The Urologist and the Appendix: A Review of Appendiceal Use in Genitourinary Reconstructive Surgery

Recently, genitourinary reconstruction has experienced a renaissance. Over the past several years, there has been an expansion of the literature regarding the use of buccal mucosa for the repair of complex ureteral strictures and other pathologies. The appendix has been an available graft utilized for the repair of ureteral stricture disease and has been infrequently reported since the early 1900s. This review serves to highlight the use of the appendix for reconstruction in urology, particularly focusing on the anatomy and physiology of the appendix, historical use, and current applications, particularly in robotic upper tract reconstruction.

Factors associated with palliative care utilization in advanced and metastatic renal cell carcinoma

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Background: Palliative care (PC) offers various benefits for patient with cancer that include, but are not limited to, decrease in disease-specific symptoms and improvement in functional status. Several oncological guidelines have adopted early integration of PC into oncologic care to improve quality of life among patients with advanced malignancies. However, PC utilization patterns and factors associated with its use in advanced renal cell carcinoma (RCC) remain poorly understood. Methods: Using the National Cancer Database (NCDB), we abstracted patients with Stage III and IV RCC from 2004-2014 and evaluated PC utilization amongst this cohort. Socioeconomic and clinical factors were compared for patient receiving and not receiving PC for advanced RCC. Multivariable logistic regression identified factors that were associated with receipt of PC among the overall cohort and treatment-based cohorts. Results: Among 20,122 and 42,014 patients with Stage III and IV RCC, 329 and 9,317 patients received PC, respectively. From 2004 to 2014, PC utilization was stable at ̃1% for Stage III RCC and minimally increased from 17% to 20% for Stage IV RCC. Multivariable analysis demonstrated that increased comorbidities, insurance status, higher education status, facility location, care at a comprehensive cancer program or integrated network, sarcomatoid histology, and prior treatments significantly increased likelihood of palliative care utilization. We uncover socioeconomic and clinical factors that are associated with receipt of palliative care use in a treatment-specific manner. Conclusions: While PC utilization has minimally increased for Stage IV RCC, there are several demographic, socioeconomic, and clinical factors that predict PC use, especially in a treatment-specific manner, among patients with advanced RCC. Taken together, this suggests the need for more equitable and systematic use of PC among patients with advanced RCC.

Immune Checkpoint Inhibitors in the Management of Urothelial Carcinoma

Urothelial carcinoma is one of the most common cancers in the United States, yet outcomes are historically suboptimal. Since 2016, the approval of five programmed cell death 1 and programmed death-ligand 1 immune checkpoint inhibitors for locally advanced and metastatic urothelial carcinoma has led to improved oncologic outcomes for many patients in the second-line setting. Two checkpoint inhibitors, pembrolizumab and atezolizumab subsequently earned approval for first-fine therapy with restricted indications. More recently, pembrolizumab was approved for bacillus Calmette-Guérin-unresponsive high-risk non-muscle invasive bladder cancer, opening the door for other immune checkpoint inhibitors to be integrated into treatment in earlier disease stages. Recent bacillus Calmette-Guérin shortages have highlighted the need for alternative treatment options for patients with non-muscle invasive bladder cancer. Currently, there are no FDA-approved checkpoint inhibitors for non-metastatic muscle-invasive bladder cancer. Furthermore, many patients are ineligible for standard cisplatin-based chemotherapy regimens. Numerous ongoing clinical trials are employing immune checkpoint inhibitors for muscle-invasive bladder cancer patients in the neoadjuvant, adjuvant, perioperative, and bladder-sparing setting. Although up to 10% of urothelial carcinoma tumors arise in the upper urinary tract, few studies are designed for this population. We highlight the need for more trials designed for patients with upper tract disease. Overall, there are numerous clinical trials investigating the safety and efficacy of immune checkpoint inhibitors in all stages of disease as single-agents and combined with dual-immune checkpoint inhibition, chemotherapy, radiotherapy, and other pharmacologic agents. As the field continues to evolve rapidly, we aim to provide an overview of recent and ongoing immunotherapy clinical trials in urothelial carcinoma.

