Instructions: To be completed by attending surgeon. Please complete within 7 days of hospital discharge. Surgeons should be provided with this form prior to the surgical event. All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red and write AMENDED across top of form

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header Module
C1320722 (UMLS CUI-1)
Trial subject ID SWOG
Item
SWOG Patient ID
float
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1519429 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25699 (NCI Thesaurus Property-2)
Protocol ID SWOG
Item
SWOG Study No.
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1519429 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25699 (NCI Thesaurus Property-2)
Registration Number
Item
Registration Step
text
C25337 (NCI Thesaurus ValueDomain)
C1514821 (UMLS CUI-1)
C25646 (NCI Thesaurus ObjectClass)
C0237753 (UMLS CUI-2)
C16154 (NCI Thesaurus Property)
C16154 (NCI Thesaurus ValueDomain-2)
Patient Initials
Item
Patient Initials (L, F M)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
FormCompletionDate
Item
Date of completion (MM DD YYYY)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
Institution Name
Item
Institution/Affiliate
text
C25454 (NCI Thesaurus ObjectClass)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)
Investigator Name
Item
Physician
text
C25191 (NCI Thesaurus ValueDomain)
C2826892 (UMLS CUI-1)
C25364 (NCI Thesaurus Property)
C17089 (NCI Thesaurus ObjectClass)
C25644 (NCI Thesaurus ObjectClass-2)
Participating Group
Item
Participating Group Name
text
C25191 (NCI Thesaurus ValueDomain)
C2347449 (UMLS CUI-1)
C25608 (NCI Thesaurus ObjectClass)
C17005 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
Study Number Participating Group
Item
Participating Group Study No.
text
C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Trial subject ID Participating Group
Item
Participating Group Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Item Group
Hospitalization
ProtocolSurgeryDate
Item
Protocol Surgery Date (MM DD YYYY)
date
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C42651 (NCI Thesaurus ObjectClass-2)
C0442711 (UMLS 2011AA ObjectClass-2)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
InpatientHospitalDischargeDate
Item
Discharge Date (MM DD YYYY)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C16696 (NCI Thesaurus ObjectClass)
C0019994 (UMLS 2011AA ObjectClass)
C25182 (NCI Thesaurus ObjectClass-2)
C0021562 (UMLS 2011AA ObjectClass-2)
C25166 (NCI Thesaurus Property)
C0030685 (UMLS 2011AA Property)
HospitalIntensiveCareUnitAdmissionDayCount
Item
Number of days in ICU
float
C16696 (NCI Thesaurus ObjectClass)
C0019994 (UMLS 2011AA ObjectClass)
C25385 (NCI Thesaurus Property)
C0809949 (UMLS 2011AA Property)
C53511 (NCI Thesaurus Property-2)
C0021708 (UMLS 2011AA Property-2)
C25301 (NCI Thesaurus ValueDomain)
C0439228 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
Item
Did patient require an unplanned admission to ICU at any time
text
C16696 (NCI Thesaurus ObjectClass)
C25385 (NCI Thesaurus Property)
C53511 (NCI Thesaurus Property-2)
C88009 (NCI Thesaurus Property-3)
C38147 (NCI Thesaurus ValueDomain)
C0019994 (UMLS CUI-1)
C0809949 (UMLS CUI-2)
C0021708 (UMLS CUI-3)
C1512698 (UMLS CUI-4)
CL.1
Code List
Did patient require an unplanned admission to ICU at any time
HospitalDischargeDayCount
Item
Length of hospital stay (ICU and acute care)
float
C16696 (NCI Thesaurus ObjectClass)
C0019994 (UMLS 2011AA ObjectClass)
C25301 (NCI Thesaurus ValueDomain)
C0439228 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
C0012621 (NCI Metathesaurus Property)
Item
Was TPN used postoperatively (Central/Total Parenteral Nutrition)
text
C38148 (NCI Thesaurus ValueDomain)
C38276 (NCI Thesaurus Property)
