John Pfail

Introduction: Ureteral stents are traditionally placed intraoperatively during radical cystectomy (RC) to optimize healing and avoid short and long-term complications. However, strong evidence supporting this practice is lacking. We aim to assess the impact of ureteral stent placement with postoperative complications following RC. Methods: The National Surgical Quality Improvement Program database included 4,375 patients who underwent RC from 2019 to 2021. Baseline characteristics and complication rates were stratified by utilization of ureteral stenting. Primary endpoints included 30-day complications, length of stay (LOS), and readmissions. Multivariable analyses was performed to determine the association of no stent placement with postoperative morbidity. Results: Of the 4,375 patients who underwent RC, 413 (9.4%) did not receive intraoperative stent placement. Patients without stent placement had lower ASA (ASA < 3: 21% v. 27%; p < 0.01), lower median BMI 27 v. 28; p < 0.01), and lower median operative times (292 min v. 322; p < 0.01). There was no difference in preoperative median estimated glomerular filtration rate (CKD-EPI creatine Eq. 2021) between patients with or without stents placed (70 mL/min/1.73m ² v. 71 respectively; p = 0.8). Patients without stent placement had similar median LOS (6 days v. 6 days; p = 0.34) and readmission rates (23% v. 21%; p = 0.43) compared to those who had stents placed. After controlling for potential confounders, RC without stent placement was not associated with increased rates of any complication (OR: 1.23; 95% CI [0.99–1.51]), renal failure (OR: 1.4 [0.77–2.54]), ureteral stricture (OR: 0.6 [0.29–1.24]), urine leak (OR: 1.54 [0.91–2.62]), or UTI (OR: 1.18 [0.79–1.72]) at 30 days postoperatively. Conclusions: The omission of ureteral stents in a select population of patients did not appear to increase the risk of morbidity including 30-day complications, postoperative renal failure, UTI, urine leak, or ureteral strictures, indicating stentless RC may be performed safely in select patients.

Background: Intravesical Bacillus Calmette–Guérin (BCG) is the standard treatment for intermediate-risk, high-grade, and high-risk non-muscle invasive bladder cancer (NMIBC). However, it is associated with adverse effects, potentially causing treatment interruptions or discontinuation. Objectives: This study analyzed the tolerability and efficacy of induction BCG, with associated patient- and disease-related factors. Methods: A retrospective analysis was conducted on BCG-naive patients diagnosed with high-grade NMIBC, who received induction BCG at our institution between 2011 and 2021. Tolerability was defined as the completion of a 6-week induction course of BCG without treatment interruption or discontinuation. Multivariable logistic regression was performed to determine risk factors associated with the inability to tolerate treatment. Results: Induction BCG was given to 203 NMIBC patients, where 147 (72%) patients tolerated the treatment. Treatment interruptions occurred in 44 (22%) patients, while 12 (5.9%) patients discontinued the treatment. The median length of interruption was 1 week, primarily due to concerns about urinary tract infection (UTI) (n = 18, 41%) or gross hematuria (n = 5, 11%). No significant difference in 1-year recurrence rates was observed between those who tolerated BCG and those who did not (50% vs. 48%). Risk factors associated with the inability to tolerate induction BCG included male sex (odds ratio [OR] = 5.76, p < 0.01), hypertension (OR = 3.47, p = 0.02), and low pre-treatment hemoglobin levels (OR = 0.73, p = 0.03). Conclusion: Inability to tolerate BCG occurred in 28% of patients, with 5.9% experiencing discontinuation. Interruptions were short, mostly concerning UTI, and rarely leading to discontinuation. Poor tolerability was associated with male sex, hypertension, and low pre-treatment hemoglobin levels, highlighting critical targets for reducing the risk of BCG interruption or discontinuation.