Treatment of Urethral Stricture Disease in Women: Nonsystematic Review of Surgical Techniques and Intraoperative Considerations

Female urethral strictures are rare, but underdiagnosed pathologies that can cause voiding dysfunction. These strictures are best managed with open reconstruction, as endoscopic treatments have high rates of failure. A flap urethroplasty can be performed with vaginal, labial or bladder tissue. Meanwhile, graft urethroplasties can utilize vaginal, labial, buccal or lingual tissue. It is important to consider the etiology and type of stricture, local vascularity, and prior attempts at repair when selecting the type of repair. Multiple different techniques have been described with theoretical advantages to each one. While some studies have reviewed a few of the reconstructive techniques to treat female urethral strictures, no single study has accounted for each individual technique. In this review, we discuss techniques captured by a number of systematic reviews and other articles. We will herein focus on reviewing and describing each unique technique of reconstruction in the setting of female urethral stricture.

A challenging frontier - the genomics and therapeutics of nonclear cell renal cell carcinoma

PURPOSE OF REVIEW

As molecular profiling of renal cell carcinoma (RCC) continues to elucidate novel targets for nonclear cell histologies, understanding the landscape of these targets is of utmost importance. In this review, we highlight the genomic landscape of nonclear cell RCC and its implications for current and future systemic therapies.

RECENT FINDINGS

Several genomic studies have described the mutational burden among nonclear cell histologies. These studies have highlighted the importance of MET in papillary RCC and led to several clinical trials evaluating the efficacy of MET inhibitors for papillary RCC. The success of immune checkpoint inhibitors, such as ipilimumab and nivolumab, in clear cell RCC has led to ongoing trials evaluating these novel therapeutics in nonclear cell RCC.

SUMMARY

Genomic profiling has allowed for the evaluation of novel targets for nonclear cell RCC. This evolving therapeutic landscape is being explored in promising, ongoing trials that have the potential for changing how nonclear cell RCC is managed.

Trends in the use of administrative databases in urologic oncology: 2000 – 2019

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Background: Administrative databases (AD) provide investigators with nationally representative study populations to answer research questions using large sample sizes. We aimed to quantify the trends and incidence of AD use in published manuscripts in urologic oncology. We examined six commonly used databases: National Cancer Database (NCDB), Surveillance, Epidemiology and End Results Database (SEER), SEER-Medicare (SEER-M), Nationwide Inpatient Sample (NIS), National Surgical Quality Improvement Program (NSQIP), and Premier Healthcare Database (PHD). Methods: A literature review powered by PubMed and DistillerSR from 7/1/2000 to 6/30/2019 aggregated manuscripts that used the aforementioned databases to study a genitourinary malignancy. Included publications were categorized by database used, corresponding author department affiliation, organ, journal, year, and contribution – defined as temporal treatment trends, outcomes and survival, comparative effectiveness research, or cost-effectiveness. Results: There were 2,265 publications across 302 journals that met the inclusion criteria. Between 2000 and 2019 the compound annual growth rate of these publications was 18.7%. SEER contributed most heavily over the study period, with a 14.6% growth rate. NCDB use grew 75.6% annually starting in 2012. Prostate cancer comprised the majority of publications (51.3%), followed by kidney (23.1%) and bladder (22.5%) cancer. Journals publishing these manuscripts had a median impact factor of 3.28 (IQR = 1.84 – 5.74) in 2019. Urologists published 52.5% of AD manuscripts over the study period. Conclusions: Our results show substantial growth in the use of ADs for the study of urologic oncology. Given the broad use of ADs, investigators and specialty societies should advocate for continued improvement in the data captured by them.