C25382 (NCI Thesaurus Property-2)
C15433 (NCI Thesaurus ObjectClass)
C1512699 (UMLS CUI-1)
C1522726 (UMLS CUI-2)
C1521801 (UMLS CUI-3)
C0242739 (UMLS CUI-4)
CL.2
Code List
Was TPN used postoperatively (Central/Total Parenteral Nutrition)
Item
Were enteral tube feedings used postoperatively
text
C38148 (NCI Thesaurus ValueDomain)
C25471 (NCI Thesaurus Property)
C73430 (NCI Thesaurus ObjectClass)
C25409 (NCI Thesaurus Property-2)
C1512699 (UMLS CUI-1)
C0521116 (UMLS CUI-2)
C0041281 (UMLS CUI-3)
C1533734 (UMLS CUI-4)
CL.3
Code List
Were enteral tube feedings used postoperatively
Item Group
Disease Description
Item
Pathologic T Stage
text
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C12414 (NCI Thesaurus ObjectClass-2)
C0005682 (UMLS 2011AA ObjectClass-2)
C25610 (NCI Thesaurus Property)
C1521733 (UMLS 2011AA Property)
C25728 (NCI Thesaurus Property-2)
C0475455 (UMLS 2011AA Property-2)
C25610 (NCI Thesaurus ValueDomain)
C1521733 (UMLS 2011AA ValueDomain)
C4912 (NCI Thesaurus ValueDomain-2)
C0699885 (UMLS 2011AA ValueDomain-2)
C16899 (NCI Thesaurus ValueDomain-3)
C1300072 (UMLS 2011AA ValueDomain-3)
C25728 (NCI Thesaurus ValueDomain-4)
C0475455 (UMLS 2011AA ValueDomain-4)
CL.4
Code List
Pathologic T Stage
CL Item
Tumor Invades Superficial Muscularis Propria (inner Half) (pT2a)
CL Item
Tumor Invades Deep Muscularis Propria (outer Half) (pT2b)
CL Item
Tumor Invades Perivesical Tissue Microscopically (pT3a)
CL Item
Tumor Invades Perivesical Tissue Macroscopically (extravesical Mass) (pT3b)
CL Item
Tumor Invades Prostatic Stroma, Uterus, Vagina (pT4a)
Item
Pathologic N Stage
text
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C12414 (NCI Thesaurus ObjectClass-2)
C0005682 (UMLS 2011AA ObjectClass-2)
C25610 (NCI Thesaurus Property)
C1521733 (UMLS 2011AA Property)
C25580 (NCI Thesaurus Property-2)
C0456532 (UMLS 2011AA Property-2)
C25610 (NCI Thesaurus ValueDomain)
C1521733 (UMLS 2011AA ValueDomain)
C4912 (NCI Thesaurus ValueDomain-2)
C0699885 (UMLS 2011AA ValueDomain-2)
C16899 (NCI Thesaurus ValueDomain-3)
C1300072 (UMLS 2011AA ValueDomain-3)
C25580 (NCI Thesaurus ValueDomain-4)
C0456532 (UMLS 2011AA ValueDomain-4)
CL.5
Code List
Pathologic N Stage
CL Item
Lymph Nodes Cannot Be Assessed (pNX)
CL Item
No Lymph Node Metastasis (pN0)
CL Item
Single Regional Lymph Node Metastasis In The True Pelvis (hypogastric, Obturator, External Iliac Or Presacral Lymph Node) (pN1)
CL Item
Multiple Regional Lymph Node Metastasis In The True Pelvis (hypogastric, Obturator, External Iliac Or Presacral Lymph Node Metastasis) (pN2)
CL Item
Lymph Node Metastasis To The Common Iliac Lymph Nodes (pN3)
Item
Histologic Type (select all that apply)
text
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C12414 (NCI Thesaurus ObjectClass-2)
C0005682 (UMLS 2011AA ObjectClass-2)
C25526 (NCI Thesaurus Property)
C0205462 (UMLS 2011AA Property)
C25161 (NCI Thesaurus Property-2)
C0008902 (UMLS 2011AA Property-2)
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C25526 (NCI Thesaurus ValueDomain-2)
C0205462 (UMLS 2011AA ValueDomain-2)
CL.6
Code List
Histologic Type (select all that apply)
CL Item
Urothelial Carcinoma (Urothelial cell carcinoma)
C4030 (NCI Thesaurus)
C0007138 (UMLS 2011AA)
CL Item
Squamous Cell Carcinoma (Squamous cell carcinoma)
C2929 (NCI Thesaurus)
C0007137 (UMLS 2011AA)
CL Item
Adenocarcinoma (Adenocarcinoma)
C2852 (NCI Thesaurus)
C0001418 (UMLS 2011AA)
CL Item
Micropapillary Transitional Cell Carcinoma (Micropapillary carcinoma)
C65182 (NCI Thesaurus)
C1266012 (UMLS 2011AA)
CL Item
Other Specify (Other, specify)
Histologic Type, other
Item
Other specify
text
C25685 (NCI Thesaurus ValueDomain)
C1299220 (UMLS CUI-1)
C3262 (NCI Thesaurus ObjectClass)
C25526 (NCI Thesaurus Property)
C25161 (NCI Thesaurus Property-2)
Item
