopy with intraurethral lidocaine and plain lubricant was -0.22 (95% CI -0.39--0.05). Evidence was insufficient to evaluate other interventions to mitigate the discomfort of invasive bladder procedures.Intraurethral lidocaine provides statistically significant pain reduction in men who undergo flexible cystoscopy, particularly with a longer dwell time. The evidence was insufficient for other tested interventions. A prospective study is needed to further clarify interventions to decrease patient discomfort during cystoscopy and other intravesical procedures in a diverse population.

INTRODUCTION AND OBJECTIVE:Palliative care (PC) is underutilized amongst patients with advanced urothelial cancer despite known benefits and guideline recommendations. Little is known regarding the...

INTRODUCTION AND OBJECTIVE:IO/TKI combinations are a new standard of care for the initial treatment (tx) of mRCC. Efficacy and toxicity of such combination regimens beyond the first-line (1L) setti...

INTRODUCTION AND OBJECTIVE:Hospice improves quality of life as patients with cancer reach the end of life. Patients who die of bladder cancer have some of the lowest described rates of hospice use ...

Purpose:Smoking is the most common risk factor for bladder cancer and it is associated with adverse clinical outcomes. The bladder cancer diagnosis represents a teachable moment for smoking cessati...

INTRODUCTION AND OBJECTIVE:Emergency Department (ED) discharge practices are subject to inter-provider variation that can limit the implementation of evidence-based medicine. We convened a multi-di...

We described and compared the frequency and type of lower urinary tract symptoms reported by men and women at the time that they were recruited from urology and urogynecology clinics into the Symptoms of Lower Urinary Tract Dysfunction Research Network multicenter, prospective, observational cohort study.At 6 research sites treatment seeking men and women were enrolled who reported any lower urinary tract symptoms at a frequency more than rarely during the last month on the LUTS (Lower Urinary Tract Symptoms) Tool. At baseline the study participants underwent a standardized clinical evaluation and completed validated questionnaires. Urological tests were performed, including pelvic/rectal examination, post-void residual urine measurement and urinalysis.A total of 545 women and 519 men were enrolled in the study. Mean ± SD age was 58.8 ± 14.1 years. At baseline nocturia, frequency and a sensation of incomplete emptying were similar in men and women but men experienced more voiding symptoms (90% vs 85%, p = 0.007) and women reported more urgency (85% vs 66%, p0.001). Women also reported more of any type of urinary incontinence than men (82% vs 51% p0.001), which was mixed incontinence in 57%. Only 1% of men reported stress incontinence but they had other urinary incontinence, including post-void dribbling in 44% and urgency incontinence in 46%. Older participants had higher odds of reporting symptoms of nocturia and urgency.In this large, treatment seeking cohort of men and women lower urinary tract symptoms varied widely by gender and age. Men reported more voiding symptoms and nonstress or urgency urinary incontinence while women reported more incontinence overall and urgency. Older participants had greater odds of urgency and nocturia.

Introduction Prevention of catheter associated urinary tract infection relies on timely catheter removal and care of indwelling catheters. Educational and quality improvement initiatives to prevent catheter associated urinary tract infection should address the basics of urinary catheter placement and management. Internal medicine residents are an appropriate target for these efforts and they may lack formal training in these issues. We developed a resident driven orientation session that covers basic Foley catheter management principles called the TIPS (Troubleshooting, Indications and Practice Sessions) program. Methods Urology residents at our institution were queried on common consultations for urinary catheter related issues. The incoming intern internal medicine class at our institution completed a pre-TIPS survey that evaluated their baseline urological experience and knowledge. A 1-hour didactic session led by urology residents was followed by hands-on directed practice with mannequins. The web based survey was repeated 1 month later. Results Of the total of 60 residents 54 (90%) completed the initial survey. In medical school 38 of 54 residents (70%) had never rotated in urology. Upon repeating the survey at 1 month the response rate was 34 of 60 residents (57%). The proportion of residents confident in their ability to troubleshoot catheter problems increased from 50% to 88% (p Conclusions A focused educational session about common urological catheter management scenarios resulted in improved internal medicine resident confidence in catheter troubleshooting and knowledge of basic urinary catheter placement indications. These educational sessions may be a method to improve nonurology resident education and awareness of common urological issues.

INTRODUCTION AND OBJECTIVES:Recent institutional series suggest that diabetes mellitus (DM) as well as the DM medication metformin may be associated with adverse outcomes in various malignancies, i...

