Urology Practice最新文献

Introduction: The United States has a high incarceration rate, with documented racial and socioeconomic disparities in incarceration. Cancer is the leading cause of death in prisons, accounting for nearly a third of deaths. Previous studies suggest that incarcerated patients may present with more advanced disease and worse cancer-specific outcomes. We aimed to assess the association between incarceration status and stage at presentation in bladder cancer.

Methods: We used the Michigan Cancer Surveillance Program, a statewide, population-based registry. We included patients diagnosed with bladder cancer between 2004 and 2019. Advanced stage was defined as pathological T stage ≥ 2, nodal involvement (N+), or distant metastasis (M+). Demographic and clinicopathological variables included were age, sex, race/ethnicity, year of diagnosis, smoking history, histological grade, and tumor stage. Patients were stratified by incarceration status. Univariable and multivariable logistic regression analyses were performed to assess the association between incarceration status and advanced disease at the diagnosis, after adjusting for relevant covariates.

Results: Among 29,429 patients with bladder cancer, 31 (0.1%) were incarcerated at diagnosis. Incarcerated patients were younger (median age 58 vs 72 years, P < .001), more frequently Black (16.1% vs 6.2%), and had a higher proportion of ≥T2 stage disease (32.3% vs 20.4%). In unadjusted analysis, incarceration was not significantly associated with advanced disease (odds ratio [OR] 1.82, 95% CI: 0.82-3.77; P = .12). However, in multivariable analysis adjusting for age, sex, race, smoking, and grade, incarceration was associated with higher odds of advanced stage at presentation (OR 2.46, 95% CI: 1.01-5.82; P = .04). Female sex, Black race, smoking status, and high-grade tumors were also independently associated with advanced disease.

Conclusions: Incarceration at the time of diagnosis was independently associated with higher odds of presenting with advanced-stage bladder cancer. These findings highlight incarceration status as a marker of clinical vulnerability, not fully explained by known risk factors such as smoking or race. Addressing this disparity will require both preventive strategies targeting modifiable risk factors and structural interventions to ensure timely access to cancer diagnosis and care within correctional settings.

Introduction: Immune checkpoint inhibitors targeting programmed death-1 (PD-1) in combination with tyrosine kinase inhibitors have reshaped the first-line treatment landscape of advanced renal cell carcinoma (RCC). However, the relative efficacy and safety of different PD-1-based regimens remain unclear. This meta-analysis aims to evaluate the efficacy and safety of first-line anti-PD-1-based combinations with tyrosine kinase inhibitors compared with sunitinib in metastatic RCC and to explore whether clinical outcomes differ according to the PD-1 inhibitor subtype.

Methods: We performed a systematic review and meta-analysis of phase III randomized controlled trials comparing anti-PD-1-based combinations (pembrolizumab + axitinib, pembrolizumab + lenvatinib, nivolumab + cabozantinib) vs sunitinib in treatment-naïve advanced RCC. HRs for overall survival (OS) and progression-free survival (PFS) were pooled using random-effects models. Subgroup analyses were conducted according to PD-L1 status.

Results: Three pivotal trials enrolling 2224 patients were included. Anti-PD-1-based regimens significantly improved OS (pooled HR = 0.66, 95% CI 0.53-0.83) and progression-free survival (pooled HR = 0.56, 95% CI 0.47-0.67) compared with sunitinib, with consistent gains in objective response rate. Subgroup analyses showed benefit irrespective of PD-L1 status: pooled HRs for OS were 0.54 (95% CI 0.42-0.68) in PD-L1-negative and 0.53 (95% CI 0.38-0.74) in PD-L1-positive tumors.

Conclusions: First-line anti-PD-1-based immunotherapy combinations significantly improve survival and response outcomes over sunitinib in advanced RCC, with consistent efficacy across PD-1 subtypes and PD-L1 expression groups.

Introduction: This study aims to evaluate demographic and clinical factors associated with noncompliance with intravesical bacillus Calmette-Guérin (BCG) therapy in patients with nonmuscle-invasive bladder cancer (NMIBC).

Methods: A retrospective chart review was conducted of 239 patients with International Bladder Cancer Group intermediate- or high-risk NMIBC who received BCG therapy between 2012 and 2020 at a single academic/community practice. Compliance was assessed separately for receipt of adequate BCG, defined per FDA guidelines (≥5/6 induction doses and ≥2/3 maintenance doses), and for maintenance therapy adherence based on SWOG protocols (1 year for intermediate-risk disease, 3 years for high-risk disease). Compliance with maintenance instillations was defined as therapy administered within 1 month (intermediate risk) or 3 months (high risk) of the scheduled date. Associations between compliance and clinical or demographic factors, including clinical trial participation, were analyzed.

