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Objectives To elucidate the national burden of emergency department (ED) visits for radiation cystitis (RC), a known complication of radiation therapy to the pelvic area, among patients with a prostate cancer history, and identify those who are at increased risk of requiring invasive measures. Methods This study queried the Nationwide Emergency Department Sample for all ED visits from January 2006 to December 2015 with a primary diagnosis of radiation cystitis and secondary diagnosis of prostate cancer. ED visits were characterized by demographic factors, socioeconomic factors, and hospital characteristics. Weighted frequencies were used to create national estimates for all data analysis. Results A weighted total of 17,382 ED visits occurred for RC among patients with a prostate cancer history, of which 9,655 (55.5%) were treated with an invasive procedure. Notable factors associated with undergoing an invasive procedure included having a prior prostatectomy (odds ratio [OR], 5.48; 95% confidence interval [CI], 2.62-11.46), urinary retention (OR, 1.35; 95% CI, 1.12-1.64), hematuria (OR, 1.20; 95% CI, 1.01-1.42), and undergoing a blood transfusion (OR 2.12; 95% CI, 1.72-2.62). ED visits that were associated with invasive procedures had a higher median total charge ($34,707.53 vs $15,632.53) and an increased median length of stay (5 days vs 3 days) compared to visits without an invasive procedure. Conclusions Among ED visits for RC in prostate cancer, approximately one half required an invasive procedure for treatment. While radiation remains an effective modality for patients with prostate cancer, providers should be mindful of RC as a potential complication.

Rationale & Objective The impact of prostate cancer on mortality in patients with end-stage kidney disease may be different from the general population. Prostate cancer may also delay the kidney transplant but has not been studied in a population-based cohort. We examined how prostate cancer influenced time to kidney transplant and death in a dialysis population. Study Design Retrospective population-based, risk-set propensity score–matched cohort study. Setting & Participants Men, 40-79 years old, who were dialysis-dependent Medicare beneficiaries without prior documented prostate cancer, from the United States Renal Data System. Exposures Incident prostate cancer, identified using International Classification of Disease, Ninth Revision, Clinical Modification system diagnosis code 185. Outcomes Time to kidney transplant and death. Analytical Approach Propensity-based risk-set matching to reduce bias between cases and controls. Cox proportional hazards model for time to death, and Fine-Gray competing risk model for time to kidney transplant. Results Among a total of 588,478 male dialysis patients who met the eligibility criteria, 18,162 had claims for prostate cancer. After propensity-based risk-set matching, 15,554 pairs of prostate cancer cases and controls were identified. Among the matched pairs, survival rates were 76%, 48%, and 30% at 1, 3, and 5 years in the prostate cancer group, compared with 80%, 51%, and 33% in the control group, with relative mortality of 95%, 94%, and 91% respectively (log-rank test P < 0.001). Prostate cancer was associated with a 22% lower likelihood of kidney transplant (HR: 0.78; 95% CI: 0.72-0.85) and 11% higher likelihood of death (HR: 1.11; 95% CI: 1.08-1.14) compared with controls. Kidney transplant was associated with a 4-fold improvement in overall survival, both in patients with and without prostate cancer (HR: 0.20; 95% CI: 0.18-0.21). Limitations Retrospective registry study. Conclusions Prostate cancer is associated with a modest increase in the risk of death and time to transplant in patients with end-stage kidney disease. Kidney transplant is associated with the same degree of survival benefit among those with pretransplant prostate cancer as those without.

This study was designed to: (1) characterize longitudinal patient-reported outcomes (PROs) between breast cancer patients undergoing lumpectomy and mastectomy and (2) compare return to baseline scores at 3 months and 6 months postoperatively. Newly diagnosed breast cancer patients seen at an academic breast center between June 2019 and February 2021 were invited to participate in longitudinal PRO surveys at their initial clinic visit. If willing to participate, patients were emailed the validated BREAST-Q™ questionnaire at the initial clinic visit (baseline), 2 weeks after surgery, and then every 3 months for the first year. We used linear mixed models to estimate the differences in slopes over time between lumpectomy and mastectomy for each PRO measure. Pearson’s Chi-square tests with Yates’ continuity correction were used to compare proportions of patients who return to baseline PRO scores. P < 0.05 was considered significant. Of 164 patients invited to participate, 100 (61%) completed a baseline survey and were included in analyses. Mastectomy patients had significantly greater decreases in breast satisfaction (P = 0.002), psychosocial well-being (P < 0.0001), and sexual well-being (P < 0.0001) over time compared with lumpectomy patients. Both surgical groups reported a decrease in physical well-being, although the decline was more significant in lumpectomy patients (P = 0.005). At 3 months and 6 months after surgery, significantly larger proportions of lumpectomy patients returned to their baseline breast satisfaction, psychosocial well-being, and physical well-being compared with mastectomy patients. Understanding how outcomes important to patients change over the care continuum can provide opportunities for early intervention and may prevent debilitating long-term morbidities of treatment.

To (1) examine the contemporary incidence of occult inguinal LN metastases and (2) identify predictors of occult inguinal LN metastases to improve selection of cN0 patients for inguinal lymphadenectomy (ILND).We identified 590 men with cTany cN0 cM0 penile cancer who underwent partial/radical penectomy and ILND from 2006-2016 in the NCDB. Rates of pN+ disease were examined, and a multivariable regression model was constructed to identify features associated with pN+ disease.Tumors were ≤pT1 in 21%, pT2 in 43%, and pT3/pT4 in 24% of patients. A median of 15 (IQR 8-22) LNs were removed at ILND. The overall pN+ rate was 24% and did not vary over the study period. The pN+ rate, stratified by pT stage, varied from 18-33%. On multivariable analysis, only higher tumor grade (OR 2.16; P = 0.02 for grade 2; OR 2.81; P = 0.005 for grade 3-4, versus grade 1) and lymphovascular invasion (OR 3.12; P0.001) were independently associated with pN+ disease, whereas pT stage was not.The contemporary rate of occult LN metastases in men with cN0 penile cancer remains high at approximately 24%. Our results suggest that high tumor grade and/or lymphovascular invasion are better determinants of lymph node involvement than primary tumor stage.