420 Background: We compared the effectiveness of a patient-centered (PC) version of bladder biopsy pathology reports derived from PC outcomes research methods with standard pathology reports. Methods: Local bladder cancer experts provided consensus on the important elements of a bladder biopsy pathology. Patient focus groups reviewed these elements and identified PC formats and language. Candidate reports were iterated with patients to arrive at a pilot PC bladder biopsy report. We enrolled 40 patients undergoing bladder biopsy for suspicion of initial or recurrent bladder cancer. Block randomization was performed to the standard report or the standard report and the pilot patient-centered pathology report (PCPR). Through web-based surveys, we assessed self-efficacy with the PEPPI (Perceived Efficacy in Patient-Physician Interactions), physician communication with the CAT (Communication Assessment Tool), knowledge based on comprehension of report elements prioritized by experts, and format preferences at pathology disclosure and one month later. We compared study groups with descriptive statistics. Results: The 26-member expert clinician panel identified stage, grade, and histology as the most important elements of a pathology report. Patients prioritized data expressed in a narrative format, an illustration of tumor stage, and risk stratification for future recurrence. From July 2014 to 2015, 39 patients completed initial and follow-up assessments. Patients that received the PCPR had an improved ability to identify their cancer stage (initial 58% vs 20%, p = 0.02; follow-up 47% vs 15%, p = 0.03) and trended toward improved identification of cancer grade (initial 74% vs 50%, p = 0.12) compared with patients that only received standard reports. Ratings of patient self-efficacy did not differ by report format and communication trended toward improved communication for patients exposed to PCPR. Conclusions: PCPR are associated with greater patient knowledge about their new cancer diagnosis and may aid patient-provider communication around a new cancer diagnosis. While these results require validation in larger cohorts, this pilot may serve as a model for the development of PCPR for other cancers.

Introduction Shared decision making is a collaborative approach to care that seeks to improve the quality of medical decisions by helping patients choose options concordant with their values and in accordance with the best available scientific evidence. Methods A literature review was performed targeting publications between 2003 and 2014 on the topic of shared decision making and decision aids for urological conditions. An expert panel was convened to evaluate this information and create this white paper with the purpose of educating the urological community on these issues. Results Shared decision making represents the state of the art in patient counseling. Patients who have engaged in shared decision making have greater knowledge and satisfaction as well as greater engagement with care. Numerous organizations make available free resources for shared decision making including decision aids and tools to evaluate the quality of shared decision making. Conclusions Shared decision making is an important component of high quality health care delivery and future reimbursement models. In appropriate circumstances urologists should adopt shared decision making into routine clinical practice.

Radical cystectomy is associated with high complication and rehospitalization rates. An understanding of the root causes of hospital readmissions and the modifiability of factors contributing to readmissions may decrease the morbidity associated with radical cystectomy. We characterize the indications for rehospitalization following radical cystectomy, and determine whether these indications represent immutable patient disease and procedure factors or whether they are modifiable.From MarketScan® databases we identified patients younger than 65 years with a diagnosis of bladder cancer who underwent radical cystectomy between 2008 and 2011 and were readmitted to the hospital within 30 days of radical cystectomy. All associated ICD-9 codes in the index admission, subsequent outpatient claims and readmission claims were independently reviewed by 3 surgeons to determine a root cause of rehospitalization. Causes were broadly categorized as medical, surgical or infectious, and reviewers determined whether the readmission was modifiable. Multivariate logistical regression models were used to identify factors associated with rehospitalization.A total of 1,163 patients were included in the study and 242 (21%) were readmitted to the hospital within 30 days. Of these readmissions 26% were considered modifiable (kappa=0.71). Of the nonmodifiable readmissions an infectious cause accounted for 52% and a medical cause accounted for 48%, whereas of the modifiable readmissions 62% were due to surgical causes, 30% to medical and 8% to infectious causes. On multivariate analysis only discharge to a skilled nursing facility was associated with modifiable (OR 6.12, 95% CI 2.32-16.14) or nonmodifiable (OR 3.27, 95% CI 1.63-6.53) hospital readmissions.The majority of rehospitalizations after radical cystectomy are attributable its inherent morbidity. However, optimization of aspects of peri-cystectomy care could minimize the morbidity of radical cystectomy.

