Trimodal therapy vs radical cystectomy in patients with muscle-invasive bladder cancer: a systematic review and meta-analysis of comparative studies

OBJECTIVE

To perform a systematic review and meta-analysis of trials comparing trimodal therapy (TMT) and radical cystectomy (RC), evaluating differences in terms of oncological outcomes, quality of life, and costs.

MATERIALS AND METHODS

In July 2023, a literature search of multiple databases was conducted to identify studies analysing patients with cT2-4 N any M0 muscle-invasive bladder cancer (MIBC; Patients) receiving TMT (Intervention) compared to RC (Comparison), to evaluate survival outcomes, recurrence rates, costs, and quality of life (Outcomes). The primary outcome was overall survival (OS). Secondary outcomes were cancer-specific survival (CSS) and metastasis-free survival (MFS). Hazard ratios (HRs) were used to analyse survival outcomes according to different treatment modalities and odds ratios were used to evaluate the likelihood of receiving each type of treatment according to T stage.

RESULTS

No significant difference in terms of OS was observed between RC and TMT (HR 1.07, 95% confidence interval [CI] 0.81-1.4; P = 0.6), even when analysing radiation therapy regimens ≥60 Gy (HR 1.02, 95% CI 0.69-1.52; P = 0.9). No significant difference was observed in CSS (HR 1.12, 95% CI 0.79-1.57, P = 0.5) or MFS (HR 0.88, 95% CI 0.66-1.16; P = 0.3). The mean cost of TMT was significantly higher than that of RC ($289 142 vs $148 757; P < 0.001), with greater effectiveness in terms of cost per quality-adjusted life-year. TMT ensured significantly higher general quality-of-life scores.

CONCLUSION

Trimodal therapy appeared to yield comparable oncological outcomes to RC concerning OS, CSS and MFS, while providing superior patient quality of life and cost effectiveness.

Symptomatic and functional recovery after transurethral resection of bladder tumor: Data from ecological momentary symptom assessment

OBJECTIVES

To quantitatively describe the nature, severity, and duration of symptoms and functional impairment during recovery from transurethral resection of bladder tumors.

MATERIALS AND METHODS

All patients scheduled for transurethral resection were approached for enrollment in a text-message based ecological momentary symptom assessment platform. Nine patients reported outcomes were measured 7 days before surgery and on postoperative days 1, 2, 3, 5, 7, 10, and 14 using a 5-point Likert scale. Self-reported degree of hematuria was collected using a visual scale. Clinical data was collected via retrospective chart review.

RESULTS

A total of 159 patients were analyzed. Postoperative symptoms were overall mild, with the largest differences from baseline to postoperative day 1 seen in dysuria (median 0/5 vs. 3/5) and ability to work (median 5/5 vs. 4/5). Recovery was generally rapid, with 76% of patients reporting ≥4/5 agreement with the statement "I feel recovered from surgery" by postoperative day 2, although 15% of patients reported persistently lower levels of agreement on postoperative day 10 or 14. Patients undergoing larger resections (≥2cm) did take longer to return to baseline in multiple symptom domains, but the difference of medians vs. those undergoing smaller resections was less than 1 day across all domains. Multivariable analysis suggested that receiving perioperative intravesical chemotherapy was associated with longer time to recovery. 84% of patients reported clear yellow urine by postoperative day 3.

CONCLUSION

In this population, hematuria and negative effects on quality of life resulting from transurethral resection of bladder tumors were generally mild and short-lived, although a small number of patients experienced longer recoveries.

Population Estimates of Ovarian Cancer Risk in a Cohort of Patients with Bladder Cancer

BACKGROUND AND OBJECTIVE

The rationale for oophorectomy during female cystectomy is not adequately supported. The co-occurrence and timing of bladder cancer (BC) and ovarian cancer (OC) in females harboring OC germline mutations remain unclear. Our objective was to determine the frequency and temporal occurrence of OC germline variants among females with BC.

METHODS

We used genetic and phenotypic data from the UK Biobank (UKB). The study cohort was defined using ICD-10/ICD-9 codes for BC and further stratified to identify 1347 females. Analysis was restricted to variants with high/moderate impact for initial regression. ClinVar was used to interpret pathogenicity. Pathogenic/likely pathogenic (P/LP) variants were assessed by age of presentation, family history, and concomitant malignancies. Statistical analysis was performed using UKB DNAnexus JupyterLab and RStudio.

KEY FINDINGS AND LIMITATIONS

Some 3.4% of the patients had at least one of 15 variants for OC. CHEK2 and PALB2 mutations represented the highest ratio of overall/pathogenic variants (15.8% and 6.6%). Although females with P/LP OC mutations had a higher risk of OC, diagnosis of OC preceded BC by 11.3 yr (±12.5 yr) in the group with mutations and by 15.6 yr (±11.3 yr) in the group without mutations. The group with P/LP variants had higher rates of maternal (14.63% vs 8.12%; p = 0.04) and sibling (9.76% vs 3.98%; p = 0.02) breast cancer and of maternal colon cancer (9.76% vs 4.21%), and lower maternal life expectancy (75.34 vs 68.15 yr; p = 0.0014). UKB provides limited staging/treatment history and its exome sequencing platform may miss variants or provide insufficient coverage for genotyping.

CONCLUSIONS AND CLINICAL IMPLICATIONS

This study provides evidence against routine oophorectomy for reducing OC risk in females with BC. The results highlight that the development of OC occurred 11 yr before diagnosis of BC for patients with OC mutations and 15 yr before diagnosis of BC for patients without OC mutations.

PATIENT SUMMARY

Although removal of the ovaries in women with bladder cancer is common, no studies have shown that this strategy has a benefit. Our study of women diagnosed with bladder cancer who had genetic mutations associated with ovarian cancer shows that their risk of developing ovarian cancer after bladder cancer is low. These findings provide evidence against removal of the ovaries when the bladder is being removed as treatment for bladder cancer.

Real-time estimation of nephron activity with a linear measurement system (RENAL-MS) predicts postoperative estimated glomerular filtration rate

OBJECTIVE

To determine whether a simple point-of-care measurement system estimating renal parenchymal volume using tools ubiquitously available could be used to replace nuclear medicine renal scintigraphy (NMRS) in current clinical practice to predict estimated glomerular filtration rate (eGFR) after nephrectomy by estimating preoperative split renal function.

PATIENTS AND METHODS

We performed a retrospective review of patients who underwent abdominal cross-sectional imaging (computed tomography/magnetic resonance imaging) and mercaptoacetyltriglycine (MAG3) NMRS prior to total nephrectomy at a single institution. We developed the real-time estimation of nephron activity with a linear measurement system (RENAL-MS) method of estimating postoperative renal function via the following technique: renal parenchymal volume of the removed kidney relative to the remaining kidney was estimated as the product of renal length and the average of six renal parenchymal thickness measurements. The utility of this value was compared to the utility of the split renal function measured by MAG3 for prediction of eGFR and new onset Stage 3 chronic kidney disease (CKD) at ≥90 days after nephrectomy using uni- and multivariate linear and logistic regression.

RESULTS

A total of 57 patients met the study criteria. The median (interquartile range [IQR]) age was 69 (61-80) years. The median (IQR) pre- and postoperative eGFR was 74 (IQR 58-90) and 46 (35-62) mL/min/1.73 m2 , respectively. [Correction added on 29 December 2023, after first online publication: The data numbers in the preceding sentence have been corrected.] Correlations between actual and predicted postoperative eGFR were similar whether the RENAL-MS or NMRS methods were used, with correlation using RENAL-MS being slightly numerically but not statistically superior (R = 0.82 and 0.76; P = 0.138). Receiver operating characteristic curve analysis using logistic regression estimates incorporating age, sex, and preoperative creatinine to predict postoperative Stage 3 CKD were similar between RENAL-MS and NMRS (area under the curve 0.93 vs. 0.97). [Correction added on 29 December 2023, after first online publication: The data numbers in the preceding sentence have been corrected.] CONCLUSION: A point-of-care tool to estimate renal parenchymal volume (RENAL-MS) performed equally as well as NMRS to predict postoperative eGFR and de novo Stage 3 CKD after nephrectomy in our population, suggesting NMRS may not be necessary in this setting.

Molecular Characterization of TFE3-Rearranged Renal Cell Carcinoma: A Comparative Study With Papillary and Clear Cell Renal Cell Carcinomas

TFE3-rearranged renal cell carcinoma (rRCC) is a rare subtype of renal cell carcinomas belonging to the MiT family translocation RCC. To further elucidate the co-alterations that occur along with TFE3 fusions in rRCC, we characterized the genomic, transcriptional, and immune landscapes in comparison to clear cell (ccRCC) and papillary renal cell carcinoma (pRCC). Next-generation sequencing of RNA (whole transcriptome) and DNA (592-gene panel or whole exome) for rRCC (N = 20), pRCC (N = 20), and ccRCC samples (N = 392) was performed. Patients with rRCC were significantly younger and more frequently female (median 44.5 years, 75.0% female) as compared with patients with pRCC (68.5 years, 25.0% female; P < .05) and ccRCC (62.0 years, 27.8% female; P < .05). A total of 8 unique fusion partners were observed, including a novel fusion with SRRM2::TFE3 in 2 patients. ccRCC exhibited significantly higher mutation rates of VHL (0% rRCC, 0% pRCC, 78.7% ccRCC; P < .05) and PBMR1 (0% rRCC, 5.0% pRCC, 49.4% ccRCC; P < .05). The genomic landscapes of rRCC were sparse with no mutations occurring with a prevalence higher than 10% other than pTERT (18.2% rRCC, 0% pRCC, 9.2% ccRCC). rRCC were associated with significantly less M1 macrophages (0.8%) as compared with pRCC (1.4%) and ccRCC (2.7%) (P < .05), suggesting a cold tumor-immune microenvironment. However, rRCC were more commonly PD-L1+ (rRCC 50%, pRCC 19.0%, ccRCC 12.2%; P < .05). Gene set enrichment analysis showed that rRCC are enriched in genes related to oxidative phosphorylation when compared with both ccRCC and pRCC. Despite having a colder tumor-immune microenvironment than pRCC and ccRCC, increased PDL1+ rates in rRCC suggest a potential benefit from immune checkpoint inhibitor therapy.

