Publications by authors named "Ross E Krasnow"

15 Publications

  • Page 1 of 1

Determinants of neoadjuvant chemotherapy use in muscle-invasive bladder cancer.

Investig Clin Urol 2020 07 26;61(4):390-396. Epub 2020 May 26.

Department of Urology, Medstar Georgetown University Hospital, Washington, DC, USA.

Purpose: Cisplatin-based neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC) is standard of care for muscle-invasive bladder cancer (MIBC). However, NAC is used in less than 20% of patients with MIBC. Our goal is to investigate factors that contribute to underutilization NAC to facilitate more routine incorporation into clinical practice.

Materials And Methods: We identified 5,915 patients diagnosed with cT2-T3N0M0 MIBC who underwent RC between 2004 and 2014 from the National Cancer Database. Univariate and multivariable models were created to identify variables associated with NAC utilization.

Results: Only 18.8% of patients received NAC during the study period. On univariate analyses, NAC utilization was more likely at academic hospitals, US South and Midwest (p<0.05). Higher Charlson score was associated with decrease use of NAC (p<0.05). On multivariate analysis, treatment in academic hospitals (odds ratio [OR], 1.367; 95% confidence interval [CI], 1.186-1.576), in the Midwest (OR, 1.538; 95% CI, 1.268-1.977) and South (OR, 1.424; 95% CI, 1.139-1.781) were independently associated with NAC utilization. Older age (75 to 84 years old; OR, 0.532; 95% CI, 0.427-0.664) and higher Charlson score (OR, 0.607; 95% CI, 0.439-0.839) were associated with decreased NAC utilization. Sixty-eight percent of patients did not receive NAC because it was not planned and only 2.5% of patients had contraindications for NAC treatment.

Conclusions: Our study demonstrates that NAC is underutilized. Decreased utilization of NAC was associated with older patients and higher Charlson score. This underutilization may be related to practice patterns as very few patients have true contraindications.
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http://dx.doi.org/10.4111/icu.2020.61.4.390DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7329637PMC
July 2020

Delayed blood transfusion is associated with mortality following radical cystectomy.

Scand J Urol 2020 Aug 13;54(4):290-296. Epub 2020 Jun 13.

Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

To examine the temporal association between blood transfusion and 90-day mortality in patients with bladder cancer treated with radical cystectomy. This represents a retrospective cohort study of patients treated with radical cystectomy within the Premier Hospital network between 2003 and 2015. Patients outcomes were stratified those who received early blood transfusion (day of surgery) vs delayed blood transfusion (postoperative day ≥1) during the index admission. Primary end point was 90-day mortality following surgery. The median age of 12,056 patients identified was 70 years. A total of 7,201 (59.7%) patients received blood transfusion. Within 90 days following surgery, 57 (2.2%), 162 (5.9%) and 123 (6.7%) patients in the early, delayed and both early and delayed transfused patients died respectively. Following multivariate logistic regression to account for patient (age and Charlson Comorbidity Index [CCI]) and hospital (surgeon volume, surgical approach and academic status) factors, delayed blood transfusion was independently associated with 90-day mortality (Odds ratio [OR], 2.64; 95% Confidence Interval [CI], 1.98-3.53;  < 0.001). A sensitivity analysis defining early blood transfusion as <2 days postoperatively, increased 90-day mortality persisted in patients receiving delayed transfusion (OR, 2.20; 95% CI, 1.63-3.00;  < 0.001). Older patients (≥77 years) with the highest CCI (≥2) had a 7% absolute increase in the predicted probability of 90-day mortality if they were transfused late compared to patients transfused early. Patient undergoing cystectomy may benefit from expedited transfusion to prevent subsequent clinical deterioration which may lead to patient mortality. Future work is needed to elucidate the optimal timing of blood transfusion.
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http://dx.doi.org/10.1080/21681805.2020.1777195DOI Listing
August 2020

Prostate Cancer in Men With Treated Advanced Heart Failure: Should we Keep Screening?