Results: After exclusions, 209 patients were included. Adequate BCG was received by 189 (90.4%) patients. Male patients demonstrated higher maintenance compliance than female patients (82% vs 68%, P = .048). Clinical trial participation was strongly associated with maintenance compliance (97.8% vs 63.3%, P < .0001), as was high-risk disease status compared with intermediate-risk disease (P = .036). Race, age, insurance type, and distance to clinic were not significantly associated with compliance. Recurrence rates were low (13.3%) in this highly compliant cohort.

Conclusions: High rates of BCG compliance and low recurrence rates are achievable in an academic/community setting. Clinical trial participation, high-risk disease status, and male sex were associated with improved compliance. These findings may inform strategies to optimize BCG delivery and improve outcomes in NMIBC.

Introduction: While the use of carbonic anhydrase inhibitors (CAIs) rises, studies of urinary stone formation with CAIs are limited. We sought to study the association between CAIs and reports of stone-related adverse drug reactions (ADRs), investigate dose-dependent associations, and identify at-risk clinical subgroups.

Methods: We conducted a pharmacovigilance case-noncase study of signals of stone formation reported with CAIs in VigiBase, a WHO global database of case-safety reports. We included all adverse events (1967-2022); only duplicate reports identified by VigiBase were excluded. We conducted disproportionality analysis with a significance threshold of the lower bound 95% Empiric Bayes Estimator > 1 and described the reporting odds ratio (ROR) and 95% CI.

Results: Of 63,448,915 adverse events, we identified 246 reports of stone-related ADRs with CAI use. CAIs were significantly associated with stone-related ADRs (ROR 5.02; 95% CI: 4.43-5.70). Significant disproportionality signals were observed for topiramate (ROR 4.91; 95% CI: 4.27-5.65), zonisamide (ROR 8.00; 95% CI: 5.84-10.96), and acetazolamide (ROR 2.56; 95% CI: 1.42-4.62). Stone-related ADRs were heavily reported in patients aged < 45 (ROR 8.72; 95% CI: 7.06-10.76) and patients taking zonisamide and topiramate for seizure (ROR 9.40; 95% CI: 6.87-12.85). Dose-dependent associations were observed with topiramate (ROR 25-99 mg: 3.20; ROR 100-199 mg: 5.92; ROR 200-400 mg: 6.57) and zonisamide (ROR 100-199 mg: 6.79; ROR 200-399 mg: NS, ROR 400-600 mg: 14.29).

Conclusions: CAIs were significantly associated with dose-dependent reporting of stone-related ADRs. Younger patients and patients with indication of seizure had higher risk of reporting stone-related ADRs. At-risk patients should be counseled on the risk of developing stones when taking CAIs.

Introduction: Minimally invasive therapies (MITs) for overactive bladder (OAB) are effective for patients who have failed or cannot tolerate medical management. Despite this, rates of MIT are low and have remained stagnant. Using the AQUA database, we examine trends in utilization of MIT over time with a focus on patient and provider factors that affect selection of sacral neuromodulation (SNM) over other MITs for OAB.

Methods: The AQUA Registry was queried for adults with idiopathic OAB who received MIT from 2014 to 2023. Patients were analyzed by age, race, sex, insurance, and MIT trends over time. Multivariable logistic regression was used to evaluate patient and provider factors associated with SNM selection.

Results: Of 2,006,684 patients with idiopathic OAB, 58,840 (2.9%) received MIT; 19,582 (0.98%) SNM; 28,463 (1.4%) bladder onabotulinum toxin injection (BTX-A); and 17,045 (0.85%) percutaneous tibial nerve stimulation. There was an increase in those undergoing BTX-A and a decline in those undergoing SNM and percutaneous tibial nerve stimulation over time. Patients receiving SNM vs other MITs were more likely to be younger than 51 years, male, in a rural area, and seen in a high-volume OAB practice. Patients in the Southeastern and South Central sections were more likely to receive SNM.

Conclusions: Overall utilization of MIT was 2.9% over a 9-year period. While SNM has seen a decline in relative utilization compared with BTX-A, overall MIT use has stayed stagnant. Patient and provider demographics impact choice of SNM over other MITs. These findings highlight an opportunity to better understand trends and limitations when providing MITs.