Radical prostatectomy (RP) has undergone a remarkable transformation from open to minimally- invasive surgery over the last two decades. However, it is important to recognize there is still conflicting evidence regarding key outcomes. We aimed to summarize current literature on comparative effectiveness of robotic and open RP for key outcomes including oncologic results, health-related quality of life (HRQOL) measures, safety and postoperative complications, and healthcare costs. The bulk of the paper will discuss and interpret limitations of current data. Finally, we will also highlight future directions of both surgical approaches and its potential impact on health care delivery.

Purpose:African American men are more likely to be diagnosed with, die of and experience decisional regret about their prostate cancer than nonAfrican American men. Although some clinical discrepan...

BACKGROUND: Magnetic resonance imaging (MRI) of the prostate (MRI-prostate) facilitates better detection of clinically significant prostate cancer (PCa). Yet, the national trends of MRI at the time of prostate biopsy and its ability to increase the detection of PCa in a biopsy-naïve population remain unknown. OBJECTIVE: To elucidate the contemporary trends of MRI and prostate biopsy, and whether it improved PCa diagnosis among privately insured patients. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective cohort study of a large private health insurance database in the USA—the OptumLabs Data Warehouse. We identified all men [notdef]40 yr of age who underwent index prostate biopsies from 2010 through 2016. INTERVENTION: MRI-prostate at the time of index biopsy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Utilization of the MRI at the time of biopsy and incident PCa diagnosis constituted the primary outcomes. We enumerated unadjusted and age-specific annual rates of MRI over time to elucidate trends using regression models (trend analysis). Bivariate and multivariable regression analyses identified patient characteristics associated with MRI-prostate, and the association between the use of MRI and PCa diagnosis. RESULTS AND LIMITATIONS: Overall, 119 202 men underwent index prostate biopsies. Unadjusted annual rates of MRI at the time of biopsy significantly increased from 7 per 1000 biopsies in 2010 to 83 per 1000 biopsies in 2016 (p < 0.001 for trend). Age-specific rates increased across all age groups (40–49, 50–59, 60–65, 66–74, and 75 +yr; all p < 0.001). On multivariable analysis, black patients had a lower likelihood of MRI compared with white patients (odds ratio [OR]: 0.6; p < 0.01). MRI at the time of biopsy was not associated with a higher likelihood of incident PCa compared with traditional systematic biopsy (OR: 1.0; p = 0.7). The retrospective design and the inability to detect clinically significant PCa (Gleason 7+) constitute the limitations of this study. CONCLUSIONS: While the use of MRI at the time of biopsy rose markedly, it was not associated with a higher detection rate of PCa. Further research is needed to address effective dissemination of MRI and targeted biopsies, and racial disparities. PATIENT SUMMARY: From 2010 to 2016, our study found a significant rise in the utilization of magnetic resonance imaging of the prostate (MRI-prostate) at the time of index biopsy, although only a minority of patients undergo MRI-prostate. The use of MRI-prostate was not associated with a higher likelihood of diagnosing incident prostate cancer.

Objective To assess the contribution of unknown institutional factors (contextual effects) in the de-implementation of completion axillary node dissection (cALND) in women with breast cancer. Summary background data Women included in the National Cancer Database with invasive breast carcinoma from 2012-2016 that underwent upfront lumpectomy and were found to have a positive sentinel node. Methods A multivariable mixed effects logistic regression model with a random intercept for site was used to determine the effect of patient, tumor, and institutional variables on the risk of cALND. Reference Effect Measures (REM) were used to describe and compare the contribution of contextual effects to the variation in cALND use to that of measured variables. Results By 2016, cALND was still performed in at least 50% of the patients in a quarter of the institutions. Black race, younger women and those with larger or hormone negative tumors were more likely to undergo cALND. However, the width of the 90% REM range for the contextual effects exceeded that of the measured site, tumor, time, and patient demographics, suggesting institutional contextual effects were the major drivers of cALND de-implementation. For instance, a woman at an institution with low-risk of performing cALND would have 74% reduced odds of having a cALND than if she was treated at a median-risk institution, while a patient at a high-risk institution had 3.91 times the odds. Conclusion Compared to known patient, tumor and institutional factors, contextual effects had a higher contribution to the variation in cALND use.

Purpose To evaluate practice patterns of planned post-operative radiation therapy (RT) among men with positive surgical margins (PSM) at radical prostatectomy. Methods We identified 43,806 men within the National Cancer Database with pathologic node-negative prostate cancer diagnosed in 2010 through 2014 with PSM. The primary endpoint was receipt of planned (RT) within a patient's initial course of treatment. We examined post-RP androgen deprivation therapy (ADT) with RT as a secondary endpoint. We evaluated patterns of post-operative management and characteristics associated with planned post-prostatectomy RT. Results Within 12 months of RP, 87.0% received no planned RT, 8.5% RT alone, 1.3% ADT alone, and 3.1% RT with ADT. In a multivariable logistic regression model, planned RT use was associated with clinical and pathologic characteristics as estimated by surgical Cancer of the Prostate Risk Assessment (CAPRA-S) category (intermediate versus low, OR = 2.87, 95% CI 2.19-3.75, P Conclusion The use of planned post-prostatectomy RT remained stable among patients with PSM and appears driven primarily by the presence of other adverse pathologic features.

Background Magnetic resonance imaging (MRI) of the prostate and fusion biopsy have been advanced to improve the detection of clinically significant prostate cancer (PCa). Yet, frequency of their use and contemporary attitudes among radiation oncologists (ROs) and urologists (UROs) remain largely unknown. Objective We performed a national survey of UROs and ROs to assess the perceived attitudes towards and frequency of prostate MRI and fusion biopsy. Design, setting, and participants We conducted a national survey of 915 ROs and 940 UROs about prostate MRI and fusion biopsy in 2017. Outcome measurements and statistical analysis The survey queried respondents about perceptions of prostate MRI and fusion biopsy and inquired about self-reported utilization. Pearson chi-square test and multivariable logistic regression were used to identify physician characteristics associated with survey responses. Results and limitations The overall response rate was 37% (n = 691). Both UROs and ROs demonstrated similar positive views that MRI with fusion biopsy improves PCa risk stratification (67% vs 71%; p = 0.19) and fusion biopsy increases the confidence recommending active surveillance (55% vs 60%; p = 0.18). Yet, only a quarter of both specialties reported frequent use of prostate MRI for treatment decisions for low- and intermediate-risk PCa. Compared with respondents practicing in community practices, those in academic practices were more likely to report using prostate MRI for low- (44% vs 19%; adjusted odds ratio [OR]: 3.96; p Conclusions While both specialties have perceived value in favor of prostate MRI and fusion biopsy, only a quarter of respondents report their use in clinical practice. Physicians practicing in academic medical centers had greater self-reported use. Patient summary Magnetic resonance imaging of the prostate and targeted biopsies have growing evidence of their use as a superior diagnostic methodology for prostate cancer diagnosis and treatment decisions. Our survey study found that a majority of radiation oncologists and urologists view both favorably in improving prostate cancer detection and treatment decisions. Yet, only a quarter report using it in routine clinical practice for men diagnosed with prostate cancer.