Although reported success rates after pediatric pyeloplasty to correct ureteropelvic junction are high, failure may require intervention. We sought to characterize the incidence and timing of secondary procedures after pediatric pyeloplasty using a national employer based insurance database.Using the MarketScan® database we identified patients 0 to 18 years old who underwent pyeloplasty from 2007 to 2013 with greater than 3 months of postoperative enrollment. Secondary procedures following the index pyeloplasty were identified by CPT codes and classified as stent/drain, endoscopic, pyeloplasty, nephrectomy or transplant. The risk of undergoing a secondary procedure was ascertained using Cox proportional hazards models adjusting for demographic and clinical characteristics.We identified 1,976 patients with a mean ± SD followup of 23.9 ± 19.8 months. Overall 226 children (11.4%) had undergone at least 1 post-pyeloplasty procedure. The first procedure was done within 1 year in 87.2% of patients with a mean postoperative interval of 5.9 ± 11.1 months. Stents/drains, endoscopic procedures and pyeloplasties were noted in 116 (5.9%), 34 (1.7%) and 71 patients (3.1%), respectively. Length of stay was associated with undergoing a secondary procedure. Compared with 2 days or less the HR of 3 to 5 and 6 days or greater was 1.65 and 3.94 (p = 0.001 and0.001, respectively).Following pediatric pyeloplasty 1 of 9 patients undergoes at least 1 secondary procedure with the majority performed within the first year. One of 11 patients undergoes intervention more extensive than placement of a single stent or drain, requiring management strategies that generally signify recurrent or persistent obstruction. Estimates of pyeloplasty success in this national data set are lower than in other published series.

Introduction The purpose of this document is to provide guidance for urologists on the integration of advanced practice providers into the urological care setting with a focus on the current state and federal regulatory environment, reimbursement considerations, core competency benchmarks, patient satisfaction with the advanced practice provider-physician team approach and proposed models of team based integrative care. Methods Since 1983, the AUA (American Urological Association) has issued its position on allied health professionals, recognizing that in some areas allied health personnel contribute to the care of the patient with genitourinary disease and, therefore, encourages the proper use of allied health personnel. A 2013 AUA survey on workforce revealed that 62% of urologists surveyed were using an advanced practice provider in their practice. In 2012 there were nearly 8,000 advanced practice providers working in urology departments and practices in the United States, including more than 3,300 nurse practitioners and more than 4,000 physician assistants. In 2013 the AUA convened an ad hoc work group of a diverse set of urology providers, including physicians, nurse practitioners and physician assistants. The consensus statement was drafted over 10 months and approved by the AUA Board of Directors in November 2014. Results Urologists work with advanced practice providers frequently but many may not know the most efficient way to incorporate them into their practice. The consensus statement examines advanced practice provider integration from a regulatory and practice management approach, as well as provides several applicable examples of how this applies to urologists in various clinical settings throughout the United States. Conclusions This document supports the AUA’s policy statement that in a team based approach with a board certified urologist in a supervisory role, allied health personnel contribute to the care of the patient with genitourinary disease and, therefore, encourages the proper use of allied health personnel.

Background Clinical trial evidence shows minimal survival gains and higher complication rates from radical prostatectomy (RP) versus watchful waiting (WW) for elderly men with localized prostate cancer (PCa). It is believed that these patients are overtreated. The current analyses aim to explore patient-level heterogeneity in survival effects, examine matching of patients to treatments in practice, and identify patient characteristics driving heterogenous effects, in order to present more comprehensive evidence about the concerns of overtreatment. Methods Eleven-year all-cause and PCa-specific survival among SEER-Medicare patients diagnosed during 1996-2002 were analyzed using local instrumental variable approaches. Results A total of 8462 (77%) of 11,036 patients received RP. The average effects of RP over WW on 11-year overall and cancer-specific survival were 1.1 months (95%CI, -25, 28; P=0.94) and 1.7 months (95%CI, -25, 29; P=0.90) respectively; effects did not differ significantly according to age, race, grade, and stage. Fewer than 1% of patients had significant cancer-specific survival benefit from RP at the 10% level; 6% were expected to gain over 15 months from RP. However, patients with larger expected survival gains from RP were much more likely to receive RP in practice. Such positive self-selection was driven by PCa-specific survival than overall survival. Several comorbidities may play a critical role in predicting who could benefit from RP. Conclusions Our analyses corroborate concerns about PCa overtreatment. A small fraction of screen-detected PCa patients derive survival benefits from RP. Prediction tools should account for patient comorbidities to accurately predict survival benefits of RP over WW.

