Purpose Malnutrition is emerging as a significant factor in patient outcomes. A contemporary review of malnutrition has not been performed for the urologist. We review the available literature and ...current standards of care for malnutrition screening, assessment and intervention, focusing on patients with bladder cancer treated with cystectomy. Materials and Methods Our multidisciplinary team searched PubMed® for available literature on malnutrition, focusing on definition and significance, importance to urologists, screening, assessment, diagnosis, immunological and economic impacts, and interventions. Results The prevalence of malnutrition in hospitalized patients is estimated to range from 15% to 60%, reaching upward of 71% in those with cancer. Malnutrition has been shown to increase inflammatory markers, further intensifying catabolism and weight loss. Bladder cancer is catabolic and patients undergoing cystectomy have increased resting energy expenditure postoperatively. Data are emerging on the impact of malnutrition in the cystectomy population. Recent studies have identified poor nutritional status based on low albumin or sarcopenia (loss of muscle) as having an adverse impact on length of hospitalization, complications and survival. The current standard of care malnutrition assessment tool, the 2012 consensus statement of the Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition, has not been evaluated in the urological literature. Perioperative immunonutrition in patients undergoing colorectal surgery has been associated with significant decreases in postoperative complications, and recent pilot work has identified the potential for immunonutrition to positively impact the cystectomy population. Conclusions Malnutrition has a significant impact on surgical patients, including those with bladder cancer. There are emerging data in the urological literature regarding how best to identify and improve the nutritional status of patients undergoing cystectomy. Additional research is needed to identify malnutrition in these patients and interventions to improve surgical outcomes.
Microhematuria: AUA/SUFU Guideline Barocas, Daniel A; Boorjian, Stephen A; Alvarez, Ronald D ...
The Journal of urology,
10/2020, Volume:
204, Issue:
4
Journal Article
Peer reviewed
Open access
Patients presenting with microhematuria represent a heterogeneous population with a broad spectrum of risk for genitourinary malignancy. Recognizing that patient-specific characteristics modify the ...risk of underlying malignant etiologies, this guideline sought to provide a personalized diagnostic testing strategy.
The systematic review incorporated evidence published from January 2010 through February 2019, with an updated literature search to include studies published up to December 2019. Evidence-based statements were developed by the expert Panel, with statement type linked to evidence strength, level of certainty, and the Panel's judgment regarding the balance between benefits and risks/burdens.
Microhematuria should be defined as ≥ 3 red blood cells per high power field on microscopic evaluation of a single specimen. In patients diagnosed with gynecologic or non-malignant genitourinary sources of microhematuria, clinicians should repeat urinalysis following resolution of the gynecologic or non-malignant genitourinary cause. The Panel created a risk classification system for patients with microhematuria, stratified as low-, intermediate-, or high-risk for genitourinary malignancy. Risk groups were based on factors including age, sex, smoking and other urothelial cancer risk factors, degree and persistence of microhematuria, as well as prior gross hematuria. Diagnostic evaluation with cystoscopy and upper tract imaging was recommended according to patient risk and involving shared decision-making. Statements also inform follow-up after a negative microhematuria evaluation.
Patients with microhematuria should be classified based on their risk of genitourinary malignancy and evaluated with a risk-based strategy. Future high-quality studies are required to improve the care of these patients.
We evaluated the AUA (American Urological Association)/SUO (Society of Urologic Oncology) nonmuscle invasive bladder cancer risk model to predict nonmuscle invasive bladder cancer recurrence and ...progression prior to death.
We performed a retrospective analysis using electronic medical records and cancer registry data of patients with nonmuscle invasive bladder cancer in a multicenter United States patient population. We evaluated recurrence-free and progression-free survival according to the AUA/SUO nonmuscle invasive bladder cancer risk model. We then assessed discriminative performance with the c-index and compared the cumulative incidence of recurrence, progression and death across 4 age groups.
We identified 1,297 patients with nonmuscle invasive bladder cancer. Median followup in the cohort was 3.2 years. The c-index of the AUA/SUO recurrence model was 0.62 and for progression it was higher at 0.77. Patients younger than 60 years had a 40% greater probability of recurrent nonmuscle invasive bladder cancer vs death while patients 84 years old or older had a 12% greater probability of death prior to recurrence at 5 years. This study was limited by its retrospective design.