Urology 2020 Feb 28;136:46-50. Epub 2019 Nov 28.

MedStar Georgetown Department of Urology, Washington, DC. Electronic address:

Objective: To evaluate the outcomes of men diagnosed with prostate cancer (CaP) following implanted treatments for advanced heart failure. Given the increasingly favorable 10-year life expectancy, MedStar Washington Hospital Center screens heart transplant (HT) candidates for CaP and other malignancies prior to intervention.

Methods: Men aged 18-90 with available pretransplant Prostate Specific Antigen (PSA) who underwent left ventricular assist device (LVAD) and/or HT at MedStar Washington Hospital Center from 2007 to 2018 were identified. Serum PSA, CaP diagnosis, and treatment were captured and analyzed. Survival was analyzed using Kaplan-Meier curves.

Results: Data were available for 34 patients. Median age was 53 [IQR = 51-58]. Median follow-up was 77 months (95% CI = 40-87 months). Six men had postimplant elevated PSA (5.3; SD = 8.5) and 4 were diagnosed with CaP. Median age of CaP diagnosis was 59 [IQR = 58.5-62). As of 2018, 31 of the 34 patients were living, and none died from CaP. Five-year survival was 96% in those without CaP and 100% in those with CaP (Figure 2).

Conclusion: Our cohort represents the largest known cohort with heart failure treated by LVAD and/or HT and CaP. Our median age of 59 at CaP diagnosis is considerably younger than the national median of 66. Of the 4 individuals diagnosed with CaP, 3 had high-grade disease. Given the favorable long-term survival of these patients post-LVAD and/or HT, age-appropriate treatment for CaP should be continued postimplantation.
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http://dx.doi.org/10.1016/j.urology.2019.11.022DOI Listing
February 2020

Trends in Adherence to Thromboprophylaxis Guideline in Patients Undergoing Radical Cystectomy.

Urology 2020 Jan 3;135:44-49. Epub 2019 Oct 3.

Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA. Electronic address:

Objective: To examine the use of in-hospital pharmacologic thromboprophylaxis (PTP) in patients undergoing radical cystectomy between 2004 and 2014 and to assess the risk of venous thromboembolism (VTE) across the study period.

Material And Methods: We identified 8322 patients without contraindications to PTP undergoing radical cystectomy in the US using the Premier Healthcare Database. Nonparametric Wilcoxon type test for trend was employed to examine the trend of PTP utilization across the study period. Ensuing, we employed multivariable logistic regression and generalized linear regression models to examine the odds of receiving PTP and the risk of being diagnosed with VTE, respectively.

Results: Based on VTE risk-stratification, the majority of patients (87.8%) qualified as "high-risk." Across the study period the use of PTP increased (Odds ratio 1.02, 95% confidence interval (CI) 1.00-1.03, P = .044), but remained underutilized as the maximum percentage of patients receiving in-hospital PTP did not exceed 58.6%. The risk of VTE did not vary across the study period (risk ratio 0.97, 95%CI 0.92-1.02, P = .178).

Conclusion: Utilization of PTP increased throughout the study period, while the risk of VTE did not change. Future studies are necessary to improve implementation of guideline-driven care, as PTP remained underutilized throughout the study period.
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http://dx.doi.org/10.1016/j.urology.2019.09.029DOI Listing
January 2020

Resident burnout in USA and European urology residents: an international concern.

BJU Int 2019 08 8;124(2):349-356. Epub 2019 May 8.

Department of Urology, MedStar Washington Hospital Center, Washington, DC, USA.

Objective: To describe the prevalence and predictors of burnout in USA and European urology residents, as although the rate of burnout in urologists is high and associated with severe negative sequelae, the extent and predictors of burnout in urology trainees remains poorly understood.

Subjects And Methods: An anonymous 32-question survey of urology trainees across the USA and four European countries, analysing personal, programme, and institutional factors, was conducted. Burnout was assessed using the validated abridged Maslach Burnout Inventory. Univariate analysis and multivariable logistic regression models assessed drivers of burnout in the two cohorts.