Although robot assistance can facilitate the advantages of minimally invasive surgery, it is unclear whether it offers benefits in settings in which laparoscopic surgery has been established as the standard of care.To examine the comparative effectiveness of robot-assisted laparoscopic radical nephrectomy (RALRN) and laparoscopic radical nephrectomy (LRN) using a nationwide data set.8316 adults who underwent RALRN or LRN for non-urothelial renal cancer from the Nationwide Inpatient Sample from 2010 to 2013.RALRN and LRN.The associations of surgical approach with perioperative outcomes and total hospital costs were evaluated using multivariable logistic regression.Over the study period, utilization of RALRN increased from 46% to 69%. Compared to LRN, RALRN was associated with lower rates of intraoperative (0.9% vs 1.8%; p0.001) and postoperative complications (20.4% vs 27.2%; p0.001), but there were no differences in perioperative blood transfusion (5.6% vs 6.2%; p=0.27) and prolonged hospitalization (7.2% vs 7.1%; p=0.81). RALRN was also significantly associated with higher total hospital costs (median $16 207 vs $15 037; p0.001). In multivariable analyses, RALRN remained independently associated with a lower risk of intraoperative (odds ratio [OR] 0.50; p=0.001) and postoperative complications (OR 0.72; p0.001) but not perioperative blood transfusion (OR 1.10; p=0.34), and with a higher risk of prolonged hospitalization (OR 1.29; p=0.007) and higher mean total hospital costs (+$1468; p0.001). There was no effect modification by hospital volume.Although RALRN was independently associated with a reduction in perioperative complications compared to LRN, it was associated with prolonged hospitalization and higher total hospital costs. These relationships must be interpreted in light of potential differences in case mix.Although robot-assisted laparoscopic radical nephrectomy was independently associated with a reduction in perioperative complications compared to laparoscopic radical nephrectomy, it was associated with prolonged hospitalization and higher total hospital costs.

Placenta percreta is the most severe form of placenta accreta and is characterized by placental invasion through the entirety of the myometrium and possibly into extrauterine tissues. It is associated with prior cesarean deliveries and placenta previa. Herein, we present the case of a patient who developed placenta percreta and experienced massive blood loss of 27 liters. She developed many complications over the next 11 months, including deep vein thrombosis, pulmonary embolism, preeclampsia after pregnancy, hematoma, blood clots in the bladder, lactation failure, ileus, vesicovaginal fistula, excessive scar tissue requiring surgery, loss of an ovary, and recurrent bladder perforation. We analyze the mechanisms of these complications and the most common complications associated with placenta percreta.

INTRODUCTION AND OBJECTIVE:Clinical practice guidelines recommend antibiotic prophylaxis for transrectal prostate biopsy. However, infectious complications following biopsy have been an emerging co...

Key Points Question Was the Patient Protection and Affordable Care Act (ACA) associated with changes in insurance coverage and stage of diagnosis for patients with renal cell carcinoma (RCC), and were differences based on income? Findings In this cohort study of 78 099 patients with RCC, the ACA was associated with increased insurance coverage through Medicaid for low-income patients and detection at an earlier stage of disease. Insurance coverage increased to a greater degree in states that expanded their Medicaid eligibility. Meaning These findings suggest that the ACA was associated with significant increases in insurance coverage for lower-income patients and early diagnosis of RCC., Importance The association of the Patient Protection and Affordable Care Act (ACA) with insurance status and cancer stage at diagnosis among patients with renal cell carcinoma (RCC) is unknown. Objective To test the hypothesis that the ACA may be associated with increased access to care through expansion of insurance, which may vary based on income. Design, Setting, and Participants This retrospective cohort analysis included patients diagnosed with RCC from January 1, 2010, to December 31, 2016, in the National Cancer Database. Data were analyzed from July 1 to December 31, 2020. The periods from 2010 to 2013 and from 2014 to 2016 were defined as pre- and post-ACA implementation, respectively. Patients were categorized as living in a Medicaid expansion state or not. Exposures Implementation of the ACA. Main Outcomes and Measures The absolute percentage change (APC) of insurance coverage was calculated before and after ACA implementation in expansion and nonexpansion states. Secondary outcomes included change in stage at diagnosis, difference in the rate of insurance change, and change in localized disease between expansion and nonexpansion states. Adjusted difference-in-difference modeling was performed. Results The cohort included 78 099 patients (64.7% male and 35.3% female; mean [SD] age, 54.66 [6.46] years), of whom 21.2% had low, 46.2% had middle, and 32.6% had high incomes. After ACA implementation, expansion states had a lower proportion of uninsured patients (adjusted difference-in-difference, −1.14% [95% CI, −1.98% to −1.41%]; P = .005). This occurred to the greatest degree among low-income patients through the acquisition of Medicaid (APC, 11.0% [95% CI, 8.6%-13.3%]; P, This cohort study tests the hypothesis that implementation of the Patient Protection and Affordable Care Act may be associated with increased access to care through expansion of insurance, which may vary based on income, among patients with renal cell carcinoma.

Clinical factors and barriers affecting adoption of active surveillance (AS) for low-risk prostate cancer (PCa) remain poorly understood. We performed a national survey of radiation oncologists (RO) and urologists (URO) about the perceptions and recommendations of AS for low-risk PCa.In 2017, we surveyed 915 RO and 940 URO about AS for low-risk PCa in the United States. Survey items queried respondents about their attitudes toward AS and recommendations of AS for low-risk PCa. Pearson chi-square and multivariable logistic regression identified clinical and physician factors related toward AS for low-risk PCa.Overall, the response rate was 37.3% (n = 691) and was similar for RO and URO (35.7% vs. 38.7%; P = .18). RO were less likely to consider AS effective for low-risk PCa (86.5% vs. 92.0%; P = .04) and more likely to rate higher patient anxiety on AS (49.5% vs. 29.5%; P .001) than URO. Recommendations of AS varied modestly on the basis of age, prostate-specific antigen (PSA), and number of cores positive for Gleason 3 + 3 PCa. For a 55-year-old man with PSA 8 with 6 cores of Gleason 6 PCa, both RO and URO infrequently recommended AS (4.4% vs. 5.2%; adjusted odds ratio = 0.6; P = .28). For a 75-year-old patient with PSA 4 with 2 cores of Gleason 6 PCa, URO and RO most often recommended AS (89.6% vs. 83.4%; adjusted odds ratio = 0.5; P = .07).RO and URO consider AS to be effective in the clinical management of low-risk PCa, but this varies by clinical and physician factors.

