Daniel Willis

PURPOSE: While many urologists recommend radical cystectomy for micropapillary bladder cancer invading the lamina propria (cT1), contradictory small reports exist on the efficacy of conservative management with intravesical bacillus Calmette-Guérin for this disease. We report our updated experience in what to our knowledge is the largest series of patients with cT1 micropapillary bladder cancer. MATERIALS AND METHODS: An institutional review board approved review of our cancer database identified 283 patients with micropapillary bladder cancer, including 72 staged with cT1N0M0 disease at diagnosis and initiation of therapy. Survival analysis was performed using the Kaplan-Meier estimator and compared using the log rank test. RESULTS: In this cohort of 72 patients 40 received primary intravesical bacillus Calmette-Guérin and 26 underwent up-front radical cystectomy. Of patients who received bacillus Calmette-Guérin 75%, 45% and 35% experienced disease recurrence, progression and lymph node metastasis, respectively. Patients treated with up-front cystectomy had improved survival compared to patients treated with primary bacillus Calmette-Guérin (5-year disease specific survival 100% vs 60% p = 0.006) and patients who underwent delayed cystectomy after recurrence (5-year disease specific survival 62%, p = 0.015). Prognosis was especially poor in patients who waited for progression before undergoing radical cystectomy with an estimated 5-year disease specific survival of only 24% and a median survival of 35 months. In patients treated with up-front cystectomy pathological up-staging was found in 27%, including 20% with lymph node metastasis. CONCLUSIONS: While certain patients with T1 micropapillary bladder cancer may respond to intravesical bacillus Calmette-Guérin, survival is improved in those who undergo early radical cystectomy. Further molecular studies are needed to identify subsets of patients in whom the bladder can be safely spared.

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Few studies exist comparing functional outcomes between RALP and LRP using validated questionnaires. This single surgeon study utilizes data from the EPIC questionnaire that was collected prospectively to compare urinary and sexual function after prostatectomy. In this comparison, return of post‐prostatectomy continence was similar between groups while RALP patients demonstrated earlier return of sexual function. OBJECTIVE To compare perioperative, oncological and functional outcomes of laparoscopic radical prostatectomy (LRP) and robot‐assisted laparoscopic radical prostatectomy (RALP) with emphasis on health‐related quality of life (HRQOL) data as few studies exist. PATIENTS AND METHODS Patients underwent RALP or LRP by a single, fellowship trained surgeon with a standard clinical care pathway. HRQOL data using the Expanded Prostate Cancer Index Composite (EPIC) were collected at 0, 3, 6 and 12 months after 175 consecutive LRP and 174 RALP procedures. Urinary and sexual function outcomes were compared using two methods: (1) EPIC summary/subscale analyses described as percent return to baseline function and (2) traditional single‐question analysis. RESULTS The two groups were statistically similar with respect to demographics, clinical stage, perioperative outcomes, stage‐specific surgical margin rates, and baseline urinary and sexual function scores. There was no statistical difference in postoperative urinary function between RALP and LRP using EPIC or single‐question analyses at 3, 6 and 12 months. EPIC questionnaire data showed a greater return to baseline sexual function over time (mixed model analysis) in RALP than in LRP patients who had a bilateral nerve sparing procedure (Sexual Summary Score, P = 0.005; Sexual Function and Bother Subscales, P = 0.007). Using EPIC, RALP patients receiving a bilateral nerve sparing procedure showed improved percent return to baseline potency at 3 and 6 months ( P < 0.025) compared with LRP patients, but had similar outcomes at 12 months (73.7% vs 66.2%, P = 0.3). Single‐question analysis suggested improved potency after RALP compared with LRP, with a greater percentage of RALP patients reporting successful sexual intercourse in the past 4 weeks (87.5% vs 66.7% at 12 months, P = 0.06). CONCLUSIONS When comparing surgical techniques, RALP and LRP groups showed statistically similar postoperative urinary function outcomes. RALP patients had an earlier return of sexual function when compared with LRP patients after a bilateral nerve sparing procedure.

What's known on the subject? and What does the study add? Citation rates have been previously studied in the general medical literature and in a few subspecialties. The results of these studies have differed showing an association with citation rates and multiple study characteristics that include the design of the study, study topic, industry funding, the number of authors and institutions, newsworthiness, sample size, and journal prestige. Correlates with citation rates have never been studied within the field of urology, but are important as urology is a unique surgical discipline with complex disease processes and rapidly changing technology. Our study is the first to evaluate the factors associated with increased citation rates in the urological literature and will assist authors in improving the impact of their work in urology. To assess the factors associated with increased citation rates in the urological literature by reviewing articles published in the four major urological journals to help authors improve the impact of their work. A random sample of 200 original research articles published between January and June 2004 was analysed from The Journal of Urology, Urology, European Urology and BJU International . Study information was abstracted by two independent reviewers and citation counts within 4 years of publication were collected using Web of Science TM . Study characteristics and citation rates were analysed using median and interquartile ranges (IQRs), and logistic regression analysis was used to evaluate which factors predicted greater citation rates. The overall median number of citations per published article was 6.0 (IQR 3–12). After univariate analysis, we found that study design, study topic, continent of origin and sample size were associated with greater median citation rates. In a multivariate linear regression model, study design and study topic (oncology) predicted increased citation rates. Randomized controlled trials were cited a median of 13.5 times and were the strongest predictor of citation rates with an odds ratio of 115.5 (95% confidence interval 9.4–1419.6). Citation rates are associated with study design and study topic in the urological literature. Authors may improve the impact of their work by designing clinical studies with greater methodological safeguards against bias.