Results: Overall, 40% of participants met the criteria for burnout as follows: Portugal (68%), Italy (49%), USA (38%), Belgium (36%), and France (26%). Response rates were: USA, 20.9%; Italy, 45.2%; Portugal, 30.5%; France, 12.5%; and Belgium, 9.4%. Burnout was not associated with gender or level of training. In both cohorts, work-life balance (WLB) dissatisfaction was associated with increased burnout (odds ratio [OR] 4.5, P < 0.001), whilst non-medical reading (OR 0.6, P = 0.001) and structured mentorship (OR 0.4, P = 0.002) were associated with decreased burnout risk. Lack of access to mental health services was associated with burnout in the USA only (OR 3.5, P = 0.006), whilst more weekends on-call was associated with burnout in Europe only (OR 8.3, P = 0.033). In both cohorts, burned out residents were more likely to not choose a career in urology again (USA 54% vs 19%, P < 0.001; Europe 43% vs 25%, P = 0.047).

Conclusion: In this study of USA and European urology residents, we found high rates of burnout on both continents. Despite regional differences in the predictors of burnout, awareness of the unique institutional drivers may help inform directions of future interventions.
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http://dx.doi.org/10.1111/bju.14774DOI Listing
August 2019

Examining the relationship between complications and perioperative mortality following radical cystectomy: a population-based analysis.

BJU Int 2019 07 14;124(1):40-46. Epub 2019 Apr 14.

Division of Urology, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA.

Objective: To examine the incidence of perioperative complications after radical cystectomy (RC) and assess their impact on 90-day postoperative mortality during the index stay and upon readmission.

Patients And Methods: A total of 57 553 patients with bladder cancer (unweighted cohort: 9137 patients) treated with RC, at 360 hospitals in the USA between 2005 and 2013 within the Premier Healthcare Database, were used for analysis. The 90-day perioperative mortality was the primary outcome. Multivariable regression was used to predict the probability of mortality; models were adjusted for patient, hospital, and surgical characteristics.

Results: An increase in the number of complications resulted in an increasing predicted probability of mortality, with a precipitous increase if patients had four or more complications compared to one complication during hospitalisation following RC (index stay; 1.0-9.7%, P < 0.001) and during readmission (2.0-13.1%, P < 0.001). A readmission complication nearly doubled the predicted probability of postoperative mortality as compared to an initial complication (3.9% vs 7.4%, P < 0.001). During the initial hospitalisation cardiac- (odds ratio [OR] 3.1, 95% confidence interval [CI] 1.9-5.1), pulmonary- (OR 4.8, 95% CI 2.8-8.4), and renal-related (OR 3.6, 95% CI 2-6.7) complications had the most significant impact on the odds of mortality across categories examined.

Conclusions: The number and nature of complications have a distinct impact on mortality after RC. As complications increase there is an associated increase in perioperative mortality.
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http://dx.doi.org/10.1111/bju.14636DOI Listing
July 2019

The impact of age at the time of radiotherapy for localized prostate cancer on the development of second primary malignancies.

Urol Oncol 2018 11 21;36(11):500.e11-500.e19. Epub 2018 Sep 21.

Center for Surgery and Public Health, Division of Urology, Brigham and Women's Hospital, Harvard Medical School Boston, MA.

Purpose: There is a known increased risk of second primary malignancy (SPM) in patients with prostate cancer (CaP) treated with radiotherapy (RT). It is unclear how age at diagnosis influences the risk of SPMs.

Materials And Methods: Using the 1973 to 2013 Surveillance, Epidemiology, and End Results Program, we studied the impact of age on SPMs (defined as a bladder or rectal tumor) after localized CaP treatment with radical prostatectomy (RP) or RT. SPM risk was compared using inverse probability of treatment weighting (IPTW)-adjusted cumulative incidence function and competing-risk proportional hazard models. Overall survival (OS) in patients with SPM was compared using Kaplan Meier and Cox regression analyses.