Transition to Value-based Healthcare: Development, Implementation, and Results of an Optimal Surgical Care Framework at a National Cancer Institute-designated Comprehensive Cancer Center

BACKGROUND

The continued rise in healthcare expenditures has not produced commensurate improvements in patient outcomes, leading US healthcare stakeholders to emphasize value-based care. Transition to such a model requires all team members to adopt a new strategic and organizational framework.

OBJECTIVE

To describe and report a strategy for the implementation of a novel patient-centered value-based "optimal surgical care" (OSC) framework, with validation and cost analysis in kidney surgery.

DESIGN, SETTING, AND PARTICIPANTS

An observational study of care episodes at a single institution from 2014 to 2019 was conducted.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Multidisciplinary teams defined OSC by core and procedure-specific metrics using a combination of provider-based ("bottom-up") and "clinical leadership"-based ("top-down") strategies. Baseline OSC rates across were established, while identifying proportions of OSC achieved by coefficient of variation (CV) in total direct costs. Multivariable linear regression comparing cost between OSC and non-OSC encounters was performed, adjusting for patient characteristics.

RESULTS AND LIMITATIONS

An analysis of 30 261 perioperative care episodes was performed. Following the implementation of an OSC framework, there was an increase in OSC rates across all procedure buckets using core (25%) and procedure-specific (26%) metrics. Among the tumors tested, kidney cancer surgical episodes held the highest OSC rate improvement (67%) with lowest variability in cost (CV 0.5). OSC was associated with significant total cost savings across all tumor types after adjusting for inflation (p < 0.05). Compared with non-OSC episodes, a significant reduction in the cost ratio of OSC was noted for renal surgery (p < 0.01), with estimated costs savings of $2445.87 per OSC encounter.

CONCLUSIONS

Institutional change directing efforts toward optimizing surgical care and emphasizing value rather than focusing solely on expense reduction is associated with improved outcomes, while potentially reducing costs. The strategy for implementation requires serial performance analyses, engaging and educating providers, and continuous ongoing adjustments to achieve durable results.

PATIENT SUMMARY

In this study, we report our strategy and outcomes for transitioning to a value-based healthcare model using a novel "optimal surgical care" framework at a National Cancer Institute-designated comprehensive cancer center. We observed an increase in optimal surgical care episodes across all specialties after 5 yr, with a potential associated reduction in cost expenditure. We conclude that the key to a successful and sustained transition is the implementation strategy, focusing on continual review and provider engagement.

Diabetes, Obesity, and Pathological Upstaging in Renal Cell Carcinoma: Results From a Large Multi-institutional Consortium

PURPOSE

We sought to determine whether clinical risk factors and morphometric features on preoperative imaging can be utilized to identify those patients with cT1 tumors who are at higher risk of upstaging (pT3a).

MATERIALS AND METHODS

We performed a retrospective international case-control study of consecutive patients treated surgically with radical or partial nephrectomy for nonmetastatic renal cell carcinoma (cT1 N0) conducted between January 2010 and December 2018. Multivariable logistic regression models were used to study associations of preoperative risk factors on pT3a pathological upstaging among all patients, as well as subsets with those with preoperative tumors ≤4 cm, renal nephrometry scores, tumors ≤4 cm with nephrometry scores, and clear cell histology. We also examined association with pT3a subsets (renal vein, sinus fat, perinephric fat).

RESULTS

Among the 4,092 partial nephrectomy and 2,056 radical nephrectomy patients, pathological upstaging occurred in 4.9% and 23.3%, respectively. Among each group independent factors associated with pT3a upstaging were increasing preoperative tumor size, increasing age, and the presence of diabetes. Specifically, among partial nephrectomy subjects diabetes (OR=1.65; 95% CI 1.17, 2.29), male sex (OR=1.62; 95% CI 1.14, 2.33), and increasing BMI (OR=1.03; 95% CI 1.00, 1.05 per 1 unit BMI) were statistically associated with upstaging. Subset analyses identified hilar tumors as more likely to be upstaged (partial nephrectomy OR=1.91; 95% CI 1.12, 3.16; radical nephrectomy OR=2.16; 95% CI 1.44, 3.25).

CONCLUSIONS

Diabetes and higher BMI were associated with pathological upstaging, as were preoperative tumor size, increased age, and male sex. Similarly, hilar tumors were frequently upstaged.

Preference Elicitation and Treatment Decision-Making Among Men Diagnosed With Prostate Cancer: Randomized Controlled Trial Results of Healium

BACKGROUND

Elicitation of patients' preferences is an integral part of shared decision-making, the recommended approach for prostate cancer decision-making. Existing decision aids for this population often do not specifically focus on patients' preferences. Healium is a brief interactive web-based decision aid that aims to elicit patients' treatment preferences and is designed for a low health literate population.

OBJECTIVE

This study used a randomized controlled trial to evaluate whether Healium, designed to target preference elicitation, is as efficacious as Healing Choices, a comprehensive education and decision tool, in improving outcomes for decision-making and emotional quality of life.

METHODS

Patients diagnosed with localized prostate cancer who had not yet made a treatment decision were randomly assigned to the brief Healium intervention or Healing Choices, a decision aid previously developed by our group that serves as a virtual information center on prostate cancer diagnosis and treatment. Assessments were completed at baseline, 6 weeks, and 3 months post baseline, and included decisional outcomes (decisional conflict, satisfaction with decision, and preparation for decision-making), and emotional quality of life (anxiety/tension and depression), along with demographics, comorbidities, and health literacy.

RESULTS

A total of 327 individuals consented to participate in the study (171 were randomized to the Healium intervention arm and 156 were randomized to Healing Choices). The majority of the sample was non-Hispanic (272/282, 96%), White (239/314, 76%), married (251/320, 78.4%), and was on average 62.4 (SD 6.9) years old. Within both arms, there was a significant decrease in decisional conflict from baseline to 6 weeks postbaseline (Healium, P≤.001; Healing Choices, P≤.001), and a significant increase in satisfaction with one's decision from 6 weeks to 3 months (Healium, P=.04; Healing Choices, P=.01). Within both arms, anxiety/tension (Healium, P=.23; Healing Choices, P=.27) and depression (Healium, P=.001; Healing Choices, P≤.001) decreased from baseline to 6 weeks, but only in the case of depression was the decrease statistically significant.

CONCLUSIONS

Healium, our brief decision aid focusing on treatment preference elicitation, is as successful in reducing decisional conflict as our previously tested comprehensive decision aid, Healing Choices, and has the added benefit of brevity, making it the ideal tool for integration into the physician consultation and electronic medical record.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05800483; https://clinicaltrials.gov/study/NCT05800483.

Clinical Performance of Technetium-99m-Sestamibi SPECT/CT Imaging in Differentiating Oncocytic Tumors From Renal Cell Carcinoma in Routine Clinical Practice

PURPOSE

Technetium-99m-sestamibi single-photon emission CT/x-ray CT is an emerging clinical tool to differentiate oncocytic tumors from renal cell carcinomas. We report data from a large institutional cohort of patients who underwent technetium-99m-sestamibi scans during evaluation of renal masses.

MATERIALS AND METHODS

Patients who underwent technetium-99m-sestamibi single-photon emission CT/x-ray CT between February 2020 and December 2021 were included in the analysis. Scans were defined as "hot" for oncocytic tumor when technetium-99m-sestamibi uptake was qualitatively equivalent or higher between the mass of interest and normal renal parenchyma, suggesting oncocytoma, hybrid oncocytic/chromophobe tumor, or chromophobe renal cell carcinoma. Demographic, pathological, and management strategy data were compared between "hot" and "cold" scans. For individuals who underwent diagnostic biopsy or extirpative procedures, the concordance between radiological findings and pathology was indexed.

RESULTS

A total of 71 patients (with 88 masses) underwent technetium-99m-sestamibi imaging with 60 (84.5%) patients having at least 1 "cold" mass on imaging and 11 (15.5%) patients exhibiting only "hot" masses. Pathology was available for 7 "hot" masses, with 1 biopsy specimen (14.3%) being discordant (clear cell renal cell carcinoma). Five patients with "cold" masses underwent biopsy. Out of 5 biopsied masses, 4 (80%) were discordant oncocytomas. Of the extirpated specimens, 35/40 (87.5%) harbored renal cell carcinoma and 5/40 (12.5%) yielded discordant oncocytomas. In sum, 20% of pathologically sampled masses that were "cold" on technetium-99m-sestamibi imaging still harbored oncocytoma/hybrid oncocytic/chromophobe tumor/chromophobe renal cell carcinoma.