African-Americans have prostate cancer mortality rates that are double their White counterparts. To reduce prostate cancer disparities, it is suggested that men engage in shared decision making about prostate cancer screening with their healthcare provider after learning about the benefits and harms of these screenings. While researchers have developed decision aids to support African-American’s screening decisions, there is some uncertainty whether these aids lead to shared decision making. The goal of the current study was to investigate the efficacy of iDecide, a computerized decision aid, for promoting African-American men’s engagement in shared decision making. Six months after their use of iDecide, a prostate cancer screening decision aid, 76 participants were surveyed to determine whether they spoke with a provider about screening, what this conversation entailed, and if shared decision making occurred. While iDecide is an effective tool for enhancing African-American’s intention to engage in shared decision making, there is no evidence this aid increased their likelihood of discussing prostate cancer with a provider or participation in shared decision making. Future research should employ stronger research designs and assess the various contexts that can affect the relationship between decision-aid use and shared decision making among African-Americans.

Context Despite established guidelines for the treatment of muscle-invasive bladder cancer, it has been reported that radical cystectomy (RC) is markedly underused, especially among patients of advanced age and those with higher comorbidity burden and lower access to care. Understanding the interactions between patient, provider, and hospital factors may inform targeted interventions to optimize RC utilization. Objective To systematically review the literature regarding factors associated with RC utilization. Evidence acquisition A systematic search was conducted using Ovid and Medline according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to identify studies between 1970 and 2017 reporting on RC utilization. Prospective and retrospective studies were included. Evidence synthesis There are no published randomized control trials on RC utilization. Variations in study quality and design precluded a formal statistical meta-analysis. RC receipt significantly depended on patient, provider, and hospital factors. Patient factors associated with lower RC use included advanced age, African American and Hispanic race/ethnicity, higher comorbidity burden, unmarried marital status, higher tumor stage and grade, and lower socioeconomic status. Provider factors associated with underutilization included lower surgeon volume and a metropolitan location. Finally, hospital factors associated with lower RC use included low hospital volume, nonacademic affiliation, and hospital location in the Midwest. Conclusions RC is reportedly underutilized. We found that age, race, marital status, socioeconomic factors, cancer severity, comorbidity burden, surgeon volume, and facility type and location significantly determined RC receipt. Improved understanding of the varying contributions of the risk factors according to patient, provider, and hospital determinants may assist in developing targeted interventions to improve RC utilization. Patient summary In this review we explored the clinical evidence for factors predicting the utilization of radical cystectomy for muscle-invasive bladder cancer. Many factors related to the patient, provider, and hospital determine whether patients receive this guideline-recommended treatment. However, there remains a lack of understanding on characterization and targeted interventions according to these levels, which may improve use.

Objectives To study trends in Bacillus Calmette-Guerin (BCG) utilization for nonmuscle invasive bladder cancer (NMIBC) before and during national BCG shortages. Methods The National Cancer Database was used to identify patients with localized NMIBC. Multivariate logistic regression was used to assess factors associated with BCG use. Temporal trends in BCG use were studied using segmented regression analysis. Results We identified 238,279 patients with NMIBC from 2004 to 2015. Overall, 33,660 (14.1%) patients with NMIBC received intravesical BCG during the study period. Segmented regression revealed a slower rate of rise of BCG utilization following major supply interruptions in 2011 and 2012 (2004-2012: +0.62% increase per year [P Conclusions BCG utilization for NMIBC increased significantly over the study period, possibly representing increased adoption of national guidelines for BCG in NMIBC. In the years following interruptions in BCG supply, BCG use appears to have been rationed based on clinical risk, with the steepest declines in BCG use occurring in the lowest risk patients.

Although prediction tools for prostate cancer (PCa) are essential for high-quality treatment decision-making, little is known about the degree of confidence in existing tools and whether they are used in clinical practice from radiation oncologists (RO) and urologists (URO). Herein, we performed a national survey of specialists about perceived attitudes and use of prediction tools. In 2017, we invited 940 URO and 911 RO in a national survey to query their confidence in and use of the D’Amico criteria, Kattan Nomogram, and CAPRA score. The statistical analysis involved bivariate association and multivariable logistic regression analyses to identify physician characteristics (age, gender, race, practice affiliation, specialty, access to robotic surgery, ownership of linear accelerator and number of prostate cancer per week) associated with survey responses and use of active surveillance (AS) for low-risk PCa. Overall, 691 (37.3%) specialists completed the surveys. Two-thirds (range 65.6–68.4%) of respondents reported being “somewhat confident”, but only a fifth selected “very confident” for each prediction tool (18.0–20.1%). 19.1% of specialists in the survey reported not using any prediction tools in clinical practice, which was higher amongst URO than RO (23.9 vs. 13.4%; p

Breast-conserving therapy (BCT) offers oncologic outcomes similar to those of mastectomy, yet many patients, when provided the option, choose mastectomy. This study aimed to evaluate the relationship between patient-reported distress and surgical decisions and to determine factors predictive of choosing BCT versus mastectomy. Patients with newly diagnosed breast cancer deemed candidates for BCT who completed a distress screen at their initial visit to an academic institution between 2016 and 2019 were retrospectively reviewed. This screening tool captures distress in emotional, social, health, and practical domains on a scale of 0 to 10. The distress scores were compared against surgical decisions using nonparametric Wilcoxon rank-sum tests. Patient factors associated with surgical choice were analyzed using chi-square, Fisher’s exact, and Student’s t tests. A two-sided p value lower than 0.05 was considered significant. Of 506 patients deemed eligible for BCT, 430 (85%) chose BCT and 76 (15%) pursued mastectomy. The distress levels did not differ significantly between the surgical options. The patients who underwent mastectomy were on the average younger (50.7 vs 60.4 years; p