Results: A total of 579,608 patients met inclusion criteria, and 51.8% of the cohort was treated with RT. The 10- and 20-year cumulative incidences of competing risk (IPTW adjusted) of SPMs were 1.9% (95%CI = 1.8-1.9%) and 3.6% (95%CI = 3.4-3.7%) after RP vs. 2.7% (95%CI = 2.6-2.8%) and 5.4%(95%CI = 5.3-5.6%) after RT. IPTW-adjusted competing risk hazard ratio (HR) of SPM after RT compared to RP was increased in the entire cohort (HR 1.46; 95%CI = 1.39-1.53, P < 0.001) and was highest in the youngest patients: Age <55 HR = 1.83 (95% confidence interval [CI] = 1.49-2.24, P<0.001), Age 55 to 64 HR = 1.66 (95%CI = 1.54-1.79, P < 0.001), Age 65-74 HR = 1.41 (95%CI = 1.33-1.48, P < 0.001), Age ≥75 HR = 1.14 (95%CI = 0.97-1.35, P = 0.112). At 10 years, SPM-specific mortality occurred in 28.9% of patients treated with RT, though OS with SPM was worse in the youngest patients: Age <55 HR = 1.88 (95%CI = 1.25-2.81, P = 0.002), Age 55-64 HR = 1.60 (95%CI = 1.42-1.81, P < 0.001), Age 65-74 HR = 1.40 (95%CI = 1.30-1.52, P < 0.001), Age ≥ 75 HR = 1.27 (95%CI = 1.06-1.53, P = 0.009). All of the age categories had similar median follow-up times.

Conclusion: At 10 years there is a 1.8% increased incidence of SPM after RT compared to RP, of which <30% of RT-treated patients with an SPM die as a result of a SPM. However, the risk of SPMs was greatest among younger men treated with RT for localized CaP, and this relationship could not be explained solely by follow-up time, latency time, or life expectancy. An improved understanding of those at the highest risk of SPMs may help tailor treatment and surveillance strategies.
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http://dx.doi.org/10.1016/j.urolonc.2018.06.007DOI Listing
November 2018

A contemporary population-based analysis of the incidence, cost, and outcomes of postoperative delirium following major urologic cancer surgeries.

Urol Oncol 2018 Jul 24;36(7):341.e15-341.e22. Epub 2018 May 24.

Center for Surgery & Public Health and Division of Urology, Brigham and Women's Hospital, Boston, MA.

Purpose: Postoperative delirium (PD) is associated with poor outcomes and increased health care costs. The incidence, outcomes, and cost of delirium for major urologic cancer surgeries have not been previously characterized in a population-based analysis.

Materials And Methods: We performed a population-based, retrospective cohort study of patients with PD at 490 US hospitals between 2003 and 2013 to evaluate the incidence, outcomes, and cost of delirium after radical prostatectomy, radical nephrectomy, partial nephrectomy, and radical cystectomy (RC). Delirium was defined using ICD-9 codes in combination with postoperative antipsychotics, sitters, and restraints. Regression models were constructed to assess mortality, discharge disposition, length of stay (LOS), and direct hospital admission costs. Survey-weighted adjustment for hospital clustering achieved estimates generalizable to the US population.

Results: We identified 165,387 patients representing a weighted total of 1,097,355 patients. The overall incidence of PD was 2.7%, with the greatest incidence occurring after RC, with 6,268 cases (11%). Delirious patients had greater adjusted odds of in-hospital mortality (odds ratio [OR] = 3.65, P<0.001), 90-day mortality (OR = 1.47, P = 0.013), discharge with home health services (OR = 2.25, P<0.001), discharge to skilled nursing facilities (OR = 4.64, P<0.001), and a 0.9-day increase in median LOS (P<0.001). Patients with delirium also experienced a $2,697 increase in direct admission costs (P<0.001), with the greatest costs incurred in RC patients ($30,859 vs. $26,607; P<0.001).