CONCLUSIONS

Further work is needed to define utility of technetium-99m-sestamibi in real-world clinical practice. Our data suggest this imaging strategy is not yet ready to replace biopsy.

Sequential intravesical gemcitabine-docetaxel vs. bacillus Calmette-Guerin (BCG) in the treatment of non-muscle invasive bladder cancer: A preliminary cost-effectiveness analysis

INTRODUCTION

Treatment naïve patients with high-risk non-muscle invasive bladder cancer (NMIBC) are treated with bacillus Calmette-Guérin (BCG) therapy as the standard of care. Recently, intravesical sequential gemcitabine-docetaxel in the BCG-naïve setting was shown to be well-tolerated and effective, raising the possibility of a new first line intravesical therapy. Cost effectiveness of this intervention remains unknown; therefore, we designed a cost effectiveness study evaluating BCG vs. sequential gemcitabine-docetaxel in patients with high risk NMIBC.

METHODS

Using TreeAgePro 2019 software, we developed a Markov model to evaluate BCG vs. gemcitabine-docetaxel from the U.S. Medicare perspective with a 2-year time horizon. Model probabilities and utilities were derived from published literature. Direct costs were obtained from Medicare cost databases. Our primary outcomes were effectiveness (measured in quality adjusted life years [QALYs]), cost and the incremental cost-effectiveness ratio with a willingness to pay threshold of $100,000.

RESULTS

Our results indicate that while both treatments resulted in similar QALYs of 1.76, the mean costs per patient at 2 years were $12,363 and $7,090 for BCG and gemcitabine-docetaxel, respectively. Therefore, the BCG strategy was dominated by the gemcitabine-docetaxel strategy as it was equally effective and less costly. One way sensitivity analyses were completed and gemcitabine-docetaxel remained a cost-effective strategy.

CONCLUSIONS

The findings of this preliminary cost-effectiveness analysis are novel in that they highlight a well tolerated, efficacious drug that is less expensive than the traditional gold standard therapy. In modern medicine, we are more often challenged by agents with marginally increased efficacy but at significantly higher costs; gemcitabine-docetaxel represents a rare entity which is a success for both patients and healthcare systems alike.

Partial versus radical nephrectomy for complex renal mass: multicenter comparative analysis of functional outcomes (Rosula collaborative group)

BACKGROUND

Utility of partial nephrectomy (PN) for complex renal mass (CRM) is controversial. We determined the impact of surgical modality on postoperative renal functional outcomes for CRM.

METHODS

We retrospectively analyzed a multicenter registry (ROSULA). CRM was defined as RENAL Score 10-12. The cohort was divided into PN and radical nephrectomy (RN) for analyses. Primary outcome was development of de-novo estimated glomerular filtration rate (eGFR)<45 mL/min/1.73 m². Secondary outcomes were de-novo eGFR<60 and ΔeGFR between diagnosis and last follow-up. Cox proportional hazards was used to elucidate predictors for de-novo eGFR<60 and <45. Linear regression was utilized to analyze ΔeGFR. Kaplan-Meier Analysis (KMA) was performed to analyze 5-year freedom from de-novo eGFR<60 and <45.

RESULTS

We analyzed 969 patients (RN=429/PN=540; median follow-up 24.0 months). RN patients had lower BMI (P<0.001) and larger tumor size (P<0.001). Overall postoperative complication rate was higher for PN (P<0.001), but there was no difference in major complications (Clavien III-IV; P=0.702). MVA demonstrated age (HR=1.05, P<0.001), tumor-size (HR=1.05, P=0.046), RN (HR=2.57, P<0.001), and BMI (HR=1.04, P=0.001) to be associated with risk for de-novo eGFR<60 mL/min/1.73 m². Age (HR=1.03, P<0.001), BMI (HR=1.06, P<0.001), baseline eGFR (HR=0.99, P=0.002), tumor size (HR=1.07, P=0.007) and RN (HR=2.39, P<0.001) were risk factors for de-novo eGFR<45 mL/min/1.73 m². RN (B=-10.89, P<0.001) was associated with greater ΔeGFR. KMA revealed worse 5-year freedom from de-novo eGFR<60 (71% vs. 33%, P<0.001) and de-novo eGFR<45 (79% vs. 65%, P<0.001) for RN.

CONCLUSIONS

PN provides functional benefit in selected patients with CRM without significant increase in major complications compared to RN, and should be considered when technically feasible.

Between the Hammer and Anvil: Resolution of unresectable muscle invasive bladder cancer in a renal transplant patient after cessation of immunosuppressive therapy

Multimodal immunosuppression is the backbone of modern solid organ transplantation. However, immunosuppression itself is an independent risk factor for post-transplant malignancy. Although skin malignancy is the most common post-transplant malignancy, genitourinary cancers are also described. Dose reduction or cessation of immunosuppression has a beneficial role in the management of transplant patients with concomitant malignancy, but only limited data exist with respect to bladder cancer (BCa). We describe a patient who developed metastatic muscle invasive bladder cancer (MIBC) after diseased donor kidney transplant (DDKT) who was successfully managed with dose reduction and elimination of an immunosuppression regimen.

Point of care parenchymal volume analyses to estimate split renal function and predict functional outcomes after radical nephrectomy

Accurate prediction of new baseline GFR (NBGFR) after radical nephrectomy (RN) can inform clinical management and patient counseling whenever RN is a strong consideration. Preoperative global GFR, split renal function (SRF), and renal functional compensation (RFC) are fundamentally important for the accurate prediction of NBGFR post-RN. While SRF has traditionally been obtained from nuclear renal scans (NRS), differential parenchymal volume analysis (PVA) via software analysis may be more accurate. A simplified approach to estimate parenchymal volumes and SRF based on length/width/height measurements (LWH) has also been proposed. We compare the accuracies of these three methods for determining SRF, and, by extension, predicting NBGFR after RN. All 235 renal cancer patients managed with RN (2006-2021) with available preoperative CT/MRI and NRS, and relevant functional data were analyzed. PVA was performed on CT/MRI using semi-automated software, and LWH measurements were obtained from CT/MRI images. RFC was presumed to be 25%, and thus: Predicted NBGFR = 1.25 × Global GFR_Pre-RN × SRF_{Contralateral}. Predictive accuracies were assessed by mean squared error (MSE) and correlation coefficients (r). The r values for the LWH/NRS/software-derived PVA approaches were 0.72/0.71/0.86, respectively (p < 0.05). The PVA-based approach also had the most favorable MSE, which were 120/126/65, respectively (p < 0.05). Our data show that software-derived PVA provides more accurate and precise SRF estimations and predictions of NBGFR post-RN than NRS/LWH methods. Furthermore, the LWH approach is equivalent to NRS, precluding the need for NRS in most patients.

Abstract 5891: Identification of intratumor pathogens from single-cell RNA sequencing, cellular dysfunction and immune response

Introduction: We aim to assess the transcriptomic features of the single cell level to identify intracellular pathogens in patients with high grade bladder cancer.

Methodology: CellRanger and Alevin were utilized to extract cell barcodes and unique molecular identifiers. After quality control, reads were aligned with human reference genome with Kraken2 for species level identification of bacteria. Contaminants (false positives) were removed based on higher frequencies and negative control (reference control) of 2,491 sterile cell experiments. Seuret Findmarkers, scIntegrate, and scDensity Plot were utilized to normalize the data, cluster the cells, and calculate markers in each cluster of differentially expressed genes between the two conditions. We focused our analysis on Pseudomonas aeruginosa due to high urogenital virulence, and immunomodulation capabilities by pattern recognition receptors and inflammasome.

Results: We identified presence of three over-represented intracellular taxa in tissue biopsies of patients with BC compared to healthy controls (after false discovery rate correction and cross validation of contaminants). Patients with history of high-grade BC demonstrated increased presence of Aeromonas (175,473 reads, 54%), Pseudomonas (75,002 reads, 26.73%), and Bacillus (15,410 reads, 5.49%) in their tissue samples, not visualized in healthy controls (counts &lt;10). Among 8,324 cells (across 7 patients), classical CD14+ monocyte subtype was most likely to be exposed to Pseudomonas species (4150/5069, 81.8%), followed by non-classical CD16+ monocytes (722/1040, 69.4%), and CD8+ Tcells (348/680, 51.1%). (Figure 1A-C). Relative gene expression level between exposed and non-exposed monocytes demonstrated total 25 upregulated genes, with increased expression GNBL21 (aka: RACK1, log10 4.1), MALAT1(log10 3.7), TCEB2(log10 2.9) (increasing proliferation, migration, and reduction of cell autophagy) compared to non-infected, and normal controls. Pseudomonas involvement of non-monocyte cells (CD8+, CD4+Th17, CD4+ naïve) was associated with disease progression (2/5 patients), as well as increased expression of IFI6/27(interferon alpha inducible protein 6 &27), ITAC (interferon inducible T cell alpha-chemoattractant).

Conclusion: Altogether, our analysis depicted the distribution of intracellular bacteria not previously recognized within tumor microenvironment utilizing scRNAseq, and revealed overexpression of RACK1 in Pseudomonas positive cells, associated with apoptosis resistance.