Quantifying publication rates and time to publication for urologic oncology podium presentations

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Background: The American Urological Association (AUA) annual meetings serve as a large platform for unpublished research. Among the selected abstracts, podium presentations represent the most impactful submissions. Furthermore, between large meeting attendance and social media promotion, authors can disseminate their findings to a potentially large audience prior to final manuscript publication. While all AUA abstracts do undergo peer review, it is not with the same level of scrutiny that full-length manuscripts receive. Thus, we investigated the publication rates, impact factors, and time to publication of urologic oncology podium presentations at the AUA. Methods: Of 875 podium presentation abstracts from the 2017 AUA Annual meeting, 394 (45.0%) were classified as urologic oncology. We chose 2017 to allow for a three-year window for publication. Abstracts were assessed for subsequent publication between January 1, 2015 and May 31, 2020 with a pre-determined PubMed search protocol. Abstract authors were searched for individually, with key terms being added sequentially until <30 results were generated in PubMed. Each search result was then reviewed until a matching publication was found. Abstracts were deemed published if at least one author of the presented abstract was a manuscript author and/or at least one conclusion in the presented abstract was included in the conclusions of the publication. Publication rates, time to publication, and 2019 journal impact factors were collected. Results: Of 394 urologic oncology podium presentations at the 2017 AUA, 228 (57.9%) focused on prostate cancer, while 81 (20.6%) and 58 (14.7%) presentations focused on kidney and bladder cancer, respectively (table). Overall, 211 (53.6%) podium presentations were published. Median time from presentation to publication was 13.6 months (IQR: 7.5-21.5). There were 9 (2.3%) publications that were published prior to the submission deadline and 57 (14.5%) podium presentations that were published prior to the 2017 AUA meeting. The number of articles published at one, two and three years after the meeting was 90, 170 and 202, respectively. The median journal impact factor of all published works was 3.4 (IQR: 2.7-5.9). Conclusions: While AUA podium presentations disseminate valuable data, approximately half of these presentations were not published in peer-reviewed journals within three years. Therefore, care must be taken when promoting data or adopting new practices based on these presentations alone. [Table: see text]

Delaying surgery for clinical T1b-T2bN0M0 renal cell carcinoma: Oncologic implications in the COVID-19 era and beyond

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Background: During COVID-19, many operating rooms were reserved exclusively for emergent cases. As a result, many elective surgeries for renal cell carcinoma (RCC) were deferred, with an unknown impact on outcomes. Since surveillance is commonplace for small renal masses, we focused on larger, organ-confined, RCCs. Our primary endpoint was pT3a upstaging and our secondary endpoint was overall survival (OS). Methods: We retrospectively abstracted cT1b-cT2bN0M0 RCC patients from the National Cancer Database (NCDB), stratifying them by clinical stage and time from diagnosis to surgery. We selected only those patients who underwent surgery. Patients were grouped by having surgery within <1 month, 1-3 months, or >3 months after diagnosis. Logistic regression models measured pT3a upstaging risk. Kaplan Meier curves and Cox proportional hazards models assessed OS. Results: 29,746 patients underwent partial or radical nephrectomy. Delaying surgery >3 months after diagnosis did not confer pT3a upstaging risk among cT1b (OR=0.90; 95%CI: 0.77–1.05, p = 0.170), cT2a (OR=0.90; 95%CI: 0.69–1.19, p=0.454), or cT2b (OR=0.96; 95%CI:0.62–1.51, p=0.873) masses (Table). In all clinical stage strata, non-clear cell RCCs were significantly less likely to be upstaged (p<0.001). A sensitivity analysis, performed for delays of <1, 1-3, 3-6, and >6 months, also showed no increase in upstaging risk. Conclusions: Delaying surgery up to, and even beyond, 3 months does not significantly increase risk of tumor progression in clinically localized RCC. However, if deciding to delay surgery due to COVID-19, tumor histology, growth kinetics, patient comorbidities, and hospital capacity/resources, should be considered. [Table: see text]

Factors associated with palliative care (PC) utilization in advanced and metastatic renal cell carcinoma (RCC)