Conclusions: Patients with PD after urologic cancer surgeries experienced worse outcomes, prolonged LOS, and increased admission costs. The greatest incidence and costs were seen after RC. Further research is warranted to identify high-risk patients and devise preventative strategies.
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http://dx.doi.org/10.1016/j.urolonc.2018.04.012DOI Listing
July 2018

Approach to the Patient with High-Risk Prostate Cancer.

Urol Clin North Am 2017 Nov;44(4):635-645

Division of Urology, Brigham and Women's Hospital, Harvard Medical School, 45 Francis Street, Boston, MA 02115, USA; Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA. Electronic address:

Men classified as having high-risk prostate cancer warrant treatment because durable outcomes can be achieved. Judicious use of imaging and considerations of risk factors are essential when caring for men with high-risk disease. Radical prostatectomy, radiation therapy, and androgen deprivation therapy all play pivotal roles in the management of men with high-risk disease, and potentially in men with metastatic disease. The optimal combinations of therapeutic regimens are an evolving area of study and future work looking into therapies for men with high-risk disease will remain critical.
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http://dx.doi.org/10.1016/j.ucl.2017.07.009DOI Listing
November 2017

Associations of specific postoperative complications with costs after radical cystectomy.

BJU Int 2018 03 16;121(3):428-436. Epub 2017 Nov 16.

Division of Urologic Surgery, Brigham and Women's Hospital, Boston, MA, USA.

Objective: To quantify the financial impact of complications after radical cystectomy (RC) and their associations with respective 90-day costs, as RC is a morbid surgery plagued by complications and the expenditure attributed to specific complications after RC is not well characterised.

Patients And Methods: We used the Premier Hospital Database (Premier Inc., Charlotte, NC, USA) to identify 9 137 RC patients (weighted population of 57 553) from 360 hospitals between 2003 and 2013. Complications were categorised according to Agency for Healthcare Research and Quality Clinical Classifications. Patients with and without complications were compared, and multivariable analysis was performed.

Results: An index complication increased costs by $9 262 (95% confidence interval [CI] 8 300-10 223) and a readmission complication increased costs by $20 697 (95% CI 18 735-22 660). The four most costly index complications (descending order) were venous thromboembolism (VTE), infection, wound and soft tissue complications, and pulmonary complications (P < 0.001, vs no complication). A complication increased length of stay by 4 days (95% CI 3.6-4.3). One in five patients were readmitted in 90 days and the four costliest readmission complications (descending order) were pulmonary, bleeding, VTE, and gastrointestinal complications (P < 0.001, vs no complication). Readmitted patients had multiple complications upon readmission (median of 3, interquartile range 2-4). On multivariable analysis, more comorbidities, longer surgery (>6 h), transfusions of >3 units, and teaching hospitals were associated with higher costs (P < 0.05), whilst high-volume surgeons and shorter surgeries (<4 h) were associated with lower costs (P < 0.05).

Conclusions: Complications after RC increase index and readmission costs for hospitals, and can be categorised based on magnitude. Future initiatives in RC may also consider costs of complications when establishing quality improvement priorities for patients, providers, or policymakers.
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http://dx.doi.org/10.1111/bju.14064DOI Listing
March 2018

Reply to B. Biswas et al.

J Clin Oncol 2017 06 4;35(18):2096. Epub 2017 May 4.

Thomas Seisen, Ross E. Krasnow, and Steven Lee Chang, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

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http://dx.doi.org/10.1200/JCO.2017.72.9277DOI Listing
June 2017

Prophylactic Antibiotics and Postoperative Complications of Radical Cystectomy: A Population Based Analysis in the United States.

J Urol 2017 08 4;198(2):297-304. Epub 2017 Mar 4.

Division of Urology, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Purpose: Infectious, wound and soft tissue events contribute to the morbidity of radical cystectomy but the association between these events and antibiotic prophylaxis is not clear. We sought to describe the contemporary use of antibiotic prophylaxis in radical cystectomy and adherence to published guidelines, and identify regimens with the lowest rates of infectious events.