With growing support of perioperative chemotherapy for upper tract urothelial carcinoma (UTUC), current biopsy methods are challenging, and little is known as to the degree to which patients would appropriately receive neoadjuvant chemotherapy (NAC) from biopsy alone. Herein, we sought to assess the rates of appropriate clinical use of NAC and identify clinicopathologic factors associated with aggressive UTUC amongst patients undergoing radical nephroureterectomy (RNU) for clinically localized disease.From 2004 to 2013, we identified all treatment naïve patients diagnosed with clinically localized, high grade UTUC (cTa-4Nx) who underwent RNU from the National Cancer Database (NCDB). Pathologic criteria for NAC (pT2-4N0,x; pTanyN1) from RNU represented the primary outcome. Bivariate and multivariable analyses were utilized to identify covariates associated with primary outcome to determine appropriate use of NAC.During the study interval, 5,362 patients were diagnosed with clinically localized UTUC and underwent RNU. Overall, 49.1% of patients presented with an unknown primary tumor stage (Tx) and 24.5% had invasive UTUC from biopsy. On multivariable analysis, upper tract tumor size was associated with invasive UTUC eligible for NAC (all P0.05). Amongst patients with cTx UTUC from biopsy, half of patients had pathologic noninvasive UTUC (pTa,is,1) from RNU and would be overtreated with NAC.Significant uncertainty persists in assigning primary upper tract tumor depth and represents a key barrier to widespread implementation of NAC for patients with high grade UTUC. Further research is needed to more accurately determine clinical criteria to identify patients for NAC.

INTRODUCTION Radiation therapy (XRT) has been investigated as a possible treatment for high-risk non-muscle invasive bladder cancer (NMIBC) with the goal of bladder preservation, especially with the ongoing Bacillus Calmette-Guerin (BCG) shortage. Yet, little is known about the clinical efficacy and the quality of evidence supporting XRT for NMIBC. Herein, we performed a systematic review and meta-analysis to evaluate XRT in the treatment of patients with high-risk NMIBC. METHODS Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, and Web of Science were searched for high-risk NMIBC (high grade T1, T1/Ta with associated risk features: carcinoma in-situ (CIS), multifocality, > 5cm in diameter, and/or multiple recurrences) treated with primary XRT. Outcomes evaluated were recurrence-free survival (RFS), cancer-specific-survival (CSS), overall survival (OS), and salvage cystectomy and progression to metastatic disease rates. A meta-analysis was performed to assess outcomes for XRT in NMIBC. RESULTS Overall,13 studies including 746 patients met the search criteria. The 5-year rates of RFS, CSS and OS were 54% (95% CI = 38% – 70%), 86% (95% CI = 80% – 92%), and 72% (95% CI = 64% – 79%). Notably, 13% of patients proceeded to salvage radical cystectomy and 9% developed metastatic disease. All studies were of poor quality, comprising single institution and retrospective studies with only one clinical trial. CONCLUSION XRT for high-risk NMIBC provides some degree of oncologic control, although distant progression was noted. In the setting of the low-quality evidence, a prospective clinical trial is needed to clearly define the risks and benefits of this approach.

OBJECTIVE The degree decision aids (DAs) can promote active surveillance (AS) for prostate cancer (PCa) remains poorly understood. Herein, we surveyed radiation oncologists (RO) and urologists (URO) about their attitudes towards DAs in counselling patients about AS for low-risk PCa. METHODS We conducted a national survey of RO (n = 915) and URO (n = 940) to assess their attitudes about DAs for AS for patients with low-risk PCa. Respondents were queried about their attitudes towards DAs and proportion of PCa patients managed with AS. Multivariable logistic regression models were used to examine physician characteristics related to attitudes about DAs. RESULTS The overall response rate was 37.3% (n = 691). Most respondents strongly agreed or agreed that DAs helped patients with low-risk PCa make informed decisions (93.9%) and also increased patient support for AS (86.6%). Having a high volume of their low-risk PCa patients on AS (>15%) was associated with endorsing the statement that use of DAs increased the likelihood of recommending AS (OR: 1.83; 95% CI: 1.00-4.61; p = .05) and being a URO versus a RO (OR: 3.37; 95% CI: 2.46-5.79; p

ObjectivesAlthough demand for price transparency in healthcare is growing, variation in private payors’ payments to surgeons for oncologic resection has not been well characterised. Our aim was to assess variation of private payors’ payments to surgeons for cancer resection using data based on fee-for-service allowed amounts, billed by a large mix of commercial payors and third-party administrators.SettingFair Health (FH), an independent, not-for-profit organisation that collects and compiles claims data from payors nationwide. FH maintains the nation’s largest repository of privately billed medical and dental claims representing over 125 million covered lives in the USA.ParticipantsWe performed a cross-sectional study assessing private payer data for five common types of cancer surgery: simple mastectomy (SM), modified radical mastectomy (MRM), open lobectomy, video-assisted thoracoscopic surgery (VATS) lobectomy and radical prostatectomy during 2012 and 2013.Primary and secondary outcome measuresTo assess variation across regions, we compared regional median allowed payments. To assess intraregion variability, we evaluated the distribution of regional IQRs of allowed payments.ResultsMedian allowed payments varied substantially across regions. For SM, median allowed payments ranged from $550 in the least expensive to $1380 in the costliest region. For MRM, the range was $842–$1760, for lobectomy $326–$3066, for VATS $317–$3307 and for prostatectomy $1716–$4867. There was also substantial variation within geographic areas. For example, the mean IQRs in surgeon payment within regions were: SM $577 (25th percentile) to $1132 (75th percentile); MRM $850–$1620; lobectomy $861–$2767; VATS $1024–$3122; and prostatectomy $2286–$3563.ConclusionsThere is a wide range of variation both across and within geographic regions in allowed amounts of surgeon payments for common oncologic resections. Transparency about these allowed amounts may have a profound impact on patient and employer choice and facilitate future assessments of value in cancer care.