297

Background: Palliative care (PC) offers various benefits for patient with cancer that include, but are not limited to, decrease in disease-specific symptoms and improvement in functional status. Several oncological guidelines have adopted early integration of PC into oncologic care to improve quality of life among patients with advanced malignancies. However, PC utilization patterns and factors associated with its use in advanced renal cell carcinoma (RCC) remain poorly understood. Methods: Using the National Cancer Database (NCDB), we abstracted patients with stage III and IV RCC from 2004-2014 and evaluated PC utilization amongst this cohort. Socioeconomic and clinical factors were compared for patient receiving and not receiving PC for advanced RCC. Multivariable logistic regression identified factors that were associated with receipt of PC. Results: We identified 20,122 and 42,014 patients with stage III and IV RCC, respectively. Among this cohort, 329 and 9,317 patients received PC for stage III and IV RCC, respectively. From 2004 to 2014, PC utilization has been stable at ~1% for stage III RCC and has significantly increased from 17% to 20% for stage IV RCC. Multivariable analysis demonstrated that Blacks, income >$48,000, regions outside of Northeast, stage III RCC, and patients that received surgery were less likely to receive PC. Patients that were female, with more comorbidities, uninsured or with government insurance, lower educational status, treated at academic or integrated cancer program, with sarcomatoid histology, receiving systemic therapy were more likely to receive PC. Conclusions: While PC utilization has significantly increased for stage IV RCC, there are several demographic, socioeconomic, and clinical factors that predict PC usage among patients with advanced RCC. Taken together, this suggests the need for more equitable and systematic use of PC among patients with advanced RCC.

Lessons Learned from the COVID-19 Pandemic: A Call for a National Video-Based Curriculum for Urology Residents

The novel coronavirus (COVID-19) pandemic has created many unique challenges in urology resident training. Urologists are operating at a fraction of normal volume to conserve personal protective equipment and prevent viral spread. Many residency programs have organized rotating skeleton crews to perform clinical duties while a portion of residents work from home. In some regions, urology residents have been deployed to emergency rooms, intensive care units, and medical floors to care for COVID-19 patients. With these interruptions in urologic education, many questions remain about how residents will proceed with their clinical and didactic training. During these unprecedented times, many residencies have transitioned their didactic sessions to video-based platforms, allowing educators to reach larger numbers of learners. This perspective addresses how innovative virtual education programs created during the pandemic can be developed into a national video-based curriculum for urology residents, incorporating both didactics and surgical skill training.

Factors Associated With Receipt of Partial Nephrectomy or Minimally Invasive Surgery for Patients With Clinical T1a and T1b Renal Masses: Implications for Regionalization of Care

PURPOSE

To identify factors associated with receipt of partial nephrectomy (PN) and minimally invasive surgery (MIS) in patients with clinical T1 renal cell carcinoma (RCC) using the National Cancer Data Base (NCDB).

METHODS

We queried the NCDB from 2010 to 2014 identifying patients treated surgically for cT1a-bN0M0 RCC. Logistic regression was used to examine associations between socioeconomic, clinical, and treatment factors, and receipt of MIS or PN within the T1 patient population.

RESULTS

Our cohort included 69,694 patients (cT1a, n = 44,043; cT1b, n = 25,651). For cT1a tumors, 70% of patients received PN and 65% underwent MIS. For cT1b tumors, 32% of patients received PN and 62% underwent MIS. cT1a and cT1b patients with household income < $62,000, without private insurance, and treated outside academic centers were less likely to receive MIS or PN. cT1a patients traveling > 31 miles were more likely to undergo MIS. For both cT1a/b, the farther a patient traveled for treatment, the more likely a PN was performed.

CONCLUSION

Data showed an increase in utilization of MIS and PN from 2010 to 2014. However, patients in the lowest socioeconomic groups were less likely to travel and were more likely to receive more invasive treatments. On the basis of these findings, additional research is needed into how regionalization of RCC surgery affects treatment disparities.