Materials And Methods: We identified the intraoperative antibiotic prophylaxis regimen in a population based, retrospective cohort study of patients who underwent radical cystectomy across the United States between 2003 and 2013. Multivariable regression was done to evaluate 90-day infectious events and length of stay.

Results: In a weighted cohort of 52,349 patients there were 579 unique antibiotic prophylaxis regimens. Cefazolin was the most commonly used antibiotic (16% of cases). The overall infectious event rate was 25%. Only 15% of patients received antibiotic prophylaxis based on guidelines. Of guideline based antibiotic prophylaxis ampicillin/sulbactam had the lowest odds of infectious events (OR 0.34, p <0.001). In 2.7% of patients a penicillin based regimen with a β-lactamase inhibitor was associated with a prominent reduction in the odds of infectious events (OR 0.45, p = 0.001) and decreased length of stay (-1.3 days, p = 0.016).

Conclusions: Antibiotic prophylaxis practices are highly heterogeneous in radical cystectomy. There is a lack of adherence to published guidelines. We observed decreased infectious event rates and shorter length of stay with regimens that included broad coverage of common skin, genitourinary and gastrointestinal flora. The ideal antibiotic regimen requires further study to optimize perioperative outcomes.
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http://dx.doi.org/10.1016/j.juro.2017.02.3340DOI Listing
August 2017

Effectiveness of Adjuvant Chemotherapy After Radical Nephroureterectomy for Locally Advanced and/or Positive Regional Lymph Node Upper Tract Urothelial Carcinoma.

J Clin Oncol 2017 Mar 3;35(8):852-860. Epub 2017 Jan 3.

Thomas Seisen, Ross E. Krasnow, Jeffrey J. Leow, Stuart R. Lipsitz, Malte W. Vetterlein, Mark A. Preston, Nawar Hanna, Adam S. Kibel, Maxine Sun, Quoc-Dien Trinh, and Steven L. Chang, Brigham and Women's Hospital, Harvard Medical School; Joaquim Bellmunt and Toni K. Choueiri, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Morgan Rouprêt, Pitié Salpétrière Hospital, Assistance Publique des Hôpitaux de Paris, Pierre and Marie Curie University, Paris, France.

Purpose There is limited evidence to support the use of adjuvant chemotherapy (AC) after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). Against this backdrop, we hypothesized that such treatment is associated with overall survival (OS) benefit in patients with locally advanced and/or positive regional lymph node disease. Patients and Methods Within the National Cancer Database (2004 to 2012), we identified 3,253 individuals who received AC or observation after RNU for pT3/T4 and/or pN+ UTUC. Inverse probability of treatment weighting (IPTW) -adjusted Kaplan-Meier curves and Cox proportional hazards regression analyses were used to compare OS of patients in the two treatment groups. In addition, we performed exploratory analyses of treatment effect according to age, gender, Charlson comorbidity index, pathologic stage (pT3/T4N0, pT3/T4Nx and pTanyN+), and surgical margin status. Results Overall, 762 (23.42%) and 2,491 (76.58%) patients with pT3/T4 and/or pN+ UTUC received AC and observation, respectively, after RNU. IPTW-adjusted Kaplan-Meier curves showed that median OS was significantly longer for AC versus observation (47.41 [interquartile range,19.88 to 112.39] v 35.78 [interquartile range, 14.09 to 99.22] months; P < .001). The 5-year IPTW-adjusted rates of OS for AC versus observation were 43.90% and 35.85%, respectively. In IPTW-adjusted Cox proportional hazards regression analysis, AC was associated with a significant OS benefit (hazard ratio, 0.77 [95% CI, 0.68 to 0.88]; P < .001). This benefit was consistent across all subgroups examined (all P < .05), and no significant heterogeneity of treatment effect was observed (all P > .05). Conclusion We report an OS benefit in patients who received AC versus observation after RNU for pT3/T4 and/or pN+ UTUC. Although our results are limited by the usual biases related to the observational study design, we believe that the present findings should be considered when advising post-RNU management of advanced UTUC, pending level I evidence.
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http://dx.doi.org/10.1200/JCO.2016.69.4141DOI Listing
March 2017

Clinical Outcomes of Patients with Histologic Variants of Urothelial Cancer Treated with Trimodality Bladder-sparing Therapy.