Citation Format: Laura Bukavina, Mohit Sindhani, Henkel Valentine, Daniel Ranti, Kirtishri Mishra, Alexander Kutikov, Shilpa Gupta, John Sfakiano, Mahmoud Ghannoum, Mauricio Retuerto, Andres Correa, Robert Uzzo, Philip Abbosh. Identification of intratumor pathogens from single-cell RNA sequencing, cellular dysfunction and immune response [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 5891.

Abstract 5141: Macrophage transcriptomic signature validation in scRNA seq and overall survival differences in urothelial carcinoma

Introduction: While the prognostic value of immune system biomarkers has been well explored, role of cancer associated macrophages in bladder cancer(BC) is unclear due to lack of consistent results, coupled with tissue nonspecific transcriptomic signature.

Methodology: Data acquisition from 3,936 patients of The Cancer Genome Atlas (TCGA) in addition to Gene Expression Omninus (GEO) data sets GSE13507, GSE16945, GSE48277, GSE32894, GSE149582, as well as European Genotype Phenotype EGAS000001004507 was obtained. Tumor associated macrophages M1 and M2 were defined utilizing 188 and 159 gene expression profiles via xCell computational algorithm. To obtain bladder tissue residence macrophage signatures, scRNA seq was performed on tissue collected from surgical resection of 5 HG bladder cancer patients and 2 healthy controls. CellRanger software package with default parameters was utilized giving a total of 8,068 cells. FindAllMarkers was utilized for integration of DEG genes (cancer vs control) among the cluster and identification of BC macrophage specific markers. Endpoint of OS were measured in months from the time of cystectomy to follow up.

Results: Surprisingly, presence of M1 infiltration was found to be associated with improved OS in two out of eight cohorts only (GSE32894, GSE70691, p&lt;0.001), while the remainder detected no significant difference. Similarly, no association with OS was detected among all 8 cohorts with M2 infiltration. To improve our understanding of tissue specific markers of macrophage population in bladder, we then analyzed macrophage clusters detected within scRNAseq of BC patients compared to healthy. Gene ontology enrichment analysis of functions within tumor specific macrophages demonstrated an exaggerated expression of mTORC1 signaling, PI3K/AKT/mTOR signaling, TGF beta and EGF receptor pathways compared to non-cancer controls. Reanalysis of 22 tissue specific markers for M1/M2 infiltration showed no difference in any of the 8 cohorts with M1 high vs low infiltration. Similarly, addition of M2 infiltration as predictive marker yielded no further associations with OS in all but one cohort (GSE32894, p=0.00041), where high M2 tumor presence was associated with improved OS.

Conclusion: Our study represents the largest TAMs evaluation of BC across 8 cohorts with additional scRNA seq exploration of tissue specific signatures, demonstrating no association with OS in bladder cancer.

Citation Format: Laura Bukavina, Spencer Bell, Daniel Geynisman, Ilaha Isali, Daniel Ranti, John Sfakianos, Henkel Valentine, Adam Calaway, Alexander Kutikov, Andres Correa, Robert Uzzo, Lee Ponsky, Philip Abbosh. Macrophage transcriptomic signature validation in scRNA seq and overall survival differences in urothelial carcinoma. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 5141.

Cost-effectiveness analysis of arterial catheter insertion on robotic-assisted laparoscopic prostatectomy

INTRODUCTION

To evaluate the utility, outcomes, and cost of arterial line placement in a single institution cohort of patients undergoing robotic-assisted laparoscopic prostatectomy (RALP).

MATERIALS AND METHODS

A retrospective chart review was performed at a large tertiary care center from July 2018 through January 2021. Hospital costs and cost-effective analysis was performed on patients with and without arterial line placement. Means with standard deviations were used to report continuous variables, while numbers and percentages were utilized to describe categorical variables. T-tests and Chi-square tests compared categorical and continuous variables across study cohorts, respectively. Multivariable analyses were used to examine the association between A-line placement and outcomes as mentioned above adjusting for the effect of other co-variables.

RESULTS

Among the 296 included patients, 138 (46.6%) had arterial lines. No preoperative patient characteristic predicted arterial line placement. Rates of complications and re-admissions were not statistically significant between the two groups. Arterial line use was associated with higher volumes of intraoperative fluid administration, as well as a longer hospital length of stay. Total cost and operative time did not significantly differ between cohorts, but arterial line placement increased variability of these factors.

CONCLUSION

The use of arterial lines in patients undergoing RALP is not necessarily guideline-driven and does not decrease the rate of perioperative complications. However, it is associated with longer length of stay and increases variability in charge. These data show that the surgical team and anesthesia team should critically evaluate the need for arterial line placement in patients undergoing RALP.

Pathological and Clinical Outcomes in a Large Surveillance and Intervention Cohort of Radiographically Cystic Renal Masses

PURPOSE

We evaluated oncologic risks in a large cohort of patients with radiographic cystic renal masses who underwent active surveillance or intervention.

MATERIALS AND METHODS

A single-institutional database of 4,340 kidney lesions managed with either active surveillance or intervention between 2000-2020 was queried for radiographically cystic renal masses. Association of radiographic tumor characteristics and high-grade pathology was evaluated.

RESULTS

We identified 387 radiographically confirmed cystic lesions in 367 patients. Of these, 247 were resected (n=240) or ablated (n=7; n=247, 203 immediate vs 44 delayed intervention). Pathologically, 23% (n=56) demonstrated high-grade pathology. Cystic features were explicitly described by pathology in only 18% (n=33) of all lesions and in 7% (n=4) of high-grade lesions. Of the intervention cohort, African American race, male gender, and Bosniak score were associated with high-grade pathology (P < .05). On active surveillance (n=184), Bosniak IV lesions demonstrated faster growth rates than IIF and III lesions (2.7 vs 0.6 and 0.5 mm/y, P ≤ .001); however, growth rates were not associated with high-grade pathology (P = .5). No difference in cancer-specific survival was identified when comparing intervention vs active surveillance at 5 years (99% vs 100%, P = .2). No difference in recurrence was observed between immediate intervention vs delayed intervention (P > .9).

CONCLUSIONS

A disconnect between "cystic" designation on imaging and pathology exists for renal lesions. Over 80% of radiographic Bosniak cystic lesions are not described as "cystic" on pathology reports. More than 1 in 5 resected cystic renal lesions demonstrated high-grade disease. Despite this finding, judiciously managed active surveillance ± delayed intervention is a safe and effective management option for most radiographic cystic renal masses.

Partial or radical nephrectomy for complex renal mass: a comparative analysis of oncological outcomes and complications from the ROSULA (Robotic Surgery for Large Renal Mass) Collaborative Group

PURPOSE

To compare outcomes of robotic-assisted partial nephrectomy (RAPN) and minimally invasive radical nephrectomy (MIS-RN) for complex renal masses (CRM).

METHODS

We conducted a retrospective multicenter analysis of CRM patients who underwent MIS-RN and RAPN. CRM was defined as RENAL score 10-12. Primary outcome was overall survival (OS). Secondary outcomes were cancer-specific survival (CSS), recurrence, and complications. Multivariable analysis (MVA) and Kaplan-Meier Analysis (KMA) were used to analyze functional and survival outcomes for RN vs. PN by pathological stage.

RESULTS

926 patients were analyzed (MIS-RN = 437/RAPN = 489; median follow-up 24.0 months). MVA demonstrated lack of transfusion (HR = 1.63, p = 0.005), low-grade (HR = 1.18, p = 0.018) and smaller tumor size (HR = 1.05, p < 0.001) were associated with OS. Younger age (HR = 1.01, p = 0.017), high-grade (HR = 1.18, p = 0.017), smaller tumor size (HR = 1.05, p < 0.001), and lack of transfusion (HR = 1.39, p = 0.038) were associated with CSS. Increasing tumor size (HR = 1.18, p < 0.001), high-grade (HR = 3.21, p < 0.001), and increasing age (HR = 1.02, p = 0.009) were independent risk factors for recurrence. Type of surgery was not associated with major complications (p = 0.094). For KMA of MIS-RN vs. RAPN for pT1, pT2 and pT3, 5-year OS was 85% vs. 88% (p = 0.078); 82% vs. 80% (p = 0.442) and 84% vs. 83% (p = 0.863), respectively. 5-year CSS was 98% for both procedures (p = 0.473); 94% vs. 92% (p = 0.735) and 91% vs. 90% (p = 0.581). 5-year non-CSS was 87% vs. 93% (p = 0.107); 87% for pT2 (p = 0.485) and 92% for pT3 for both procedures (p = 0.403).

CONCLUSION

RAPN in CRM is not associated with increased risk of complications or worsened oncological outcomes when compared to MIS-RN and may be preferred when clinically indicated.

The role of cytoreductive nephrectomy in the immuno-oncological therapy era

PURPOSE OF REVIEW

Cytoreductive nephrectomy has had a variable role in the management of metastatic renal cell carcinoma (RCC) through the different systemic therapy eras. Initially felt to be beneficial with interferon, the utility of cytoreductive nephrectomy was called into question in the tyrosine kinase inhibitor (TKI) era. However, with the advent of immunotherapy for metastatic RCC, the role of cytoreductive nephrectomy continues to be debated. This study sought to evaluate the recent literature and discuss cytoreductive nephrectomy within the context of an improved systemic therapy era.

