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Background: The use of neoadjuvant chemotherapy (NAC) before radical cystectomy (RC) is supported by results from several randomized control trials, including SWOG-8710., Objective: To look at the effectiveness of NAC before RC in current real world practice in the USA., Design, Setting, and Participants: We used the National Cancer Data Base (NCDB) to identify patients with nonmetastatic muscle-invasive urothelial carcinoma of the bladder who underwent RC between 2004 and 2012., Intervention: Receipt of NAC before RC., Outcome Measurements and Statistical Analysis: The primary endpoint was overall survival (OS). Secondary endpoints were rates of complete pathologic response (pT0), positive pathologic lymph nodes (pN+), and margin status. Using a landmark analysis to adjust for an immortal-time bias, OS comparison was performed using Cox regression analysis. Furthermore, logistic regression models examining secondary outcomes were fitted. To adjust for potential selection bias, propensity score-weighted analyses were performed., Results and Limitations: Of 8732 patients who underwent RC, 1619 (19%) received NAC. Following propensity score adjustment, receipt of NAC was not associated with an OS benefit (hazard ratio 0.97; p=0.591). On secondary outcome analysis, higher pT0 rates (odds ratio 5.03; p<0.001) were recorded among patients who received NAC, although rates of pT0 were lower than for patients treated with NAC within the SWOG-8710 trial (13% vs 38%). Limitations include the retrospective design and limited details available regarding type of chemotherapy., Conclusions: Important baseline differences between patients from the SWOG-8710 trial and those in general urologic practice exist. After adjusting for immortal-time bias, we did not find a clear survival advantage of NAC before RC when compared to RC alone in current general urology practice in the USA., Patient Summary: The benefit of chemotherapy before radical cystectomy is supported by few randomized control trials. In this study, using a large national data set from the USA we found that preoperative chemotherapy is not associated with a survival benefit in all patients in general urology practice. Hence, better selection criteria are needed to determine who will benefit the most from chemotherapy before radical cystectomy., (Copyright © 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objectives: Over the past decade, robot-assisted radical cystectomy (RARC) has gained traction as an alternative to the conventional open approach open radical cystectomy (ORC). However, the benefits of RARC over ORC remain unclear. Our objective was to conduct a comparative effectiveness analysis between RARC and ORC using data from the National Cancer Data Base., Materials and Methods: Within the National Cancer Data Base, we identified patients with localized muscle-invasive bladder cancer who underwent RC between 2010 and 2013. Patients were stratified according to surgical approach: ORC vs. RARC. Intraoperative endpoints included: the presence of positive surgical margins, the performance of a pelvic lymph node dissection, and number of lymph nodes (LN) removed. Postoperative endpoints included: length of stay (LOS), 30- and 90-day postoperative mortality (POM) rates, 30-day readmission rate, and overall survival (OS). To minimize selection bias, observed differences in baseline characteristics between RARC vs. ORC patients were controlled for using weighted propensity scores. Binary endpoints and OS were assessed using propensity score-adjusted logistic and Cox regression analyses, respectively. POM was assessed using propensity score weighted Kaplan-Meier survival estimates at 30 and 90 days after RC., Results: Of 9,561 patients who underwent RC, 2,048 (21.4%) and 7,513 (78.6%) underwent RARC and ORC, respectively. The use of RARC increased over time, from 16.7% in 2010 to 25.3% in 2013. With regard to intraoperative outcomes, RARC was associated with equivalent rates of positive surgical margins (9.3% vs. 10.7%, odds ratio [OR] = 0.86, 95% CI: 0.72-1.03; P = 0.10), higher rates of pelvic lymph node dissection (96.4% vs. 92.0%, OR = 2.30, 95% CI: 1.67-3.16; P<0.001), higher median LN count (17 vs. 12, P<0.001), higher rates of LN count above the median (56.8% vs. 40.4%, OR = 1.94, 95% CI: 1.55-2.42, P<0.001). With regard to postoperative outcomes, receipt of RARC was associated with a shorter median LOS (7 vs. 8, P<0.001), and lower rates of pLOS (45.0% vs. 54.8%, OR = 0.68, 95% CI: 0.58-0.79; P<0.001). The 30- and 90-day POM rates were 2.8%, 6.7% for ORC, and 1.4%, 4.8% for RARC, respectively (hazard ratio [HR] = 0.48, 95% CI: 0.29-0.80, P = 0.005 and HR = 0.71, 95% CI: 0.54-0.93; P = 0.014). Finally, with a mean follow-up of 26.9 months, on IPTW-adjusted Cox regression analysis, RARC vs. ORC was associated with a benefit in OS (HR = 0.79, 95% CI: 0.71-0.88; P<0.001)., Conclusions: Our large contemporary study found an increased adoption of RARC between 2010 and 2013, with more than 1 out of 4 patients undergoing RARC by the end of the study period. We found that RARC was associated with higher LN counts, shorter LOS, and lower POM. Our results allude to potential benefits of RARC while we wait for more definitive answers from randomized trials., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose Evidence from studies of other malignancies has indicated that aggressive local treatment (LT), even in the presence of metastatic disease, is beneficial. Against a backdrop of stagnant mortality rates for metastatic urothelial carcinoma of the bladder (mUCB) at presentation, we hypothesized that high-intensity LT of primary tumor burden, defined as the receipt of radical cystectomy or ≥ 50 Gy of radiation therapy delivered to the bladder, affects overall survival (OS). Patients and Methods We identified 3,753 patients within the National Cancer Data Base who received multiagent systemic chemotherapy combined with high-intensity versus conservative LT for primary mUCB. Patients who received no LT, transurethral resection of the bladder tumor alone, or < 50 Gy of radiation therapy delivered to the bladder were included in the conservative LT group. Inverse probability of treatment weighting (IPTW) -adjusted Kaplan-Meier curves and Cox regression analyses were used to compare OS of patients who received high-intensity versus conservative LT. Results Overall, 297 (7.91%) and 3,456 (92.09%) patients with mUCB received high-intensity and conservative LT, respectively. IPTW-adjusted Kaplan-Meier curves showed that median OS was significantly longer in the high-intensity LT group than in the conservative LT group (14.92 [interquartile range, 9.82 to 30.72] v 9.95 [interquartile range, 5.29 to 17.08] months, respectively; P < .001). Furthermore, in IPTW-adjusted Cox regression analysis, high-intensity LT was associated with a significant OS benefit (hazard ratio, 0.56; 95% CI, 0.48 to 0.65; P < .001). Conclusion We report an OS benefit for individuals with mUCB treated with high-intensity versus conservative LT. Although the findings are subject to the usual biases related to the observational study design, these preliminary data warrant further consideration in randomized controlled trials, particularly given the poor prognosis associated with mUCB.