Type of Variant Histology (if selected please specify)
text
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25526 (NCI Thesaurus Property)
C0205462 (UMLS 2011AA Property)
C25713 (NCI Thesaurus Property-2)
C0205419 (UMLS 2011AA Property-2)
CL.7
Code List
Type of Variant Histology (if selected please specify)
CL Item
Urothelial Carcinoma (< 50% Urothelial cell carcinoma)
C4030 (NCI Thesaurus)
C0007138 (UMLS 2011AA)
C4030 (NCI Thesaurus-3)
C0007138 (UMLS 2011AA-4)
CL Item
Urothelial Carcinoma (>= 50% Urothelial cell carcinoma)
C4030 (NCI Thesaurus)
C0007138 (UMLS 2011AA)
C4030 (NCI Thesaurus-3)
C0007138 (UMLS 2011AA-4)
CL Item
Squamous Cell Carcinoma (< 50% Squamous cell carcinoma)
C2929 (NCI Thesaurus)
C0007137 (UMLS 2011AA)
C2929 (NCI Thesaurus-3)
C0007137 (UMLS 2011AA-4)
CL Item
Squamous Cell Carcinoma (>= 50% Squamous cell carcinoma)
C2929 (NCI Thesaurus)
C0007137 (UMLS 2011AA)
C2929 (NCI Thesaurus-3)
C0007137 (UMLS 2011AA-4)
CL Item
Adenocarcinoma (< 50% Adenocarcinoma)
C2852 (NCI Thesaurus)
C0001418 (UMLS 2011AA)
C2852 (NCI Thesaurus-3)
C0001418 (UMLS 2011AA-4)
CL Item
Adenocarcinoma (>= 50% Adenocarcinoma)
C2852 (NCI Thesaurus)
C0001418 (UMLS 2011AA)
C2852 (NCI Thesaurus-3)
C0001418 (UMLS 2011AA-4)
CL Item
Micropapillary Transitional Cell Carcinoma (< 50% Micropapillary carcinoma)
C65182 (NCI Thesaurus)
C1266012 (UMLS 2011AA)
C65182 (NCI Thesaurus-3)
C1266012 (UMLS 2011AA-4)
CL Item
Micropapillary Transitional Cell Carcinoma (>= 50% Micropapillary carcinoma)
C65182 (NCI Thesaurus)
C1266012 (UMLS 2011AA)
C65182 (NCI Thesaurus-3)
C1266012 (UMLS 2011AA-4)
Item Group
Complications
C0009566 (UMLS CUI-1)
C0348025 (UMLS CUI-2)
Item
Was the assessment done
text
C38147 (NCI Thesaurus ValueDomain)
C20989 (NCI Thesaurus Property)
C41331 (NCI Thesaurus ObjectClass)
C15329 (NCI Thesaurus ObjectClass-2)
C1512698 (UMLS CUI-1)
C0031809 (UMLS CUI-2)
C0877248 (UMLS CUI-3)
C0543467 (UMLS CUI-4)
CL.8
Code List
Was the assessment done
SurgicalProcedureComplicationSpecify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C2959 (NCI Thesaurus Property)
C0009566 (UMLS 2011AA Property)
SurgicalProcedureComplicationSpecify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C2959 (NCI Thesaurus Property)
C0009566 (UMLS 2011AA Property)
AdverseEventSymptomBeginDate
Item
Start date (MM DD YYYY should be the date of surgery)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C25431 (NCI Thesaurus ValueDomain-2)
C0439659 (UMLS 2011AA ValueDomain-2)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
AdverseEventSymptomEndDate
Item
Stop date (MM DD YYYY should be the date of hospital discharge)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
Item
Surgical Complications
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C2959 (NCI Thesaurus Property)
C0009566 (UMLS 2011AA Property)
CL.9
Code List
Surgical Complications
CL Item
Superficial Wound Infection (Superficial wound infection)
C45234 (NCI Thesaurus)
C0043241 (UMLS 2011AA)
C25239 (NCI Thesaurus-3)
C0205124 (UMLS 2011AA-4)
CL Item
Deep Wound Infection (Deep wound infection)
C45234 (NCI Thesaurus)
C0043241 (UMLS 2011AA)
C25240 (NCI Thesaurus-3)
C0205125 (UMLS 2011AA-4)
CL Item
Wound Disruption (Wound disruption)
C25486 (NCI Thesaurus)
C0332453 (UMLS 2011AA)
C3671 (NCI Thesaurus-3)
C0043250 (UMLS 2011AA-4)
CL Item
Pneumonia (PNEUMONIA)
C3333 (NCI Thesaurus)
C0032285 (UMLS 2011AA)
CL Item
Intubation (Re-intubation)
C37981 (NCI Thesaurus)
C0021925 (UMLS 2011AA)
CL Item
Pulmonary Embolism (Pulmonary Embolism)
C50713 (NCI Thesaurus)
C0034065 (UMLS 2011AA)
CL Item
Deep Vein Thrombosis (Deep venous thrombosis)
C49343 (NCI Thesaurus)
C0149871 (UMLS 2011AA)
CL Item
Failure To Wean From Ventilator Within 48 Hours (Failure to wean from ventilator within 48 hours)
CL Item
Sepsis (Sepsis)
E11560 (CTCAE)