RECENT FINDINGS

The literature that exists on the use of cytoreductive nephrectomy with immunotherapy is retrospective in nature and largely derived from large, institutional databases. Although smaller, single-institution articles exist and provide more granular data, issues concerning selection bias and unmeasured confounders persist. Overall, the available studies demonstrate that patient selection is paramount, and cytoreductive nephrectomy should be reserved for patients with no more than one risk factor, those requiring palliation of local symptoms and for those patients with stable, low volume disease or with a complete response following systemic therapy exposure.

SUMMARY

The optimal use of cytoreductive nephrectomy in metastatic RCC remains unclear, but certain subgroups of patients, on evaluation of post hoc and retrospective data, seem to benefit from surgical intervention.

No difference in renal function outcomes for patients with oncocytoma managed with active surveillance vs. partial nephrectomy

OBJECTIVES

To investigate the difference in renal function outcomes for patients with oncocytomas undergoing active surveillance (AS) vs. partial nephrectomy (PN).

METHODS

We reviewed our institutional database for patients with biopsy/surgically confirmed oncocytoma from 2000-2020. The primary outcome was to assess for differences in renal function outcomes in patients undergoing AS vs. PN. We fit two generalized estimating equation (GEE) with an interaction term between follow up time and management strategy to predict 1) mean eGFR for patients managed with AS and PN and 2) the probability of progression to CKD stage III or greater.

RESULTS

We identified 114 eligible patients, of which 32 were managed with AS. Median follow-up was 21 months vs. 44 months for PN vs. AS patients. AS patients tended to be older (median: 72 years vs. 65 years, P<0.001) and have lower baseline renal function (median: eGFR: 71 mL/min/1.73m2 vs. 82 mL/min/1.73m2, P<0.001) compared with PN patients. Renal mass size from baseline imaging was similar between patients undergoing PN vs. AS (2.8 cm vs. 2.9 cm, P=0.634). For patients undergoing PN vs. AS, there was not a significant difference in predicted longitudinal eGFR (-0.079, 95% CI -0.18-0.023, P=0.129) or predicted probability of progression to CKD stage III or greater (OR: 0.61, 95% CI: 0.16-2.33, P=0.47).

CONCLUSIONS

In our institutional dataset, patients undergoing AS or PN with an oncocytoma had similar long-term renal function outcomes. Given similar renal function outcomes in patients undergoing AS and PN, surgery should remain reserved for select patients with oncocytomas.

A phase II trial of risk-enabled therapy after initiating neoadjuvant chemotherapy for bladder cancer (RETAIN)

438

Background: Cisplatin-based neoadjuvant chemotherapy (NAC) followed by cystectomy or chemoradiation is the standard of care for urothelial carcinoma (UC) patients with MIBC. Both cystectomy and chemoradiation have short and long-term toxicity and QOL implications. Mutations in DNA damage repair/response genes are associated with pathologic downstaging after NAC. We hypothesized that a combination of biomarker selection and clinical staging would identify patients prospectively for a cystectomy or chemoradiation avoidance algorithm. Methods: We conducted a single-arm, phase II, non-inferiority trial (NCT02710734) to evaluate a risk-adapted approach for MIBC. Patients with cT2-T3N0M0 UC underwent NAC with accelerated MVAC. Pre-NAC TURBT specimens were sequenced (Caris) for mutations in ATM, ERCC2, FANCC or RB1. Patients with ≥ 1 mutations and no clinical evidence of disease by restaging TUR, urine cytology and imaging post-NAC began pre-defined active surveillance (AS). Remaining patients underwent bladder-directed therapy. The primary endpoint was metastasis-free survival (MFS) at 2 years for the entire cohort. The risk-adapted approach would be declared non-inferior to the standard of care if the lower bound of an exact 1-sided 95% CI for MFS was > 64%. The study required 70 patients with a 4.5% type I error and 81.6% power. Results: 71 (ITT) patients were enrolled over 33 months at four academic centers. Median age was 70 years (47-83), 74% were male, 92% Caucasian, 81% ECOG PS 0 and 79% cT2. 90% completed 3 cycles of MVAC with 17% grade 3-4 TRAEs. In the ITT population, 33 (46%) had a relevant mutation and 26 (37%) began AS. With a median follow-up of 41 months, 47 patients (66%) are metastasis-free (CI 54%-77%). The 2-year MFS for the ITT patients (primary endpoint) was 72% (lower bound exact 1-sided 95% CI=62%). On post hoc analysis, the 2-year MFS was 65% in the AS group (CI 44%-83%) and 76% (CI 60%-87%) in the remaining patients (P=0.42). In the AS group, 18 patients (69%) had some UC recurrence, 8 had a cystectomy, 2 chemoradiation, and 13 (50%) are metastasis-free with an intact bladder. Of the 10 patients (38%) on AS who developed metastatic disease, 9 recurred with localized disease first. The 2-year OS is 83% (CI 72%-90%) and 89% (CI 68%-96%) in the ITT and AS groups, respectively. Associations between mutation presence and MFS or UC recurrence were not observed. Conclusions: The 72% 2-year MFS rate in this MIBC cohort treated with a risk-adapted approach did not satisfy the pre-specified non-inferiority condition. 38% of AS patients developed metastatic disease, with most patients first recurring locally in the bladder. With a median follow-up of 41 months, although 50% of AS patients have been able to avoid cystectomy without metastatic disease, further refinement of this approach is necessary. Clinical trial information: NCT02710734 .

A Systematic Review of Published Clinical Trials in the Systemic Treatment of Adrenocortical Carcinoma: An Initiative Led on Behalf of the Global Society of Rare Genitourinary Tumors

Adrenocortical carcinoma (ACC) is a very rare endocrine cancer and is associated with a poor prognosis. There is a paucity of randomized clinical trials for this rare disease. We aimed to perform a systematic review of the literature on systemic therapy options in different stages of ACC. A systematic review was performed using Pubmed and Embase databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A total of 24 trials of systemic therapy in the treatment of ACC were identified and included in this review. Only one clinical trial in the adjuvant setting was identified, the negative phase III trial ADIUVO, which tested mitotane in low to intermediate-risk ACC patients. In the treatment of advanced ACC, cisplatin-based chemotherapy was evaluated in small and non-randomized phase II trials, and response rates ranged from 21% to 53.5%. The phase III trial FIRM-ACT compared etoposide, doxorubicin, cisplatin, and mitotane versus treatment with streptozotocin and mitotane and showed no difference in OS, but higher RR and PFS were reported with the multi-drug regimen. Six clinical trials of immunotherapy and seven studies of targeted therapy in advanced ACC were included, with modest activity and no phase 3 trials were identified. Treatment recommendations of ACC are based on retrospective and small studies with limited systemic therapy options. International and multi-center collaboration is essential to expand clinical research and improve outcomes.

Mindfulness-based stress reduction for men on active surveillance for prostate cancer and their spouses: Design and methodology of a randomized controlled trial

BACKGROUND

Although active surveillance (AS) is an increasingly adopted treatment paradigm for management of very low risk prostate cancer, many men and their partners face a variety of AS-related psychosocial stressors. Stressors may include anxiety and fear of progression, which may negatively affect short- and long-term psychosocial adjustment and influence early withdrawal from AS in order to seek definitive therapies such as surgery or radiation. Here we describe the protocol for an NCI-funded trial, which seeks to examine the efficacy of mindfulness training compared with a time/attention-matched health promotion control condition in a geographically generalizable sample of men on AS and their spouses.

METHODS

Using a randomized, controlled, partially double-blinded study design, this study involves the delivery of 8 weeks of standardized mindfulness training (MBSR; mindfulness-based stress reduction) and patient reported outcomes over a 12-month period (proposed enrollment of 80 men on AS and spouses), compared with a health promotion control (proposed enrollment of 80 men on AS and spouses) that has been matched for time and attention. Baseline (T1) measures (e.g., anxiety, fear of progression, quality of life) are administered just prior to randomization to the two study arms, followed by repeated assessments at 2 months (T2), 6 months (T3) and 12 months (T4).

CONCLUSION

This study has the potential to offer men and their partners on AS with important educational and self-regulatory skills to better cope and adjust with known stressors related to being placed on this protocol.

Role of Gut Microbiome in Neoadjuvant Chemotherapy Response in Urothelial Carcinoma: A Multi-Institutional Prospective Cohort Evaluation

Treatment with neoadjuvant chemotherapy (NAC) in muscle invasive bladder cancer (MIBC) is associated with clinical benefit in urothelial carcinoma. While extensive research evaluating role of tumor mutational expression profiles and clinicopathologic factors into chemoresponse has been published, the role of gut microbiome (GM) in bladder cancer in chemoresponse has not been thoroughly evaluated. A working knowledge of the microbiome and its effect on all forms of cancer therapy in BC is critical. Here we examine gut microbiome of bladder cancer patients undergoing NAC. Overall, there was no significant difference in alpha and beta diversity by responder status. However, analysis of fecal microbiome samples showed that a higher abundance of Bacteroides within both institutional cohorts during NAC was associated with residual disease at the time of radical cystectomy regardless of chemotherapy regimen. Group community analysis revealed presence of favorable microbial subtypes in complete responders. Finally, fecal microbial composition outperformed clinical variables in prediction of complete response (AUC 0.88 vs AUC 0.50), however, no single microbial species could be regarded as a fully consistent biomarker. Microbiome-based community signature as compared to single microbial species is more likely to be associated as the link between bacterial composition and NAC response.