Eur Urol 2017 07 28;72(1):54-60. Epub 2016 Dec 28.

Department of Radiation Oncology, Massachusetts General Hospital. Harvard Medical School, Boston, MA, USA. Electronic address:

Background: Trimodality bladder-sparing therapy (TMT) is an acceptable treatment for selected patients with muscle-invasive urothelial cancer. Outcomes of TMT in histologic variants remains largely unknown.

Objective: To compare outcomes of pure urothelial carcinoma (PUC) to variant urothelial carcinoma (VUC) after TMT.

Design, Setting, And Participants: Retrospective study of patients treated with TMT at a single cancer center from 1993 until 2013.

Outcome Measurements And Statistical Analysis: Kaplan-Meier survival probabilities, and univariate and multivariable Cox regression analysis.

Results And Limitations: Of 303 patients treated with TMT, 66 (22%) had VUC. Fifty (76%) had VUC with squamous and/or glandular differentiation and 16 (24%) had other forms. Complete response rate after induction TMT was 83% in PUC and 82% in VUC (p=0.9). The 5-yr and 10-yr disease-specific survival (DSS) was 75% and 67% in PUC versus 64% and 64% in VUC. The 5-yr and 10-yr overall survival (OS) was 61% and 42% in PUC versus 52% and 42% in VUC. On multivariable analysis VUC was not associated with DSS (hazard ratio: 1.3, 95% confidence interval: 0.8-2.2, p=0.3) or OS (hazard ratio: 1.2, 95% confidence interval: 0.8-1.7, p=0.4). Salvage cystectomy rates were similar (log-rank p=0.3). Limitations include retrospective design and restriction to variants of urothelial cancer.

Conclusions: VUC responded to TMT, and there was no significant difference in complete response, OS, DSS, or salvage cystectomy rates compared with PUC. The presence of VUC should not exclude patients from TMT.

Patient Summary: The response of histologic variants of bladder cancer to bladder-sparing chemoradiation is largely unknown. We compared the outcomes of histologic variants of urothelial cancer to pure urothelial cancer in a large series of patients from a single institution. We found that variant histology does not significantly influence outcomes.
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http://dx.doi.org/10.1016/j.eururo.2016.12.002DOI Listing
July 2017

Robotic Intracorporeal Continent Cutaneous Urinary Diversion: Primary Description.

J Endourol 2015 Nov 5;29(11):1217-20. Epub 2015 Feb 5.

2 Department of Urology, Houston Methodist Hospital , Houston, Texas.

The purpose is to present the first report and describe our novel technique for intracorporeal continent cutaneous diversion after robotic cystectomy. After completion of robot-assisted cystectomy using a standard six-port transperitoneal technique, three additional ports are placed, and the robot is redocked laterally over the patient's right side in the modified lateral position. Our technique replicates step-by-step the principles of the open approach. Ileocolonic anastomosis, ureteroenteral anastomoses, and construction of a hand-sewn right colonic pouch are all performed intracorporeally. Tapering of efferent ileal limb and reinforcement of the ileocecal valve are performed via the extraction site, while the stoma is matured through a prospective port site. Successful robotic intracorporeal creation of a modified Indiana pouch was achieved. Operative time for diversion was 3 hours, with negligible blood loss, and without any intraoperative complications. No major (Clavien III-V) 90-day complications were observed. At a follow-up of 1 year, the patient continues to catheterize without difficulty. We demonstrate the first description of robotic intracorporeal continent cutaneous urinary diversion after robot-assisted cystectomy. We present a systematic minimally invasive approach, replicating the principles of open surgery, which is technically feasible and safe with a good functional result.
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http://dx.doi.org/10.1089/end.2014.0750DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4702439PMC
November 2015