CL Item
Anastomotic Bowel Leak (Anastomotic bowel leak)
CL Item
Renal Insufficiency Dialysis (Renal insufficiency requiring dialysis)
C1565489 (NCI Metathesaurus)
C15221 (NCI Thesaurus)
C0011946 (UMLS 2011AA)
CL Item
Symptomatic Lymph Leakage/lymphocele (Symptomatic lymph leakage/lymphocele)
CL Item
Lymph Leakage/lymphocele Requiring Intervention (Lymph leakage/lymphocele requiring intervention)
CL Item
Acute Renal Failure (Acute renal failure)
C26808 (NCI Thesaurus)
C0022660 (UMLS 2011AA)
CL Item
Urinary Tract Infection (Urinary tract infection)
C50791 (NCI Thesaurus)
C0042029 (UMLS 2011AA)
CL Item
Cerebrovascular Accident Stroke (CVA/stroke)
C3390 (NCI Thesaurus)
C0038454 (UMLS 2011AA)
E12826 (CTCAE)
CL Item
Cardiac Event With Cpr (Cardiac event with CPR)
CL Item
Myocardial Infarction (Myocardial infarction)
E10152 (CTCAE)
CL Item
Ileus (Ileus)
E10812 (CTCAE)
CL Item
Bowel Obstruction (Bowel obstruction)
CL Item
Hemorrhage Postoperative (Bleeding > 4 units postoperative)
C26791 (NCI Thesaurus)
C0019080 (UMLS 2011AA)
C28006 (NCI Thesaurus-3)
C0032790 (UMLS 2011AA-4)
CL Item
Death Within 30 Days Of Cystectomy (Death within 30 days of cystectomy)
CL Item
Death Prior To Hospital Discharge (Death prior to hospital discharge)
CL Item
Other, Specify (Other, Specify)
Item
Surgical Complication Grade
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C15329 (NCI Thesaurus Property-2)
C0543467 (UMLS 2011AA Property-2)
C2959 (NCI Thesaurus Property-3)
C0009566 (UMLS 2011AA Property-3)
C48309 (NCI Thesaurus Property-4)
C0441800 (UMLS 2011AA Property-4)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.10
Code List
Surgical Complication Grade
CL Item
Use Of Oral Medications Or Bedside Intervention (Use of oral medications or bedside intervention)
CL Item
Use Of Intravenous Medication, Total Parenteral Nutrition (tpn), Enteral Nutrition, Or Blood Transfusion (Use of intravenous medication, total parenteral nutrition (TPN), enteral nutrition, or blood transfusion)
CL Item
Interventional Radiology, Therapeutic Endoscopy, Intubation, Angiography, Or Operation (Interventional radiology, therapeutic endoscopy, intubation, angiography, or operation)
CL Item
Residual Lasting Disability Requiring Major Rehabilitation Or Organ Resection (Residual lasting disability requiring major rehabilitation or organ resection)
CL Item
Death (Death of patient)
C28554 (NCI Thesaurus)
C0011065 (UMLS 2011AA)
Item Group
Transfusions
C1879316 (UMLS CUI-1)
WholeBloodTransfusionCount
Item
Total units whole blood
float
C0370231 (NCI Metathesaurus ObjectClass)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C25256 (NCI Thesaurus Property)
C1265611 (UMLS 2011AA Property)
C15408 (NCI Thesaurus ObjectClass)
FreshFrozenPlasmaTransfusionReceivedUnitCount
Item
Total units fresh frozen plasma
float
C0016709 (NCI Metathesaurus ObjectClass)
C15408 (NCI Thesaurus ObjectClass)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C44278 (NCI Thesaurus ValueDomain)
C0439148 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
PackedRedBloodCellTransfusionReceivedUnitCount
Item
Total units PRBC
float
C44278 (NCI Thesaurus ValueDomain)
C0439148 (UMLS 2011AA ValueDomain)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
C15409 (NCI Thesaurus ObjectClass)
C0199962 (UMLS 2011AA ObjectClass)
PlateletTransfusionReceivedUnitCount
Item
Total units platelets
float
C44278 (NCI Thesaurus ValueDomain)
C0439148 (UMLS 2011AA ValueDomain)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C25463 (NCI Thesaurus ValueDomain-2)
C0750480 (UMLS 2011AA ValueDomain-2)
C15366 (NCI Thesaurus ObjectClass)
C0086818 (UMLS 2011AA ObjectClass)
Item Group
Comments
C0947611 (UMLS CUI-1)
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
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