Characterization of Changes in Penile Microbiome Following Pediatric Circumcision

BACKGROUND

While microbiome and host regulation contribute independently to many disease states, it is unclear how circumcision in pediatric population influences subsequent changes in penile microbiome.

OBJECTIVE

Our study aims to analyze jointly paired taxonomic profiles and assess pathways implicated in inflammation, barrier protection, and energy metabolism.

DESIGN, SETTING, AND PARTICIPANTS

We analyzed 11 paired samples, periurethral collection, before and after circumcision, to generate microbiome and mycobiome profiling. Sample preparation of 16S ribosomal RNA and internal transcribed spacer sequencing was adapted from the methods developed by the National Institutes of Health Human Microbiome Project.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We obtained the predictive functional attributes of the microbial communities between samples using Silva-Tax4Fun and the Greengenes-Phylogenetic Investigation of Communities by Reconstruction of Unobserved States (PICRUSt) approach. The predictive functioning of the microbial communities was determined by linearly combining the normalized taxonomic abundances into the precomputed association matrix of Kyoto Encyclopedia of Genes and Genomes orthology reference profiles.

RESULTS AND LIMITATIONS

Several notable microbiome and mycobiome compositional differences were observed between pre- and postcircumcision patients. Pairwise comparisons across taxa revealed a significant decrease (p < 0.05, false discovery rate corrected) of microbiome organisms (Clostridiales, Bacteroidales, and Campylobacterales) and mycobiome (Saccharomycetales and Pleosporales) following circumcision. A total of 14 pathways were found to differ in abundance between the pre- and postcircumcision groups (p < 0.005, false discovery rate <0.1 and linear discriminant analysis score >3; five enriched and nine depleted). The pathways reduced after circumcision were mostly involved with amino acid and glucose metabolism, while pathways prior to circumcision were enriched in genetic information processing and transcription processes. As expected, enrichment in methyl-accepting chemotaxis protein, an integral membrane protein involved in directed motility of microbes to chemical cues and environment, occurred prior to circumcision, while the filamentous hemagglutinin pathway (a strong immunogenic protein) was depleted after circumcision CONCLUSIONS: Our results offer greater insight into the host-microbiota relationship of penile circumcision and may serve to lay the groundwork for future studies focused on drivers of inflammation, infection, and oncogenesis.

PATIENT SUMMARY

Our study showed a significant reduction in bacteria and fungi after circumcision, particularly anaerobic bacteria, which are known to be potential inducers of inflammation and cancer. This is the first study of its kind showing the changes in microbiome after circumcision, and some of the changes that occur in healthy infants after circumcision that may explain the differences in cancer and inflammatory disorders in adulthood.

The Phenomenon of "Therapeutic" Nodal Yield at Cystectomy for Bladder Cancer: Do Not Discount the Will Rogers Effect

While multiple mechanisms have been hypothesized to explain the therapeutic effect of lymph node (LN) yield in patients with urothelial cell carcinoma (UCC) undergoing radical cystectomy (RC), the effect of stage migration, commonly known as the Will Rogers effect, is often discounted. We reviewed the National Cancer Database for patients with UCC undergoing RC with pathologically node-negative (pN0) disease from 2004 to 2016. We tested for an adjusted association between LN yield and overall survival using multivariable Cox proportional-hazard models. Median survival was estimated using the Kaplan-Meier method. We identified 19 939 patients with pN0 UCC treated with RC. After adjustment, patients in the highest quantile for LN yield (≥26 LNs) had a 34% lower risk of death in comparison to patients in the lowest quantile (≤5 LNs). As we increased the threshold for LN yield for dichotomization from >5 to >15 to >25 LNs, median survival increased from 83 to 95 to 103 mo. The pN0 group with higher LN yield appeared to live longer in this analysis owing to the mathematical artifact of how patients are indexed. Resection of a greater number of negative LNs will lead to higher fidelity for pN0 cohorts being evaluated, as the likelihood of contamination by pN+ cases that were missed will be lower.

Patient summary

A strategy to dissect a high number of lymph nodes in patients undergoing removal of their bladder for bladder cancer can be associated with side effects, and the benefit in terms of cancer control or survival remains uncertain. Urologists and their patients should engage in shared decision-making and consider the risks and benefits of more extensive lymph node dissection during surgery.

Optimal Dissemination of Scientific Manuscripts via Social Media: A Prospective Trial Comparing Visual Abstracts Versus Key Figures in Consecutive Original Manuscripts Published in European Urology

Visual abstracts (VAs) are graphical representations of the key findings in manuscripts and have been adopted by many journals to improve content dissemination via social media. We sought to assess whether VAs, compared to key figures (KFs), increased reader engagement via social media using articles published in European Urology. We prospectively randomized 200 consecutive new publications to representation on Twitter and Instagram using either a VA (n = 99) or a KF (n = 101). Randomization was stratified by prostate cancer content. The primary outcome was Twitter impressions. Secondary outcomes included Twitter total engagements, link clicks, likes, and retweets, as well as Instagram likes. Analysis of covariance was conducted using the stratification variable as a covariate. We found that Twitter impressions were greater for tweets containing VAs compared to KFs (8385 vs 6882; adjusted difference 1480, 95% confidence interval [CI] 434-2526; p = 0.006). VA use was also associated with more retweets and likes (p < 0.002), but fewer full-article link clicks than KFs (60 vs 105, adjusted difference 45, 95% CI 21-70; p = 0.0004). The choice between VA and KF should depend on the relative value given to impressions versus full-article link clicks. PATIENT SUMMARY: We found that use of a visual abstract increases the social media reach of new urology articles when compared to key figures from the manuscript, but was associated in a significantly lower click-through rate. In the increasingly virtual world of academic medicine, these findings may assist authors, editors, and publishers with dissemination of new research.

A Seat at the Table: The Correlation Between Female Authorship and Urology Journal Editorial Board Membership

BACKGROUND

Gender disparities in editorial board composition exist across a variety of surgical subspecialties.

OBJECTIVE

To investigate temporal variation in gender representation on the editorial boards of urology journals and assess the relationship between editorial board composition and female authorship.

DESIGN, SETTING, AND PARTICIPANTS

We analyzed female authorship and editorial board composition between 2002 and 2020 among eight high-impact urology journals. Female publication status was assessed using publication records retrieved from PubMed. Editorial board information was manually extracted and titles were grouped for comparison as Editor-in-Chief, mid-level editor, and consulting editors.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Female representation across different editorial levels was analyzed via hierarchical logistic regression with additional terms to test for between-journal differences in overall representation and change over time. The relationship between representation on editorial boards and as publication authors was assessed at the journal level via correlation.

RESULTS AND LIMITATIONS

Eight journals and 49 412 articles were analyzed. No female has held the title of Editor-in-Chief for any of these eight journals in 18 yr. Significant growth was seen for mid-level editors, whereas no growth was seen for consulting editors. Neurourology and Urodynamics and Journal of Sexual Medicine had significantly higher than average female editorial board representation (p < 0.05). Across the eight journals, there was a statistically significant correlation between the proportion of overall female authors and female editors (r = 0.93, 95% confidence interval 0.65-0.99). For all journals, the proportion of female contributing authors is greater than the proportion of female editorial board members.

CONCLUSIONS

Women in urology represent a small but increasing presence as editorial board members. Clear differences exist between journals, potentially attributable to specialty-specific demographics. Despite increasing representation, no female has ever been appointed Editor-in-Chief for any of the eight journals evaluated. At the journal-specific level, a positive correlation was observed between female editorial staff and female authorship. Given the implication of both academic authorship and editorial board assignment on academic advancement, actionable changes are outlined to guide improvement in gender diversity at the journal level.

PATIENT SUMMARY

Females are under-represented on the editorial boards for urology journals, although some roles have seen growth over time. Moreover, female editorial board membership is associated with representation of females among article authors. Gender disparities in both are noteworthy because they affect career paths and contribute to the gender gap in urology.

The Delayed Nephrogram: Point-of-care Quantitative Measurement, Validation as an Indicator of Obstruction, and Novel Use as a Predictor of Renal Functional Impairment

BACKGROUND

The diagnostic value of delayed nephrograms on contrast-enhanced computed tomography has not been studied rigorously.

OBJECTIVE

To develop a method for quantitatively assessing delayed and diminished nephrograms (DDNs) easily at the point of care and to assess the association of DDNs with renal obstruction and renal function.

DESIGN, SETTING, AND PARTICIPANTS

Data were reviewed from 76 patients who underwent a contrast-enhanced computed tomography scan within 30 days of a technetium-99m mercaptoacetyltriglycine diuretic renal scintigraphy (MAG3-DRS) which showed at least one kidney to have normal drainage (T1/2 <10 min) between 2010 and 2021 at a tertiary academic center.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Attenuations of the renal cortex and medulla were measured using circular regions of interest. These attenuations were compared between kidneys to compute several measures of DDN in the kidney with a greater concern for obstruction. Renal parenchymal volume and anterior-posterior renal pelvis diameter (APD) were estimated using simple linear measurements. Inter-rater reliability was computed using the intraclass correlation coefficient (ICC), correlations were computed using Spearman's R, and the relationships between DDN, APD, and renal function of the subject kidney were estimated using linear regression.