The comparative effectiveness of surgery and radiation therapy for high-grade, clinically localized prostate cancer remains a seminal, open question in urologic oncology, with no randomized controlled trials to inform management. We therefore emulated a hypothetical target clinical trial of radical prostatectomy (RP) versus external beam radiotherapy (EBRT) for high-grade, clinically localized prostate cancer.We conducted observational analyses using the National Cancer Database from 2006-2015 to emulate a target clinical trial in men 55-69 years with cT1-3cN0cM0, PSA20 ng/mL, Gleason 8 to 10 prostate adenocarcinoma treated with RP or 75 to 81 Gy EBRT with androgen deprivation therapy (EBRT+ADT). The associations of treatment type with overall survival (OS) were estimated using Cox regression with stabilized inverse probability weights (IPW).A total of 26,806 men formed the study cohort (RP: 23,990; EBRT+ADT: 2,816). Baseline characteristics were well-balanced after IPW-adjustment. Median follow-up was 48.4 (IQR 25.5-76.2) months. After IPW-reweighting, RP was associated with improved OS compared to EBRT+ADT (HR 0.54;95% CI 0.48-0.62; P0.001), with 5- and 10-year OS of 93% vs 87%, and 76% vs 60%, respectively. RP was associated with improved OS across all categories of Gleason score, PSA, cT stage, age, and Charlson comorbidity index examined. In sensitivity analyses adjusting for biopsy tumor volume and a biopsy-specific Gleason score, RP remained associated with improved OS compared to EBRT+ADT (HR 0.62;95% CI 0.49-0.78; P0.001).In observational analyses designed to emulate a target clinical trial of men with high-grade, clinically localized prostate cancer, RP was associated with improved OS compared with EBRT+ADT.

INTRODUCTION AND OBJECTIVE:Inguinal lymph node dissection (ILND) is recommended for men with clinically node-negative (cN0) penile cancer at increased risk of harboring lymph node (LN) metastases. ...

INTRODUCTION AND OBJECTIVE:The comparative effectiveness of surgery and radiation therapy for clinically localized prostate cancer remains a seminal, open question in urology. It represents a parti...

The reasons for low clinical adoption of active surveillance (AS) for low-risk prostate cancer (PCa) remain poorly understood. Thus, we conducted a national survey of radiation oncologists (ROs) and urologists (UROs) to elucidate perceived barriers to AS for low-risk PCa. In 2017, we undertook a four-wave mail survey of 1855 ROs and UROs. The survey instrument assessed attitudes about possible barriers towards AS for low-risk PCa. We used Pearson Chi square and multivariable logistic regression analyses to identify physician characteristics associated with attitudes about AS. We received 691 completed surveys for an overall response rate of 37.3%. A majority of respondents indicated that they felt comfortable recommending AS (90.0%), agreed that high-level evidence supports it (82.3%), and considered AS equally effective for survival compared with surgery and radiation therapy (84.4%). UROs were less likely to agree that patients were not interested in AS for low-risk PCa compared with ROs (16.5 vs. 48.9%; adjusted odds ratio [OR] 0.18, p

Our objective was to evaluate the role of retroperitoneal lymph node dissection (LND) in non-metastatic (M0) and metastatic (M1) renal cell carcinoma (RCC). We searched Medline, EMBASE, Web of Science and Scopus from database inception to 29 August 2017 for studies of patients who underwent partial or radical nephrectomy for M0 or M1 RCC. Two investigators independently selected studies for inclusion. Risk of bias was assessed using the Newcastle-Ottawa scale, Cochrane Collaboration tool and National Heart, Lung and Blood Institute Quality Assessment Tool. Random effects meta-analysis was performed for all-cause-mortality. The GRADE approach was used to characterize quality of evidence. A total of 51 unique studies were included in the qualitative systematic review. Risk of bias was low in 41/51 (80%) studies. LND was not associated with all-cause mortality in either M0 (hazard ratio [HR] 1.02, 95% confidence interval [CI] 0.92-1.12; I2 = 0%; four studies), M1 (HR 1.04, 95% CI 0.83-1.29; I2 = 0%; two studies), or pooled M0 and M1 settings (HR 1.00, 95% CI 0.92-1.09; I2 = 0%; seven studies), with no statistically significant differences according to M stage subgroups (P = 0.50). In the three studies that examined M0 subgroups with a high risk of nodal metastasis, LND was not associated with improved oncological outcomes. Studies on the association of extent of LND with survival reported inconsistent results. Meanwhile, a small proportion of patients with pN1M0 disease demonstrate durable long-term oncological control after surgery, with 10-year cancer-specific survival of 21-31%. Nodal involvement is independently associated with adverse prognosis in both M0 and M1 settings. GRADE quality of evidence was moderate or low for the outcomes examined. Although LND yields independent prognostic information, the existing literature does not support a therapeutic benefit to LND in either M0 or M1 RCC. High-risk M0 patient groups warrant further study, as a subset of patients with isolated nodal metastases experience long-term survival after surgical resection.

OBJECTIVE: To develop and validate a nomogram assessing cancer and all-cause mortality following radical cystectomy. Given concerns regarding the morbidity associated with surgery, there is a need for incorporation of cancer-specific and competing risks into patient counseling and recommendations. MATERIALS AND METHODS: A total of 5325 and 1257 diagnosed with clinical stage T2-T4a muscle-invasive bladder cancer from January 1, 2006 to December 31, 2011 from Surveillance, Epidemiology, and End Results-Medicare and Texas Cancer Registry-Medicare linked data, respectively. Cox proportional hazards models were used and a nomogram was developed to predict 3- and 5-year overall and cancer-specific survival with external validation. RESULTS: Patients who underwent radical cystectomy were mostly younger, male, married, non-Hispanic white and had fewer comorbidities than those who did not undergo radical cystectomy (P < .001). Married patients, in comparison with their unmarried counterparts, had both improved overall (hazard ratio 0.76; 95% confidence interval 0.70–0.83, P < .001) and cancer-specific (hazard ratio 0.76; 95% confidence interval 0.68–0.85, P < .001) survival. A nomogram developed using Surveillance, Epidemiology, and End Results-Medicare data, predicted 3- and 5-year overall and cancer-specific survival rates with concordance indices of 0.65 and 0.66 in the validated Texas Cancer Registry-Medicare cohort, respectively. CONCLUSION: Older, unmarried patients with increased comorbidities are less likely to undergo radical cystectomy. We developed and validated a generalizable instrument that has been converted into an online tool (Radical Cystectomy Survival Calculator), to provide a benefit-risk assessment for patients considering radical cystectomy.