Dissecting the role of lymphadenectomy in the management of renal cell carcinoma: past, present, and future

Lymph node involvement in renal cell carcinoma (RCC) portends a poor prognosis. However, the role of lymph node dissection (LND) at the time of tumor resection is not fully understood. Conflicting data have been published regarding the survival implications of LND during RCC surgery, and the optimal patient population for which LND might be beneficial has yet to be identified. Based on recent data characterizing the outcomes of node-positive RCC, some have advocated for revising the current staging guidelines to better reflect these findings. Given the paucity of high-quality evidence supporting or refuting the routine use of LND in RCC, further research is needed to shed light on this important topic. There are a number of ongoing clinical trials evaluating the role of perioperative (neoadjuvant and adjuvant) systemic therapy, which include patients with node-positive RCC, and will serve to guide changes in treatment practices for this patient population moving forward.

The human microbiome and genitourinary malignancies

The human microbiome contains a vast network of understudied organisms that have an intimate role in our health and wellness. These microbiomes differ greatly between individuals, creating what may be thought of as a unique and dynamic microbial signature. Microbes have been shown to have various roles in metabolism, local and systemic inflammation, as well as immunity. Recent findings have confirmed the importance of both the gut and urinary microbiomes in genitourinary malignancies. Numerous studies have identified differences in microbial signatures between healthy patients and those with urologic malignancies. The microbiomes have been shown to contain microbes that may contribute to the etiology of disease state as well as yield information in regard to a person’s health and their responsiveness to certain drugs such as immune checkpoint inhibitors (ICIs) and tyrosine kinase inhibitors (TKIs). Less well understood are the effects of antibiotics on oncologic outcomes in such treatment courses. This review will explore our current understanding and advancements in the field of microbiome research and discuss its intimate association with genitourinary diseases including bladder cancer, prostate cancer, and kidney cancer. With a better understanding of the association between the microbiome and genitourinary malignancy, further investigation may produce reliable predictors of disease, prognostic indicators as well as therapeutic targets.

Delaying surgery for clinical T1b-T2bN0M0 renal cell carcinoma: Oncologic implications in the COVID-19 era and beyond

Purpose

During COVID-19, many operating rooms were reserved exclusively for emergent cases. As a result, many elective surgeries for renal cell carcinoma (RCC) were deferred, with an unknown impact on outcomes. Since surveillance is commonplace for small renal masses, we focused on larger, organ-confined RCCs. Our primary endpoint was pT3a upstaging and our secondary endpoint was overall survival.

Materials and methods

We retrospectively abstracted cT1b-T2bN0M0 RCC patients from the National Cancer Database, stratifying them by clinical stage and time from diagnosis to surgery. We selected only those patients who underwent surgery. Patients were grouped by having surgery within 1 month, 1–3 months, or >3 months after diagnosis. Logistic regression models measured pT3a upstaging risk. Kaplan Meier curves and Cox proportional hazards models assessed overall survival.

Results

A total of 29,746 patients underwent partial or radical nephrectomy. Delaying surgery >3 months after diagnosis did not confer pT3a upstaging risk among cT1b (OR = 0.90; 95% CI: 0.77–1.05, P = 0.170), cT2a (OR = 0.90; 95% CI: 0.69–1.19, P = 0.454), or cT2b (OR = 0.96; 95% CI: 0.62–1.51, P = 0.873). In all clinical stage strata, nonclear cell RCCs were significantly less likely to be upstaged (P <0.001). A sensitivity analysis, performed for delays of <1, 1–3, 3–6, and >6 months, also showed no increase in upstaging risk.

Conclusion

Delaying surgery up to, and even beyond, 3 months does not significantly increase risk of tumor progression in clinically localized RCC. However, if deciding to delay surgery due to COVID-19, tumor histology, growth kinetics, patient comorbidities, and hospital capacity/resources, should be considered.