RESULTS AND LIMITATIONS

Measures of DDN were highly reliable between raters (ICC 0.71-0.87). DDN was almost always associated with prolonged drainage on MAG3-DRS (90-100%); however, 33-52% of patients with prolonged drainage on MAG3-DRS had no appreciable DDN, depending on the measure of the DDN chosen. All measures of DDN were associated with decreased renal function (<0.001). APD did not significantly predict renal function when controlling for a DDN.

CONCLUSIONS

DDNs on contrast-enhanced computed tomography are associated with renal obstruction and can easily and accurately be quantified at the point of care. A DDN is more closely associated with renal dysfunction than renal pelvic dilation and therefore may be useful in assessing the severity of upper tract obstruction.

PATIENT SUMMARY

In this report, we confirm that a "delayed nephrogram", a classic x-ray finding thought to be associated with kidney blockage, is associated with blockage of the affected kidney. Furthermore, we show that a delayed nephrogram indicates that the affected kidney is not functioning as well as we would expect for a normal kidney of the same size. Since the severity of a delayed nephrogram predicts this decreased function better than the degree of dilation of the kidney, which is a different measurement often used to measure the severity of kidney blockage, the delayed nephrogram may be a better way of measuring the severity of kidney blockage in clinical practice.

The Power of Hashtags in Social Media: Lessons Learnt from the Urology Tag Ontology Project

Standardisation of hashtags for urologic diseases in the Urology Tag Ontology (UTO) project has facilitated more efficient filtering of social media content. Hashtags must be recognisable and easy to understand. The UTO list should be expanded to include hashtags for urologic procedures and the hashtags could be used on social media platforms other than Twitter to reach a wider audience.

Splenosis in patient undergoing robotic assisted laparoscopic radical prostatectomy

Splenosis is a benign condition that is often found in patients with a history of trauma. Most cases are intra-abdominal due to direct seeding of surrounding structures. We report a case of splenosis in the pelvis found in a 59-year-old male during a robotic prostatectomy.

Association of tumor size and surgical approach with oncological outcomes and overall survival in patients with adrenocortical carcinoma

OBJECTIVES

To investigate the association of surgical approach with outcomes in patients with adrenocortical carcinomas smaller and larger than 6 cm in size.

METHODS

We reviewed the national cancer database for patients undergoing minimally invasive adrenalectomy (MIA) and open adrenalectomy (OA) from 2010 to 2017. To adjust for differences between patients undergoing MIA and OA, we performed propensity score matching within each size strata of ≤6 cm, 6.1 to 10 cm, and 10.1 to 20 cm. We fit generalized estmiating equations with a logit link function to assess for the association of surgical approach with positive surgical margins and a Cox proportional hazards model to assess for the association of surgical approach with overall survival.

RESULTS

We identified 364 patients that underwent MIA (182) and OA (182) in the matched cohort.  We noted 21% and 18% of patients undergoing MIA and OA had a positive surgical margin, respectively. We did not identify a significant association between surgical approach and positive surgical margins in the cohort as a whole or within each of strata. Furthermore, we did not appreciate a significant association between surgical approach and overall survival in the cohort as a whole or within each size strata.

CONCLUSION

In the National Cancer Database, patients undergoing MIA had similar positive surgical margins and overall survival compared with OA for masses ≤6 cm, 6.1 to 10cm, and >10 cm in size. Patients undergoing MIA should be carefully selected with surgical oncologic integrity being the primary determinants of surgical approach.

Association of Surgical Approach With Treatment Burden, Oncological Effectiveness, and Perioperative Morbidity in Adrenocortical Carcinoma

MICROABSTRACT

In the National Cancer Database (NCDB), patients treated with minimally invasive adrenalectomy (MIA) for adrenocortical carcinoma (ACC) had similar oncological outcomes and cumulative treatment burden with less morbidity compared with open adrenalectomy (OA). Although OA remains the standard of care for adrenal lesions concerninge for malignancy, MIA in appropriately selected patients may offer equivalent oncological outcomes.

INTRODUCTION/BACKGROUND

We investigated the cumulative treatment burden, oncological effectiveness, and perioperative morbidity in patients undergoing MIA compared with (OA) for patients with ACC.

PATIENTS AND METHODS

We reviewed the NCDB for patients undergoing surgical resection (MIA vs. OA) for ACC from 2010 to 2017. Inverse probability of treatment weighted logistic regression, negative binomial, and Cox proportional hazards models were fit to assess for an association of surgical approach with cumulative treatment burden (any adjuvant therapy, radiation therapy [RT], and systemic therapy), oncological effectiveness (positive surgical margins [PSM], lymph node yield [LNY], and overall survival [OS]), and perioperative morbidity (length of stay [LOS] and readmission) as appropriate.

RESULTS

We identified 776 patients that underwent adrenalectomy for ACC, of which 307 underwent MIA. We noted patients with larger tumors (OR 0.82, 95% CI 0.78-0.86, P < .001) were less likely to have MIA prior to IPTW. We did not appreciate a significant association of MIA with cumulative treatment burden or the use of any adjuvant therapy (OR 0.85, 95% CI 0.60-1.21, P = .375), adjuvant RT (OR 0.94, 95% CI 0.59-1.50, P = .801), or adjuvant systemic therapy (OR 0.84, 95% CI 0.58-1.21, P = .352). Patients undergoing MIA had similar oncological effectiveness of surgery and OS when compared with patients which underwent OA. Patients that underwent MIA had a significantly shorter LOS (IRR: 0.74, 95% CI 0.62-0.88, P = .001) and lower odds of readmission (OR 0.46, 95% CI 0.23-0.91, P = .026).

CONCLUSIONS

Although the standard of care for adrenal lesions suspicious for ACC remains OA, in appropriately selected patients, MIA may offer similar oncological effectiveness and cumulative treatment burden, with less morbidity, than OA.

On-Clamp vs. Off-Clamp Robot-Assisted Partial Nephrectomy for cT2 Renal Tumors: Retrospective Propensity-Score-Matched Multicenter Outcome Analysis

We compared perioperative outcomes after on-clamp versus off-clamp robot-assisted partial nephrectomy (RAPN) for >7 cm renal masses. A multicenter dataset was queried for patients who had undergone RAPN for a cT2cN0cM0 kidney tumor from July 2007 to February 2022. The Trifecta achievement (negative surgical margins, no severe complications, and ≤ 30% postoperative estimated glomerular filtration rate (eGFR) reduction) was considered a surrogate of surgical quality. Overall, 316 cases were included in the analysis, and 58% achieved the Trifecta. A propensity-score-matched analysis generated two cohorts of 89 patients homogeneous for age, ASA score, preoperative eGFR, and RENAL score (all p > 0.21). Compared to the on-clamp approach, OT was significantly shorter in the off-clamp group (80 vs. 190 min; p < 0.001), the incidence of sRFD was lower (22% vs. 40%; p = 0.01), and the Trifecta rate higher (66% vs. 46%; p = 0.01). In a crude analysis, >20 min of hilar clamping was associated with a significantly higher risk of sRFD (OR: 2.30; 95%CI: 1.13−4.64; p = 0.02) and with reduced probabilities of achieving the Trifecta (OR: 0.46; 95%CI: 0.27−0.79; p = 0.004). Purely off-clamp RAPN seems to be a safe and viable option to treat cT2 renal masses and may outperform the on-clamp approach regarding perioperative surgical outcomes.

Human Gut Mycobiome and Fungal Community Interaction: The Unknown Musketeer in the Chemotherapy Response Status in Bladder Cancer

Background

Until recently, the properties of microbiome and mycobiome in humans and its relevance to disease have largely been unexplored. While the interest of microbiome and malignancy over the past few years have burgeoned with advent of new technologies, no research describing the composition of mycobiome in bladder cancer has been done. Deciphering of the metagenome and its aggregate genetic information can be used to understand the functional properties and relationships between the bacteria, fungi, and cancer.

Objective

The aim of this project is to characterize the compositional range of the normal versus bladder cancer mycobiome of the gut.

Design setting and participants

An internal transcribed spacer (ITS) survey of 52 fecal samples was performed to evaluate the gut mycobiome differences between noncancer controls and bladder cancer patients.

Outcome measurements and statistical analysis

Our study evaluated the differences in mycobiome among patients with bladder cancer, versus matched controls. Our secondary analysis evaluated compositional differences in the gut as a function of response status with neoadjuvant chemotherapy. Data demultiplexing and classification were performed using the QIIME v.1.1.1.1 platform. The Ion Torrent-generated fungal ITS sequence data were processed using QIIME (v.1.9.1), and the reads were demultiplexed, quality filtered, and clustered into operation taxonomic units using default parameters. Alpha and beta diversity were computed and plotted in Phyloseq, principal coordinate analysis was performed on Bray-Curtis dissimilarity indices, and a one-way permutational multivariate analysis of variance was used to test for significant differences between cohorts. Phylogenetic Investigation of Communities by Reconstruction of Unobserved States (PICRUSt) was applied to infer functional categories associated with taxonomic composition.

Results and limitations

We found distinctive mycobiome differences between control group (n = 32) and bladder cancer (n = 29) gut flora, and identified an increasing abundance of Tremellales, Hypocreales, and Dothideales. Significant differences in alpha and beta diversity were present between the groups (control vs bladder; p = 0.002), noting distinct compositions within each cohort. A subgroup analysis by sex and neoadjuvant chemotherapy status did not show any further differences in mycobiome composition and diversity. Our results indicate that the gut mycobiome may modulate tumor response to preoperative chemotherapy in bladder cancer patients. We propose that patients with a "favorable" mycobiome composition (eg, high diversity, and low abundance of Agaricomycetes and Saccharomycetes) may have enhanced systemic immune response to chemotherapy through antigen presentation.