Objective To evaluate population-based prostate cancer (CaP) testing of men in their 40s, given the paucity of prospective data evaluating the consequences of prostate-specific antigen (PSA) testing in younger men for CaP. Materials and Methods A total of 1052 men in their 40s were followed longitudinally for prostate outcomes, from 1990 to 2010. A random subset of 268 men was selected to undergo biennial CaP testing including PSA testing, transrectal ultrasound, and a digital rectal examination. A representative population of 609 men with a subset of 159 men who also began CaP testing in their 50s was also evaluated as a comparison group. Risk of prostate biopsy (PBx), CaP, or death from CaP was compared between CaP-tested and the routine-care population cohort. Results Median follow-up was 17.2 years. Men aged 40-49, who underwent CaP testing were 2.4 times more likely to undergo a PBx (hazard ratio [HR] 2.4 95% confidence interval [CI] 1.8-3.3) and 2.2 times more likely to be diagnosed with low-risk CaP (HR 2.2, 95% CI 1.12-4.0). Those initiating CaP testing a decade earlier were 2.2 times and 1.7 times more likely to be biopsied and be diagnosed with CaP for any given age (HR 2.2 95% CI 1.4-3.5 and 1.7 95% CI 1.1-2.7, respectively). Conclusion CaP testing in men beginning at age 40 resulted in a significant increase in the risk of PBx and diagnosis of low-risk CaP, without a measurable reduction in risk of CaP-death in this low-risk population. However, given the natural history of CaP, a longer follow-up is needed to confirm this finding.

Despite efforts to define metrics assessing hospital-level quality for renal cell carcinoma (RCC) surgical care there remains a paucity of real-world data validating their ability to benchmark performance. Consequently, whether poor performance on hospital-level quality indicators is associated with inferior patient outcomes remains unknown.To determine hospital-level variations in RCC surgical quality after adjusting for differences in patient- and tumor-specific factors. Further, to determine associations between hospital-level quality performance and surgical volume, academic affiliation, and patient mortality.RCC patients undergoing surgery in the USA and Puerto Rico (2004-2014) were identified from the National Cancer Database.Hospital-level quality of care was assessed according to disease-specific process and outcome quality indicators. Case-mix adjusted hospital benchmarking was performed using indirect standardization methodology and multivariable regression models. A composite measure of quality, the Renal Cancer Quality Score (RC-QS), was subsequently derived and associations between RC-QS and surgical volume, academic affiliation, and patient mortality were determined.Over 1100 hospitals were benchmarked for quality, with 10-31% identified as providing poor care for a given quality indicator. Lower RC-QS hospitals had smaller referral volumes and were less academic compared with higher RC-QS hospitals (p0.001). Higher RC-QS was independently associated with lower 30-d, 90-d, and overall mortality (adjusted odds ratio [confidence interval]: 0.92 [0.90-0.95], odds ratio: 0.94 [0.91-0.96], hazard ratio: 0.97 [0.96-0.98] per unit increase, respectively). These data are retrospective and it is unknown whether improvement in the RC-QS improves outcomes.Widespread hospital-level variations in RCC surgical quality exist, as captured by the RC-QS. Superior quality is associated with improved patient outcomes, including mortality benefit. The RC-QS serves as a benchmarking tool for RCC quality that can provide audit level feedback to hospitals and policymakers for quality improvement.We benchmarked hospital performance across quality indicators for kidney cancer surgical care. Overall, large variations in quality exist, with high volume academic hospitals demonstrating superior performance and improved patient survival. These data can inform hospitals and policymakers for quality improvement initiatives.

Background While partial nephrectomy (PN) is the recommended treatment for many small renal masses, anatomically complex tumors necessitate a clear understanding of the potential risks and benefits of PN and radical nephrectomy (RN). Objective To critically review the comparative effectiveness evidence of PN versus RN; to describe key trade-offs involved in this treatment decision; and to highlight gaps in the current literature. Evidence acquisition A collaborative critical review of the medical literature was conducted. Evidence synthesis Patients who undergo PN for an anatomically complex or large mass may be exposed to perioperative and potential oncologic risks that could be avoided if RN were performed, while patients who undergo RN may forgo long-term benefits of renal preservation. Decision-making regarding the optimal treatment with PN or RN among patients with anatomically complex or large renal mass is highly nuanced and must balance the risks and benefits of each approach. Currently, high-quality evidence on comparative effectiveness is sparse. Retrospective comparisons are plagued by selection biases, while the one existing prospective randomized trial, albeit imperfect, suggests that nephron-sparing surgery may not benefit all patients. Conclusions For anatomically complex tumors, PN preserves renal parenchyma but may expose patients to higher perioperative risks than RN. The risks and benefits of each surgical approach must be better objectified for identification of patients most suitable for complex PN. A prospective randomized trial is warranted and would help in directing patient counseling. Patient summary Treatment decisions for complex renal masses require shared decision-making regarding the risk trade-offs between partial and radical nephrectomy.

In 2012, the United States Preventive Services Task Force (USPSTF) recommended against prostate-specific antigen (PSA) screening, despite evidence that Black men are at a higher risk of prostate cancer-specific mortality (PCSM). We evaluated whether Black men of potentially screening-eligible age (55-69 years) are at a disproportionally high risk of poor outcomes.The SEER database was used to study 390 259 men diagnosed with prostate cancer in the United States between 2004 and 2011. Multivariable logistic regression modeled the association between Black race and stage of presentation, while Fine-Gray competing risks regression modeled the association between Black race and PCSM, both as a function of screening eligibility (age 55-69 years versus not).Black men were more likely to present with metastatic disease (adjusted odds ratio [AOR] 1.65; 1.58-1.72; P 0.001) and were at a higher risk of PCSM (adjusted hazard ratio [AHR] 1.36; 1.27-1.46; P 0.001) compared to non-Black men. There were significant interactions between race and PSA-screening eligibility such that Black patients experienced more disproportionate rates of metastatic disease (AOR 1.76; 1.65-1.87 versus 1.55; 1.47-1.65; Pinteraction 0.001) and PCSM (AHR 1.53; 1.37-1.70 versus 1.25; 1.14-1.37; Pinteraction = 0.01) in the potentially PSA-screening eligible group than in the group not eligible for screening.Racial disparities in prostate cancer outcome among Black men are significantly worse in PSA-screening eligible populations. These results raise the possibility that Black men could be disproportionately impacted by recommendations to end PSA screening in the United States and suggest that Black race should be included in the updated USPSTF PSA screening guidelines.