Factors associated with clinical trial participation for patients with prostate cancer

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Background: Clinical trials are critical for the development of new treatment paradigms for Prostate Cancer (PCa). The primary aim of this study was to characterize the factors associated with clinical trial participation for patients with PCa. The secondary objective was to examine survival outcomes in the clinical trial and control cohorts. Methods: The National Cancer Database (NCDB) was queried for patients with PCa who were coded as having enrolled in a clinical trial. Trial patients were matched in a 1:8 ratio to controls based on clinical stage. Sociodemographic variables were compared between the two groups and univariate and multivariate logistic regression models evaluated factors associated with clinical trial participation. Kaplan-Meier product limit estimate was used to compare overall survival (OS) between the groups. Results: From 2004-2015, 495 patients enrolled in clinical trials were included for analysis. The mean age of trial patients was 63.2 compared to 66.4 in the matched cohort (p < 0.0001). More patients in the trial group had a Charlson-Deyo comorbidity score of 0 (89.3% vs. 82.1%, p = 0.0002). On multivariate analysis, patients who traveled between 50-250 miles (OR 1.59; 95%CI 1.15-2.19, p = 0.005) or came from a zip code where greater than 93% of the population has a high school degree (OR 4.97; 95%CI 2.89-8.54, p < 0.0001) were more likely to participate in a clinical trial. There was no association between race and insurance status on clinical trial participation. Median OS was not significantly different among clinical trial participants than the control cohort (120.9 months vs. not reached, p = 0.928). Conclusions: In this contemporary analysis of PCa patients from a national hospital registry database, we found that certain patient sociodemographic factors remain associated with clinical trial participation, though clinical trial participants do not seem to experience a difference in OS. Further work, both qualitative and quantitative, is necessary to identify clinical and non-clinical barriers to research participation in order to improve the validity of PCa trials.

Impact of pathologic lymph node-positive renal cell carcinoma on survival in patients without metastasis: Evidence in support of expanding the definition of stage IV kidney cancer

BACKGROUND

Stage III renal cell carcinoma (RCC) encompasses both lymph node-positive (pT1-3N1M0) and lymph node-negative (pT3N0M0) disease. However, prior institutional studies have indicated that among patients with stage III disease, those with lymph node disease have worse oncologic outcomes and experience survival that is similar to that of patients with American Joint Committee on Cancer (AJCC) stage IV disease. The objective of the current study was to validate these findings using a large, nationally representative sample of patients with kidney cancer.

METHODS

Patients with AJCC stage III or stage IV RCC were identified using the National Cancer Data Base (NCDB). Patients were categorized as having lymph node-positive stage III (pT1-3N1M0), lymph node-negative stage III (pT3N0M0), or stage IV metastatic (pT1-3 N0M1) disease. Cox proportional hazards models compared outcomes while adjusting for comorbidities. Kaplan-Meier estimates illustrated relative survival when comparing staging groups.

RESULTS

A total of 8988 patients met the inclusion criteria, with 6587 patients classified as having lymph node-negative stage III disease, 2218 as having lymph node-positive stage III disease, and 183 as having stage IV disease. Superior survival was noted among patients with lymph node-negative stage III disease, but similar survival was noted between patients with lymph node-positive stage III and stage IV RCC, with 5-year survival rates of 61.9% (95% confidence interval [95% CI], 60.3%-63.4%), 22.7% (95% CI, 20.6%-24.9%), and 15.6% (95% CI, 11.1%-23.8%), respectively.

CONCLUSIONS

Current RCC staging systems group pT1-3N1M0 and pT3N0M0 disease as stage III disease. However, the results of the current validation study suggest the need for further stratification and even placement of patients with pT1-3N1M0 disease into the stage IV category. Staging that accurately reflects oncologic prognosis may help clinicians better counsel and select patients who might derive the most benefit from lymphadenectomy, adjuvant systemic therapy, more rigorous imaging surveillance, and clinical trial participation.