Bladder cancer is a common, complex, and costly disease. Every year in the USA, bladder cancer is responsible for 70 ,000 diagnosed cases and over 15, 000 deaths. Once diagnosed, patients with nonmuscle invasive bladder cancer (NMIBC) are committed to a lifetime of invasive procedures and potential hospitalizations that result in substantial direct and indirect costs.Bladder cancer is the most costly cancer among the elderly, estimated at nearly $4 billion per year, and has the highest cost of any cancer when categorized on a per patient basis. The direct economic cost of NMIBC is fueled by the need for lifelong cystoscopic examination and variations in treatment algorithms. This fiscal burden is further compounded by the indirect impact on psychological health and quality of life of patients and their families. Despite the development of new technologies, such as novel urinary biomarkers and innovative cystoscopic methods, no alternative to cystoscopic surveillance has been established.The management of patients with NMIBC is responsible for a substantial financial burden with indirect costs that extend beyond quantifiable direct costs.

Although success rates are reported to be high, radiographic followup after pyeloplasty to correct ureteropelvic junction obstruction varies in intensity and modality. We characterized postoperative care after pyeloplasty to identify imaging trends.Using the MarketScan® database we identified patients 17 to 65 years old treated with pyeloplasty from 2007 to 2010. Followup imaging was classified as functional (diuretic renogram or excretory urogram) and nonfunctional (ultrasound, computerized tomography or magnetic resonance imaging). The postoperative period was divided into intervals of less than 6, 6 to 12, 12 to 24, 24 to 36 and greater than 36 months. We excluded from study patients with less than 24 months of postoperative enrollment in MarketScan. Multivariate logistic regression was used to determine associations between demographic variables and imaging utilization patterns.We identified 742 patients with a mean ± SD followup of 36.8 ± 3.7 months, of whom 65% underwent minimally invasive pyeloplasty. Of the patients 12% underwent no postoperative imaging. Within the first 6 months 554 patients (75%) underwent at least 1 imaging study and within the first 12 months 82% underwent at least 1 imaging study, which was most commonly functional. After 12 months 54% of patients underwent any imaging, which was most commonly nonfunctional. At least annual imaging was significantly associated with older age, female gender and longer hospital stay. Secondary procedures were required in 62 patients (8%).After pyeloplasty in adulthood most patients undergo a functional imaging study within 6 months. However, after 1 year only half of patients undergo followup imaging. Variability and insufficient radiological followup may bias the belief of pyeloplasty success.

The incidence of renal cell carcinoma is increasing worldwide. Cited risk factors include obesity, smoking and hypertension but few others have been confirmed in prospective studies. We used a prospective cohort to validate established renal cell carcinoma risk factors and evaluate more controversial risk factors for incident renal cell carcinoma.A total of 77,260 residents of Washington 50 to 76 years old completed a questionnaire between 2000 and 2002 on demographic, lifestyle and health data. Incident renal cell carcinoma cases were determined by linkage to the regional cancer registry through December 31, 2009. Multivariate methods using covariates and cutoffs selected a priori were applied to analyze the association between renal cell carcinoma and previously studied factors related to lifestyle (body mass index, smoking and alcohol/fruit/vegetable consumption) and health (hypertension, diabetes, kidney disease and viral hepatitis).There were 249 incident cases of renal cell carcinoma. Independent renal cell carcinoma risk factors in the fully adjusted model were body mass index (35 or greater vs less than 25 kg/m2 HR 1.71, 95% CI 1.06-2.79), smoking (greater than 37.5 pack-years vs never HR 1.58, 95% CI 1.09-2.29), hypertension (HR 1.70, 95% CI 1.30-2.22), kidney disease (HR 2.58, 95% CI 1.21-5.50) and viral hepatitis (HR 1.80, 95% CI 1.03-3.14). Diabetes was associated with renal cell carcinoma (HR 1.83, 95% CI 1.26-2.65) in a base model adjusting for age and gender but not in the multivariate model. We found no association between alcohol, fruit or vegetable intake and renal cell carcinoma.We identified a significant association of renal cell carcinoma with obesity, smoking, hypertension, renal disease and viral hepatitis. Identifying risk factors offers an opportunity for targeted education and intervention.