BACKGROUND The objective of this study was to compare the overall survival of patients who undergo radical prostatectomy or radiotherapy versus noncancer controls to discern whether there is a survival advantage according to prostate cancer treatment and the impact of selection bias on these results. METHODS A matched cohort study was performed using the Surveillance, Epidemiology, and End Results (SEER)-Medicare–linked database. In total, 34,473 patients ages 66 to 75 years were identified who were without significant comorbidity, were diagnosed with localized prostate cancer, and received treatment treated with surgery or radiotherapy between 2004 and 2011. These patients were matched to a noncancer control cohort. The rates of all-cause mortality that occurred within the study period were compared. Cox proportional hazards regression analysis was used to identify determinants associated with overall survival. RESULTS Of 34,473 patients who were included in the analysis, 21,740 (63%) received radiation therapy, and 12,733 (37%) underwent surgery. There was improved survival in patients who underwent surgery (hazard ratio, 0.35; 95% confidence interval, 0.32-0.38) and in those who received radiotherapy (hazard ratio, 0.72; 95% confidence interval, 0.68-0.75) compared with noncancer controls. Overall survival improved significantly in both treatment groups, with the greatest benefit observed among patients who underwent surgery (log rank P

Introduction/background Regional lymph node dissection (LND) may provide oncologic benefit among patients with clinical lymphadenopathy in renal cell carcinoma (RCC) at the of time radical nephrectomy (RN). Yet, little is known about contemporary use of LND for patients with RCC and regional lymphadenopathy. Thus, we assessed national trends in RN and LND among RCC patients with renal masses and clinical lymphadenopathy. Materials and methods From the National Cancer Data Base (NCDB), we identified patients with RCC and clinical lymphadenopathy without distant metastasis (clinical T1-4 N1 + M0) who underwent RN from 2001 to 2011. The primary outcome was concomitant LND at the time of RN. Multivariable logistic regression analysis was used to identify patient and hospital characteristics associated with the primary outcome. Results Among 1840 patients with clinical N1+ treated surgically, 78% received LND (n=1444). The proportion of patients who underwent LND increased from 77% in 2001 to 82% in 2011 (p Conclusion Among patients with RCC and clinical lymphadenopathy, ~20% are not receiving LND at the time of RN in the U.S. Academic hospitals and open surgery was associated with receipt of LND. Centralization to tertiary academic hospitals may facilitate greater use of LND.

The hip is a common location for heterotopic ossification after surgical trauma, blunt trauma, or muscle injury. However, the region around the pubic rami is an unusual location for heterotopic bone formation. Here, we present a case of a young, active man in the Armed Forces Reserve with a large heterotopic bone involving the left inferior pubic ramus who underwent surgical excision through an unusual approach via the perineum. The patient had notable pain relief postoperatively and returned to his active duties 1 month after surgery without discomfort or functional limitation.

Radical cystectomy with extended pelvic lymphadenectomy is recommended for treatment of patients with recurrent non-muscle invasive and muscle invasive bladder cancer (1). Despite these guideline recommendations, radical cystectomy is significantly underutilized.

There are limited data on the oncologic outcomes of upper tract urothelial carcinoma with isolated lymph node (LN) involvement (pN+ M0) following surgical resection. We examined pN+ M0 UTUC in a large, nationwide oncology dataset to characterize its natural history, describe trends in utilization of perioperative chemotherapy, and identify clinicopathologic features associated with survival. We identified 794 patients aged 18–89 years who underwent radical nephroureterectomy with lymph node dissection for pN+ M0 UTUC from 2006 to 2013 in the National Cancer Database. The associations of clinicopathologic features with overall survival (OS) were evaluated using Cox regression models, and a simplified risk score was created. Median follow-up among survivors was 39.5 months, during which time 555 (70%) patients died. Over the study period, neoadjuvant chemotherapy utilization increased from 6.7 to 14.2% (p = 0.002), while adjuvant chemotherapy utilization remained stable (42.7 to 44.3%; p = 0.86). One-, 5-, and 8-year OS rates were 63.7%, 24.2%, and 18.7%, respectively. On multivariable analysis, older age, larger tumor size, higher pT stage, positive surgical margins, number of positive LNs, and non-receipt of adjuvant chemotherapy were independently associated with worse OS. A simplified risk score consisting of age, tumor size, pT stage, number of positive LNs, and margin status was created with predicted 5-year OS ranging from 12 to 44%. In this large, contemporary cohort, pN+ M0 UTUC was associated with a 5-year OS of only 24%. Clinicopathologic predictors of survival after surgical resection may improve risk-stratification, counseling, and selection of patients for multimodal management.

OBJECTIVES: African American prostate cancer survivors experience post-treatment decisional regret more often than European Americans, which can lead to negative long-term effects on quality of life. A prominent driver of health-related decision-making is emotion, yet little work has examined the impact emotions may have on decisional regret. The goal of this study was to explore experiences, perceptions, and emotions of prostate cancer survivors in relation to their diagnostic and treatment decision-making processes, prostate cancer treatment, and outcomes. Additionally, we sought to identify factors that might explain differences in prostate cancer outcomes between African and European Americans. DESIGN: This mixed-methods study utilized a convergent parallel design, in which quantitative and qualitative data were collected simultaneously and then integrated to more robustly explain relationships between variables. Survivors were eligible for the study if they had been previously diagnosed with localized prostate cancer and were no more than six months post-treatment. The study was guided by the Risk as Feelings Model, which predicts the relationship between emotion and cognition in high risk decision-making. RESULTS: No men experienced decisional regret following treatment, even if they experienced side effects. While all men reported being surprised about their prostate cancer diagnosis, strong negative emotions were more common among men under 65. Family support and spirituality appeared to mitigate negative emotions. Perceived authenticity of provider communication was the most influential mediator in men’s decision-making and positive perceptions of their outcomes. CONCLUSIONS: To mitigate the impact emotional responses have on decision-making and post-treatment regret, providers should explore alternate therapies (e.g., counselling for men diagnosed with prostate cancer at a young age) and include family members in prostate cancer treatment discussions. Most importantly, providers should be aware of the importance of quality communication on men’s cognitive and emotional processes and their perceptions of treatment outcomes.

INTRODUCTION AND OBJECTIVES:There are limited data regarding the optimal management of clinically node-positive (cN+) bladder cancer. Although the mainstay of treatment is chemotherapy, it is uncle...