Urologic oncology surgery during COVID-19: a rapid review of current triage guidance documents

The Coronavirus Disease 2019 pandemic placed urologic surgeons, and especially urologic oncologists, in an unprecedented situation. Providers and healthcare systems were forced to rapidly create triage schemas in order to preserve resources and reduce potential viral transmission while continuing to provide care for patients. We reviewed United States and international triage proposals from professional societies, peer-reviewed publications, and publicly available institutional guidelines to identify common themes and critical differences. To date, there are varying levels of agreement on the optimal triaging of urologic oncology cases. As the need to preserve resources and prevent viral transmission grows, prioritizing only high priority surgical cases is paramount. A similar approach to prioritization will also be needed as nonemergent cases are allowed to proceed in the coming weeks. While these decisions will often be made on a case-by-case basis, more nuanced surgeon-driven consensus guidelines are needed for the near future.

The patient-urologist relationship in the COVID-19 era and beyond

The COVID-19 pandemic has impeded health care delivery and may permanently transform the patient-urologist relationship. Here we examine the long-term implications of COVID-19 pandemic on this relationship and explore the impact it has on urologic care in the post-COVID-19 era.

To Be or "Node" to Be: Nodal Disease and the Role of Lymphadenectomy in the Treatment of Renal Cell Carcinoma

Lymph node involvement in renal cell carcinoma (RCC) correlates with poor oncologic outcomes. However, current RCC staging guidelines may not fully reflect the survival impact of lymph node positive disease. Recent data demonstrates that nodal disease has significant impact on survival and modifications to current staging guidelines have been proposed. Lymph node dissection (LND) at the time of surgical intervention for RCC remains controversial. While clinical trial data have demonstrated conflicting evidence for LND, some institutional studies suggests that carefully selected patients at high-risk for recurrence may benefit from LND. Prospectively, clinical trials are examining treating nodal disease and disease at high-risk of recurrence in the neoadjuvant and/or adjuvant setting at the time of nephrectomy. These promising trials are poised, if successful, to influence the treatment paradigm for localized RCC.

Association of lymph node count and survival after primary retroperitoneal lymph node dissection (RPLND) for testicular nonseminomatous germ cell tumor (NSGCT)

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Background: RPLND for clinical stage (CS) I & IIA/B NSGCT has both staging and therapeutic implications. Single center studies have reported on the impact of lymph node count on outcome after 1° RPLND for men with NSGCT. However, this has yet to be corroborated in a nationally representative dataset. Methods: Using the National Cancer Database, patients who received a 1° RPLND from 2004-2014 for CS I & IIA/B NSGCT were identified. The analytic cohort was stratified according to LN count (≤20, 21-40, and > 40 LNs). Sociodemographic characteristics were compared among groups. The Kaplan-Meier method was calculated and pairwise comparisons performed. Based on sensitivity analyses to determine LN cutoff that impacts survival, subsequent analysis compared patients with ≤20 and > 20 LNs resected. Multivariate analysis using stepwise regression was used to determine factors associated with receipt of an RPLND with > 20 LNs resected. Results: Of 1,376 men who received 1° RPLND for Stage I or IIA/B NSGCT, 35.6%, 27.4%, and 14% had ≤20, 21-40, and > 40 LNs resected, respectively. LN count was associated with overall survival (OS), with 95%, 97%, and 98% 8-year OS for men with LN count ≤20, 21-40, and > 40 LNs, respectively. OS in men with ≤20 vs 21-40 (p = 0.018) and > 40 LNs (p = 0.042) resected differed significantly. However, no significant difference was observed when 21-40 vs > 40 LNs were resected (p = 0.677). Therefore, subsequent analysis compared those who had ≤20 and > 20 LN resected, and OS between these two groups differed significantly (Figure). Multivariate analysis demonstrated that patients with private insurance, surgery having been performed at an academic center or in the Northeast, and those with pT2 disease were more likely to have > 20 LNs resected at the time of RPLND. Conclusions: Lymph node count after 1° RPLND for NSGCT is significantly associated with overall survival, with more favorable survival seen in those who receive an RPLND with > 20 LNs resected when compared to ≤20 LNs.