Conclusions

Our study is the first to characterize the enteric mycobiome in patients with bladder cancer and describe complex ecological network alterations, indicating complex bacteria-fungi interactions, particularly highlighted among patients with complete neoadjuvant chemotherapy response.

Patient summary

Our study has demonstrated that the composition of stool mycobiome (fungal inhabitants of the gastrointestinal tract) in patients with bladder cancer is different from that in noncancer individuals. Furthermore, when evaluating how patients respond to chemotherapy given prior to their surgery, our study noted significant differences between patients who responded and those who did not.

Redefining the Gender Gap in Urology Authorship: An 18-Year Publication Analysis

BACKGROUND

Academic authorship is a critical productivity metric used for academic promotion.

OBJECTIVE

To characterize temporal changes in female representation in academic authorship in ten primary urology journals as the complement of female urologists is increasing.

DESIGN, SETTING, AND PARTICIPANTS

Publication records were retrieved from 2002 to 2020 for the ten urology journals with the highest impact factor. The names of all authors were gathered and gender was inferred using first names.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Trends in first and last/senior authorship by gender were evaluated overall, within journals, and by geographic region.

RESULTS

A total of 59,375 articles were analyzed, of which 94.1% had gender information for the first author and 94.2% had gender information for the last author. The percentage of overall female authors increased positively from 17.2% (95% highest density interval [HDI] 12.9-21.4%) in 2002 to 27.2% (HDI 21.7-33.6%; p < 0.01) in 2020. Overall female first authorship increased from 15.2% (95% HDI 11.0-19.5%) to 28.5% (95% HDI 21.8-35.6%; p < 0.01). There was also significant growth for female senior authors from 10.4% (95% HDI 7.6-13.5%) to 18.6% (95% HDI 13.6-23.8%; p < 0.01). Assessment of journal-specific changes revealed that Neurourology and Urodynamics (12.6%, 95% HDI 9.9-15.1%) and The Journal of Sexual Medicine (16.2%, 95% HDI 13.6-19.0%) had significantly higher growth in female authorship when compared to Journal of Endourology (7.2%, 95% HDI 5.5-8.7%) and Urologic Oncology (4.5%, 95% HDI 2.0-6.8%; p < 0.05).

CONCLUSIONS

Although overall female authorship increased between 2002 and 2020, women remain underrepresented in urology authorship. The percentage of females in senior (last) author positions is less than the percentage of females in first author positions. Journal-specific differences can probably be attributed to gender-based differences in subspecialized fields.

PATIENT SUMMARY

In this study, we characterized the underrepresentation of women as authors in urology journals and analyzed the change in female authorship for ten academic urology journals over the course of 18 years. Although the proportion of female authors has increased over that time, the percentage of females in senior authorship roles is less than the percentage of females in first author positions.

Oncologic Outcomes of cT1 and cT2 Micropapillary Variant Compared with cT1 and cT2 Conventional Urothelial Carcinoma Treated with Radical Cystectomy

INTRODUCTION

Our objective was to estimate the difference in outcomes for patients with clinical T stage 1 (cT1) and 2 (cT2) micropapillary (MPBC) and urothelial carcinoma (UCBC) bladder cancer treated with radical cystectomy (RC).

METHODS

We reviewed the National Cancer Database for patients with cT1/2N0M0 MPBC and UCBC treated with RC from 2004-2016. Patients were classified by cT stage and histology. Outcomes of interest included upstaging to advanced pathological stage (pT3/4), pathologically node positive disease (pN+), and overall survival (OS). The Kaplan-Meier method was used to estimate 5-year OS probability. Multivariable logistic regression models were fit to test for an association between cT stage and histology with outcomes.

RESULTS

We identified 23,871 patients, of whom 384 had MPBC and 23,487 had UCBC. More patients with cT1 and cT2 MPBC had advanced pathological stage and pN+ (cT1: 31% and 34%; cT2: 44% and 60%, respectively) compared with cT1 and cT2 UCBC (cT1: 18% and 14%; cT2: 27% and 24%, respectively). Compared with cT2 UCBC, patients with cT1 MPBC had similar odds of advanced pathological stage (OR: 0.96, 95% CI: 0.63-1.45, p=0.837) and increased odds of pN+ (OR: 1.62, 95% CI: 1.03-2.56, p=0.038). Five-year OS estimates for cT1 MPBC and UCBC were similar (58% and 60%, respectively) while cT2 MPBC had worse OS than cT2 UCBC (33% and 45%, respectively).

CONCLUSIONS

In a cohort of patients undergoing RC, cT1/2 MPBC had worse outcomes than cT1/2 UCBC. Patients and surgeons should consider aggressive therapies for patients with cT1 MPBC due to the risk of inferior outcomes associated with cT2 MPBC disease.

Estradiol-secreting adrenal oncocytoma in a 31-year old male

Oncocytic adrenocortical tumors (OAT) are rare and often are non-functional. We report a unique case of an estradiol-secreting adrenal oncocytoma in a 31-year-old male discovered upon an infertility and gynecomastia work-up. After resection of the 9 cm adrenal mass, the patient's estradiol levels normalized from 83.2 pg/ml to 19.0 pg/ml. Gonadotropins and serum dehydroepiandrosterone sulfate also normalized.

Twitter Footprint and the Match in the COVID-19 Era: Understanding the Relationship between Applicant Online Activity and Residency Match Success

INTRODUCTION

The dramatic reduction of clinical and research activities within medical and surgical departments during COVID-19, coupled with the inability of medical students to engage in research, away rotations and academic meetings, have all posed important implications on residency match.

METHODS

Using Twitter application programming interface available data, 83,000 program-specific and 28,500 candidate-specific tweets were extracted for the analysis. Applicants to urology residency were identified as matched vs unmatched based on 3-level identification and verification. All elements of microblogging were captured through Anaconda Navigator. The primary endpoint was residency match, assessed as correlation to Twitter analytics (ie retweets, tweets). The final list of matched/unmatched applicants through this process was cross-referenced with internal validation of information obtained from the American Urological Association.

RESULTS

A total of 28,500 English language posts from 250 matched and 45 unmatched applicants were included in the analysis. Matched applicants generally showed higher number of followers (median 171 [IQR 88-317.5] vs 83 [42-192], p=0.001), tweet likes (2.57 [1.53-4.52] vs 1.5 [0.35-3.03], p=0.048), and recent and total manuscripts (1 [0-2] vs 0 [0-1], p=0.006); 1 [0-3] vs 0 [0-1], p=0.016) in comparison to the unmatched cohort. On multivariable analysis, after adjusting for location, total number of citations and manuscripts, being a female (OR 4.95), having more followers (OR 1.01), individual tweet likes (OR 1.011) and total number of tweets (OR 1.02) increased overall odds of matching into a urology residency.

CONCLUSIONS

Our study of the 2021 urology residency application cycle and use of Twitter highlighted distinct differences among matched and unmatched applicants and their respective Twitter analytics, highlighting a potential professional development opportunity offered by social media in underscoring applicants' profiles.

Novel Imaging Methods for Renal Mass Characterization: A Collaborative Review

CONTEXT

The incidental detection of localized renal masses has been rising steadily, but a significant proportion of these tumors are benign or indolent and, in most cases, do not require treatment. At the present time, a majority of patients with an incidentally detected renal tumor undergo treatment for the presumption of cancer, leading to a significant number of unnecessary surgical interventions that can result in complications including loss of renal function. Thus, there exists a clinical need for improved tools to aid in the pretreatment characterization of renal tumors to inform patient management.

OBJECTIVE

To systematically review the evidence on noninvasive, imaging-based tools for solid renal mass characterization.

EVIDENCE ACQUISITION

The MEDLINE database was systematically searched for relevant studies on novel imaging techniques and interpretative tools for the characterization of solid renal masses, published in the past 10 yr.

EVIDENCE SYNTHESIS

Over the past decade, several novel imaging tools have offered promise for the improved characterization of indeterminate renal masses. Technologies of particular note include multiparametric magnetic resonance imaging of the kidney, molecular imaging with targeted radiopharmaceutical agents, and use of radiomics as well as artificial intelligence to enhance the interpretation of imaging studies. Among these, 99mTc-sestamibi single photon emission computed tomography/computed tomography (CT) for the identification of benign renal oncocytomas and hybrid oncocytic chromophobe tumors, and positron emission tomography/CT imaging with radiolabeled girentuximab for the identification of clear cell renal cell carcinoma, are likely to be closest to implementation in clinical practice.

CONCLUSIONS

A number of novel imaging tools stand poised to aid in the noninvasive characterization of indeterminate renal masses. In the future, these tools may aid in patient management by providing a comprehensive virtual biopsy, complete with information on tumor histology, underlying molecular abnormalities, and ultimately disease prognosis.

PATIENT SUMMARY

Not all renal tumors require treatment, as a significant proportion are either benign or have limited metastatic potential. Several innovative imaging tools have shown promise for their ability to improve the characterization of renal tumors and provide guidance in terms of patient management.