Purpose: Bladder cancer is one of the most common malignancies worldwide with over 614,000 new cases and 220,000 deaths annually. Five percent of newly diagnosed patients have metastatic disease. Metastatic urothelial carcinoma (mUC) is primarily treated with cisplatin-based chemotherapy, immunotherapy, targeted therapy, or combinations. Cure from disease is rarely achieved, with the overall survival being between 12 and 15 months, and the 5-year survival in the range of 5–15%. Historically, mUC has been deemed surgically incurable. There are limited data available to assess survival benefit with surgical extirpation of the primary site or metastases. In this review, we summarize findings from previous studies regarding the role of surgery in patients with clinically node-positive bladder cancer or metastatic urothelial carcinoma, focusing on cytoreductive radical cystectomy (RC) and distant metastasectomy. Materials and Methods: A literature search was conducted on The Medical Literature Analysis and Retrieval System Online (Medline), Excerpta Medica dataBASE (Embase), preprints, and ClinicalTrials.gov for studies that discussed the role of surgery in patients with clinically node-positive bladder cancer or mUC, focusing on cytoreductive radical cystectomy (RC) and distant metastasectomy. The keywords used included transitional cell carcinoma, urothelial carcinoma, bladder cancer, bladder carcinoma, bladder metastasis, bladder tumor, lymph node metastasis, metastasis, and muscle-invasive bladder cancer. Results: The final analysis included 21 studies, including 17 retrospective reviews, 2 prospective phase II trials, and 2 meta-analyses. Of the studies that assessed patients with urothelial carcinoma (UC) with nodal involvement, 15 of 17 showed improved survival with chemotherapy followed by radical cystectomy (RC). To our knowledge, few studies have solely assessed surgery in patients with distant metastases. Most studies include patients with both UC with local LN involvement and patients with distant sites of metastasis. Of these studies, 12 of 13 indicated improved survival with metastasectomy. Conclusions: While it remains to be seen whether metastasectomy will have a role in patients with mUC, patient selection is an important factor when assessing the survival benefits. Patient characteristics correlated with improved survival include good performance status, good response to chemotherapy, and single site of metastasis. Further studies of mUC patients are required to clearly assess the survival impact of cytoreductive surgery.

Purpose: Placement of a drain during robotic assisted partial nephrectomy (RAPN) and robotic assisted radical prostatectomy (RARP) is standard practice for many urologists and can aid in assessment and management of complications such as urine leak, lymphocele, or bleeding. However, drain placement can cause discomfort and delay patient discharge, with questionable benefit. We aim to assess the correlation between drain placement with post operative complications. Methods: The NSQIP targeted database was queried for patients who underwent RAPN or RARP from 2019 to 2021. Our primary outcomes included 30-day complication rates stratified by intraoperative drain placement. Secondary outcomes included procedure-specific complications, length of stay (LOS), and readmissions. Multivariable regression analyses, with Bonferroni correction, were performed for each post-operative complication. Results: We identified 4738 and 13,948 patients who underwent RAPN and RARP, respectively. Drains were not placed in 2258 (47.7%) and 6700 (48%) patients, respectively. On adjusted multivariable analysis in the RAPN cohort, omission of drain placement was associated with decreased LOS (β -0.45; 99.58% CI [-0.59, -0.32]) but no difference in overall complication rates. After adjusted analysis in the RARP cohort, omission of drain placement was associated with decreased risk of any complication (OR 0.73 [0.62–0.87]), infectious complication (OR 0.66 [0.49–0.89]), and LOS (β -0.30 [-0.37, -0.24]). Conclusions: Using a large contemporary database, this study demonstrates that omission of drains during RAPN and RARP was safe without increased risk of postoperative complications. Despite inherent selection bias in this cohort, our data suggests that routine drain placement is not necessary for these procedures.

Objective: To examine the impact of increased compliance to contemporary perioperative care measures, as outlined by enhanced recover after surgery (ERAS) guidelines, among patients undergoing radical cystectomy (RC). Patients and Methods: From the National Surgical Quality Improvement Program database we captured patients undergoing RC between 2019 and 2021. We identified five perioperative care measures: regional anaesthesia block, thromboembolism prophylaxis, ≤24 h perioperative antibiotic administration, absence of bowel preparation, and early oral diet. We stratified patients by the number of measures utilised (one to five). Statistical endpoints included 30‐day complications, hospital length of stay (LOS), readmissions, and optimal RC outcome. Optimal RC outcome was defined as absence of any postoperative complication, re‐operation, prolonged LOS (75th percentile, 8 days) with no readmission. Multivariable regressions with Bonferroni correction were performed to assess the association between use of contemporary perioperative care measures and outcomes. Results: Of the 3702 patients who underwent RC, 73 (2%), 417 (11%), 1010 (27%), 1454 (39%), and 748 (20%) received one, two, three, four, and five interventions, respectively. On multivariable analysis, increased perioperative care measures were associated with lower odds of any complication (odds ratio [OR] 0.66, 99% confidence interval [CI] 0.6–0.73), and shorter LOS ( β −0.82, 99% CI −0.99 to −0.65). Furthermore, patients with increased compliance to contemporary care measures had increased odds of an optimal outcome (OR 1.38, 99% CI 1.26–1.51). Conclusions: Among the measures we assessed, greater adherence yielded improved postoperative outcomes among patients undergoing RC. Our work supports the efficacy of ERAS protocols in reducing the morbidity associated with RC.