Accuracy of clinical staging in stage I and IIa/b testicular nonseminomatous germ cell tumors (NSGCT) and implications on survival

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Background: Clinical stage (CS) dictates treatment in men with testicular cancer and its inaccuracy may affect clinical outcome. We evaluate the accuracy of clinical staging in men with CS I and CS IIA/B NSGCT and explore the implications of inaccurate staging on overall survival. Methods: Using the National Cancer Database (NCDB), we abstracted all patients with clinical Stage I-IIB NSGCT who received a primary retroperitoneal lymph node dissection (RPLND) from 2004 to 2014. Primary RPLND was defined as RPLND performed for CS I-IIB patients without prior chemotherapy. CS was cross-tabulated with pathologic nodal staging data. Survival for patients who were accurately staged (CS I patients with pN0 disease, CS IIA patients with pN1 disease) and for CS I patients found to have pN+ disease was determined using the Kaplan Meier method. Results: 1,639 CS I-IIB patients underwent primary RPLND. Among CS I patients, 23% had upstaging of disease (pN1-3), of which 13.9%, 8%, and 1.1% were pN1, pN2, and pN3, respectively (Table). Pathologic N1-3 disease was higher in CS IB vs. CS IA patients (35.1% vs 14.2%, respectively). Of CS IIA patients, 23.1% had pN0 disease, while 44.8%, 13.4%, and 1.3% had pN1, pN2, and pN3 disease, respectively. At a median follow-up of 56.3 months, mortality rates for CS I patients who had pN1, pN2, and pN3 disease were 2.8%, 4%, and 9.1%, respectively, and < 1% for men with pN0 disease. 10-year overall survival for CS1 patients was significantly less favorable if upstaged to pN2 or pN3 disease after RPLND vs. pN0 or pN1. Conclusions: Nearly a quarter of patients with CS I NSGCT are under-staged and are found to have pN1-3 after RPLND. Nodal disease burden is associated with survival. Novel imaging techniques and biomarkers are needed to improve the sensitivity of detecting NSGCT. [Table: see text]

Trends in the use of administrative databases in urologic oncology: 2000-2019

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Background: Administrative databases (AD) provide investigators with nationally representative study populations to answer research questions using large sample sizes. Their use has significantly grown over the past 20 years, particularly in urologic oncology. We aimed to quantify the trends and incidence of AD use in published manuscripts in urologic oncology. We examined six commonly used databases: National Cancer Database (NCDB), Surveillance, Epidemiology and End Results Database (SEER), SEER-Medicare (SEER-M), Nationwide Inpatient Sample, National Surgical Quality Improvement Program, and Premier Healthcare Database. Methods: A literature review powered by PubMed and DistillerSR from 2000 to 2019 aggregated manuscripts that used the aforementioned databases to study a genitourinary malignancy. Included publications were categorized by database used, corresponding author department affiliation, organ, journal, year, and contribution - defined as temporal treatment trends, outcomes and survival, comparative effectiveness research, and cost-effectiveness. Results: There were 2265 publications across 307 journals that met the inclusion criteria. Between 2000 and 2019 the compound annual growth rate of these publications was 18.7%. SEER contributed most heavily over the study period, with a 14.6% growth rate. NCDB use grew 75.6% annually starting in 2012. Prostate cancer comprised the majority of publications (51.3%), followed by kidney (23.1%) and bladder (22.5%) cancer. Journals publishing these manuscripts had a median impact factor of 2.78 (range 0.36 - 223.68) in 2018. Urologists published 52.5% of AD manuscripts over the study period, with epidemiologists and radiation oncologists publishing 18.2% and 10.6%, respectively. Conclusions: Our results show substantial growth in the use of ADs for the study of genitourinary oncology. The increased use is likely multi-factorial and may be driven by increasing competition to secure funding, ability to answer questions previously limited by sample size, and improved quality of databases. Given the broad use of ADs, investigators and specialty societies should advocate for continued improvement in the data captured by them.