Gershman, Boris

ABSTRACT Introduction Non‐muscle invasive bladder cancer (NMIBC) is a chronic disease with a lifelong treatment burden that may cause substantial urinary morbidity. Such quality‐of‐life changes remain understudied. We therefore evaluated the incidence and predictors of treatment for overactive bladder (OAB) among older adults following diagnosis of NMIBC. Materials and Methods We identified adults aged 66–89 years with newly diagnosed NMIBC from 2007 to 2017 in the linked SEER‐Medicare database. We examined the incidence of treatment initiation for OAB following initial transurethral resection of bladder tumor (TURBT) and evaluated associations with baseline characteristics using Cox regression. Results We identified 9,819 patients, of whom 68% had Ta disease, 29% had T1 disease, and 4% had CIS. Within the first 12 months of TURBT, 7% of patients received treatment for OAB, and this increased to 15% of patients at 5 years. In the first year, the most utilized therapies were anticholinergic medications (early 3.72%, late 2.74%) and beta‐3 agonists (early 0.11%, late 0.32%), while procedural OAB therapy utilization was rare (0.2%). On multivariable analysis, female gender (HR 1.26, 95% CI 1.11–1.42), congestive heart failure (HR 1.21, 95% CI 1.03–1.43), and T1 tumor stage (HR 1.27, 95% CI 1.12–1.44 vs. Ta) were independently associated with an increased risk of OAB treatment. Conclusions The incidence of OAB requiring treatment among patients with NMIBC is substantial, with approximately one in six patients receiving treatment by 5 years after diagnosis. Predictive clinicopathologic features for OAB treatment—including, sex, high‐risk tumor features, and repeat TURBT—may be useful for clinical counseling.

Objective The aim of this study was to compare the perioperative morbidity of minimally invasive sacrocolpopexy (MISC) and nonmesh apical vaginal surgeries for repair of vaginal vault prolapse using data from a contemporary nationwide cohort. Methods The American College of Surgeons' National Surgical Quality Improvement Program database was used to identify women who underwent apical prolapse surgery via vaginal approach or MISC from 2010 to 2016. Those undergoing concomitant hysterectomy or transvaginal mesh placement were excluded. Associations of surgical approach with 30-day complications, prolonged hospitalization, and reoperation were evaluated using logistic regression. Readmission within 30 days was calculated using the person-years method and Cox proportional hazards models. Results Overall, 6390 women underwent surgery, including 3852 (60%) via vaginal approach and 2538 (40%) via MISC. Patients undergoing MISC were younger ( P < 0.0001) and less likely to have hypertension ( P = 0.04) or chronic obstructive pulmonary disease ( P = 0.008), with lower American Society of Anesthesiologists scores ( P < 0.0001) and higher preoperative hematocrit ( P = 0.009). The MISC cohort had a lower unadjusted rates of minor complications (3.9% vs 5.6%; P = 0.004), urinary tract infection (3.3% vs 4.8%; P = 0.004), and prolonged hospitalization (5.2% vs 7.9%; P < 0.0001), with a higher rate of nephrologic ( P = 0.01) complications. On multivariable analysis, there were no significant associations of MISC with the risk of 30-day complications (odds ratio [OR], 1.51; 95% confidence interval [CI], 0.92–2.51; P = 0.11), prolonged hospitalization (OR, 0.96; 95% CI, 0.76–1.21; P = 0.72), readmission (HR 1.03; 95% CI, 0.71–1.49; P = 0.88), or reoperation (OR, 0.95; 95% CI, 0.57–1.60; P = 0.86). Conclusions Minimally invasive sacrocolpopexy is associated with similar rates of 30-day complications, prolonged hospitalization, readmission, and reoperation compared with nonmesh vaginal surgeries for apical prolapse.

Oligometastatic prostate cancer has increasingly been recognized as a unique clinical state with therapeutic implications. It has been proposed that patients with oligometastases may have a more indolent course and that outcome may be further improved with metastasis-directed local ablative therapy. In addition, there are differing schools of thoughts regarding whether oligometastases represent isolated lesions—where targeted therapy may render a patient disease free—or whether they coexist with micrometastases, where targeted therapy in addition to systemic therapy is required for maximal clinical impact. As such, the approach to the patient with oligometastatic prostate cancer requires multidisciplinary consideration, with surgery, radiotherapy, and systemic therapy potentially of benefit either singularly or in combination. Indeed, mounting evidence suggests durable disease-free intervals and, in some cases, possibly cure, may be achieved with such a multimodal strategy. However, selecting patients that may benefit most from treatment of oligometastases is an ongoing challenge. Moreover, with the advent of new, highly sensitive imaging technologies, the spectrum based on CT of the abdomen and pelvis and technetium bone scan of localized to oligometastatic to widespread disease has become increasingly blurred. As such, new MRI- and PET-based modalities require validation. As some clinical guidelines advise against routine prostate-specific antigen screening, the possibility of more men presenting with locally advanced or de novo oligometastatic prostate cancer exists; thus, knowing how best to treat these patients may become more relevant at a population level. Ultimately, the arrival of prospective clinical data and better understanding of biology will hopefully further inform how best to treat men with this disease.

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; I 2 = 0%; four studies), M1 ( HR 1.04, 95% CI 0.83–1.29; I 2 = 0%; two studies), or pooled M0 and M1 settings ( HR 1.00, 95% CI 0.92–1.09; I 2 = 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 pN 1M0 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.

420 Background: Cytoreductive nephrectomy (CN) has been associated with significant morbidity, but there is little data identifying patients at increased risk. We evaluated the association of clinicopathologic features with early post-operative complications and prolonged length of stay (pLOS) among CN patients. Methods: We identified 294 patients treated with radical nephrectomy for M1 renal cell carcinoma between 1990 and 2009 at the Mayo Clinic. All complications within 30 days of surgery were reported using standardized methodology according to the Clavien classification. Associations with the presence of any early complication and pLOS (defined as ≥8 days, the top 25th percentile) were evaluated using logistic regression models. Results: Thirty-five (12%) patients experienced at least one early complication and 15 (5%) patients experienced at least one Clavien grade ≥3 early complication. The median LOS was 6 days (IQR 5-7), and 68 (23%) patients had a pLOS. On univariate analysis, liver metastases, symptomatic presentation, intraoperative transfusion, and pathologic nodal stage were significantly associated with both early complications and pLOS (Table). Two multivariate models were constructed. In Model 1 (limited to pre-operative features), only liver metastases (p<0.01) were associated with early complications while liver metastases (p=0.01) and open approach (p=0.02) were associated with pLOS. In Model 2 (all variables included), liver metastases (p=0.01), intraoperative transfusion (p<0.01), and high nuclear grade (p<0.01) were associated with early complications while intraoperative transfusion (p<0.01) and positive nodes (p=0.05) were associated with pLOS. Conclusions: CN was associated with a low incidence of early post-operative complications, particularly Clavien ≥3 complications. Presence of liver metastases and intraoperative transfusion were independently associated with increased risk of both complications and pLOS. [Table: see text]