The multidisciplinary nature of artificial intelligence (AI) has allowed for rapid growth of its application in medical imaging. Artificial intelligence algorithms can augment various imaging modalities, such as X-rays, CT, and MRI, to improve image quality and generate high-resolution three-dimensional images. AI reconstruction of three-dimensional models of patient anatomy from CT or MRI scans can better enable urologists to visualize structures and accurately plan surgical approaches. AI can also be optimized to create virtual reality simulations of surgical procedures based on patient-specific data, giving urologists more hands-on experience and preparation. Recent development of artificial intelligence modalities, such as TeraRecon and Ceevra, offer rapid and efficient medical imaging analyses aimed at enhancing the provision of urologic care, notably for intraoperative guidance during robot-assisted radical prostatectomy (RARP) and partial nephrectomy.

Background Conventional operative insufflation uses a one-way trocar to handle instruments while maintaining pneumoperitoneum. In 2007, the AirSeal® valveless trocar insufflation system was introduced, which maintains stable pneumoperitoneum while continuously evacuating smoke. Although this device has been validated in adult patients, it has not been extensively validated in the pediatric population. Materials and Methods A retrospective cohort study of pediatric urology patients aged 0 to 21 who underwent laparoscopic pyeloplasty between March 2016 and October 2021 was performed. Intraoperative physiologic parameters, procedure characteristics, postoperative outcomes, and demographics of each patient in whom either AirSeal® insufflation systems (AIS) or conventional insufflation systems (CIS) was utilized were obtained from hospital records. Data was compared across the AIS and CIS cohorts. The primary outcomes were intraoperative anesthetic and physiologic parameters, including end tidal CO2 (ETCO2), oxygen saturation (SaO2), body temperature, positive inspiratory pressure (PIP), systolic blood pressure (SBP), and heart rate (HR). Results There were no significant differences in the anesthetic and physiologic parameters in the AIS and CIS groups. In addition, no differences in demographics, procedural characteristics, or complication rates were found between the cohorts. Conclusion The AirSeal® valveless trocar insufflation system demonstrates comparable intraoperative anesthetic and physiologic outcomes compared to conventional one-way valve insufflation in pediatric laparoscopic pyeloplasty. Certain surgeon-related qualitative metrics are underappreciated in this study however, including improved visualization with vigorous suctioning and pressure maintenance with frequent instrument exchanges. Surgeon experience may mask the benefits of these characteristics as it pertains to quantitative surgical outcomes such as estimated blood loss (EBL), operative time, and perioperative complications.

PURPOSE: Targeted tyrosine kinase inhibitors (TKIs) and immune-checkpoint inhibitors (ICIs) revolutionized the treatment of metastatic renal cell carcinoma (RCC). Efforts to translate these therapies into the adjuvant setting for local and locoregional RCC have been pursued over the past decade. We sought to provide an updated review of the literature regarding adjuvant therapy in RCC, as well as an analysis of patient characteristics that may portend the most favorable responses. MATERIALS AND METHODS: Using PubMed, Google Scholar, and Wiley Online Library, we reviewed articles between 2000 and 2022. Search terms included “tyrosine kinase inhibitors,” “adjuvant,” “immunotherapy,” and “renal cell carcinoma.” The articles included were original and published in English. Information on clinical trials was collected from ClinicalTrials.gov, accessed in June 2022. RESULTS: Landmark trials investigating adjuvant vascular endothelial growth factor (VEGF) inhibitors produced conflicting results, with only a single trial of sunitinib (S-TRAC) resulting in US Food and Drug Administration–approval on the basis of a slightly prolonged progression-free survival (PFS). Subsequent meta-analyses failed to show a benefit for adjuvant VEGF inhibitors. Several trials evaluating ICIs are currently ongoing, with pembrolizumab (KEYNOTE-564) earning US Food and Drug Administration–approval for a prolonged PFS, although overall survival data are not yet mature. Preliminary results from other adjuvant ICI trials have been conflicting. CONCLUSION: There remains a lack of clear benefit for the use of adjuvant VEGF inhibitors in local and locoregional RCC. Adjuvant ICI investigations are ongoing, with promising results from KEYNOTE-564. It remains to be seen if PFS is an adequate surrogate end point for overall survival. Selection of patients at greatest risk for recurrence, and identification of those at greatest risk of rare but serious adverse events, may improve outcomes.