Our study validates the concept of randomizing patients with bladder cancer undergoing radical cystectomy to an open or robotic approach. Our results suggest no significant differences in surrogates of oncologic efficacy. Robotic assisted laparoscopic radical cystectomy demonstrates potential benefits of decreased estimated blood loss and decreased hospital stay compared to open radical cystectomy. Our results need to be validated in a larger multicenter prospective randomized clinical trial.

Study Type – Prognosis (retrospective cohort)
Level of Evidence 2b What’s known on the subject? and What does the study add? Upper‐tract urothelial carcinoma (UTUC) is a relatively uncommon urological malignancy with survival and outcomes data largely determined from single‐centre series which can be limited by relatively small case numbers. Through review of a large population based cohort, this study provides valuable information regarding epidemiological and survival patterns for over 13,000 patients with UTUC diagnosed over the past three decades. OBJECTIVE • To evaluate epidemiological and survival patterns of upper‐tract urothelial carcinoma (UTUC) over the past 30 years through a review of a large, population‐based database. PATIENTS AND METHODS • Data from the Surveillance, Epidemiology and End Results (SEER) database from 1973 to 2005 were reviewed in 10‐year increments to evaluate disease trends. • Univariate and multivariate survival analyses identified prognostic variables for outcomes. RESULTS • In total, 13 800 SEER‐registered cases of UTUC were included. The overall incidence of UTUC increased from 1.88 to 2.06 cases per 100 000 person‐years during the period studied, with an associated increase in ureteral disease (0.69 to 0.91) and a decrease in renal pelvic cancers (1.19 to 1.15). • The proportion of in situ tumours increased from 7.2% to 31.0% (P < 0.001), whereas local tumours declined from 50.4% to 23.6% (P < 0.001). • There was no change in the proportion of patients presenting with distant disease. • In multivariate analysis, increasing patient age (P < 0.001), male gender (P < 0.001), black non‐Hispanic race (P < 0.001), bilateral UTUC (P= 0.001) and regional/distant disease (P < 0.001) were all associated with poorer survival outcomes. CONCLUSIONS • The incidence of UTUC has slowly risen over the past 30 years. • Increased use of bladder cancer surveillance regimens and improved abdominal cross‐sectional imaging may contribute to the observed stage migration towards more in situ lesions. • Although pathological disease characteristics impact cancer outcomes, certain sociodemographic factors also appear to portend worse prognosis.

and 47% had invasive disease ( ≥ pT2). Lowgrade and high-grade cancers were present in 33% and 67% of patients, respectively.• Positive, atypical and negative urine cytology was noted in 40%, 40% and 20% of cases. Positive urinary cytology had sensitivity and PPV of 56% and 54% for high-grade and 62% and 44% for muscleinvasive UTUC.• Inclusion of atypical cytology with positive cytology improved the sensitivity and PPV for high-grade (74% and 63%) and muscle-invasive (77% and 45%) UTUC. Restricting analysis to patients with selective ureteral cytologies further improved the diagnostic accuracy when compared with bladder specimens (PPV > 85% for highgrade and muscle-invasive UTUC). CONCLUSIONS• In this cohort of patients with UTUC treated with radical surgery, urine cytology in isolation lacked performance characteristics to accurately predict muscleinvasive or high-grade disease.• Improved surrogate markers for pathological grade and stage are necessary, particularly when considering endoscopic modalities for UTUC. KEYWORDS transitional cell carcinoma, radical nephroureterectomy, urothelial carcinoma, cytologyWhat's known on the subject? and What does the study add? Accurate preoperative staging for upper-tract urothelial carcinoma (UTUC) lesions is presently limited. Urinary cytology has shown promise for characterizing pathological features of bladder cancer. The role of cytology for UTUC is at present poorly defined.In this large multi-institutional cohort of patients, urinary cytology was limited in its ability to accurately predict the grade and stage of upper-tract lesions. Selective ureteral sampling improved the diagnostic accuracy of cytology when compared to bladder specimens. Improved preoperative surrogate markers for staging UTUC remain necessary.Study Type -Therapy (case series) Level of Evidence 4 OBJECTIVE• To evaluate the diagnostic accuracy of urine cytology for detecting aggressive disease in a multi-institutional cohort of patients undergoing extirpative surgery for upper-tract urothelial carcinoma (UTUC). METHODS• We reviewed the records of 326 patients with urinary cytology data who underwent a radical nephroureterectomy or distal ureterectomy without concurrent or previous bladder cancer.• We assessed the association of cytology (positive, negative and atypical) with final pathology. Sensitivity and positive predictive value (PPV) of a positive ( ± atypical) cytology for high-grade and muscle-invasive UTUC was calculated. RESULTS• On final pathology, 53% of patients had non-muscle invasive disease (pTa, pTis, pT1)

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Objective To compare health‐related quality‐of‐life (HRQoL) outcomes for robot‐assisted laparoscopic radical cystectomy (RARC) with those of traditional open radical cystectomy (ORC) in a prospective randomised fashion. Patients and Methods This was a prospective randomised clinical trial evaluating the HRQoL for ORC vs RARC in consecutive patients from July 2009 to June 2011. We administered the Functional Assessment of Cancer Therapy–Vanderbilt Cystectomy Index questionnaire, validated to assess HRQoL, preoperatively and then at 3, 6, 9 and 12 months postoperatively. Scores for each domain and total scores were compared in terms of deviation from preoperative values for both the RARC and the ORC cohorts. Multivariate linear regression was used to assess the association between the type of radical cystectomy and HRQoL. Results At the time of the study, 47 patients had met the inclusion criteria, with 40 patients being randomised for analysis. The cohorts consisted of 20 patients undergoing ORC and 20 undergoing RARC, who were balanced with respect to baseline demographic and clinical features. Univariate analysis showed a return to baseline scores at 3 months postoperatively in all measured domains with no statistically significant difference among the various domains between the RARC and the ORC cohorts. Multivariate analysis showed no difference in HRQoL between the two approaches in any of the various domains, with the exception of a slightly higher physical well‐being score in the RARC group at 6 months. Conclusions There were no significant differences in the HRQoL outcomes between ORC and RARC, with a return of quality of life scores to baseline scores 3 months after radical cystectomy in both cohorts.