The AUA/SUO nonmuscle invasive bladder cancer risk model provides predictive performance of recurrence and progression similar to that of previous similar risk models, such as the models of the European Organization for Research and Treatment of Cancer, the Club Urológico Español de Tratamiento Oncológico and the National Comprehensive Cancer Network®. This work illustrates the need to consider age in predictive tools for clinicians who treat patients with nonmuscle invasive bladder cancer.
Summary The objective of this study was to compare the predictive ability of potential tissue biomarkers to known prognostic factors that predict renal cell carcinoma (RCC) recurrence using an ...automated system of immunohistochemical analysis. After institutional review board approval, a tissue microarray was constructed using tissue from patients who had partial or radical nephrectomy for RCC. Patients with metastatic disease were excluded. Immunohistochemical staining of the tissue microarray for Ki-67, C-reactive protein, carbonic anhydrase 9, and hypoxia-inducible factors 1α and 2 α was analyzed using automated image analysis. Univariable and multivariable analyses were performed to evaluate the association of putative biomarkers and known prognostic factors. Of 216 patients who met the entrance criteria, 34 (16%) patients developed metastatic recurrence within a median follow-up interval of 60.9 (interquartile range, 13.9-87.1) months. RCC morphotypes analyzed in this study include clear cell ( n = 156), papillary ( n = 38), chromophobe ( n = 16), and collecting duct/unclassified ( n = 6). Univariate analysis identified that only increased Ki-67 was predictive of RCC recurrence among the proteins evaluated, in addition to other known clinicopathological prognostic factors. After multivariate analysis, Ki-67 was identified as an independently predictive risk factor for RCC recurrence (hazard ratio HR, 3.73 confidence interval {CI}, 1.60-8.68). Other independent predictors of RCC recurrence included tumor diameter (HR, 1.20 CI, 1.02-1.41) and perinephric fat invasion (HR, 4.49 CI, 1.11-18.20). We conclude that Ki-67 positivity is independently predictive of RCC recurrence after surgery in nonmetastatic patients. Automated analysis of tissue protein expression can facilitate a more objective and expedient investigation of tissue biomarkers for RCC.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
We assessed the performance of the EORTC (European Organisation for Research and Treatment of Cancer) and CUETO (Club Urológico Español de Tratamiento Oncológico) nonmuscle invasive bladder cancer ...predictive models compared to current United States NCCN Guidelines® in an American population.
We retrospectively analyzed the electronic medical records of patients with nonmuscle invasive bladder cancer in a multicenter population in the United States. We evaluated recurrence-free and progression-free survival according to EORTC and CUETO, and assessed discriminative performance with the c-index at 1 and 5 years. We then compared the discrimination of EORTC and CUETO to the discrimination of the 4 nonmuscle invasive bladder cancer treatment groups described in NCCN Guidelines.
We identified 1,333 patients with nonmuscle invasive bladder cancer and a median followup of 37 months. At 5 years the recurrence c-index of EORTC and CUETO was 0.59 and 0.56 while for progression it was higher at 0.74 and 0.72, respectively. NCCN Guidelines demonstrated a similar c-index of 0.56 and 0.75, respectively. The discrimination of all 3 risk models decreased in patients who received bacillus Calmette-Guérin. EORTC was better able to identify patients at low risk for recurrence or progression but it overestimated the 5-year risk of progression in patients at high risk. This study was limited by its retrospective design.
Our work illustrates the need for improved predictive tools for clinicians who treat patients with nonmuscle invasive bladder cancer. However, until new tools are developed NCCN Guidelines are a simple option for clinicians who treat patients with nonmuscle invasive bladder cancer. Those guidelines provide predictive power comparable to that of the EORTC and CUETO models.
Metformin is commonly prescribed for patients with type 2 diabetes mellitus. We hypothesized that metformin plus androgen deprivation therapy may be beneficial in combination. Our objective was to ...assess this combination in a retrospective cohort of patients with advanced prostate cancer.
Using national Veterans Affairs databases we identified all men diagnosed with prostate cancer between 2000 and 2008 who were treated with androgen deprivation therapy with followup through May 2016. Study exclusions included treatment with androgen deprivation therapy for 6 months or longer, or receipt of androgen deprivation therapy concurrently with localized radiation. Three patient cohorts were developed, including no diabetes mellitus, diabetes mellitus with no metformin and diabetes mellitus with metformin. Cox proportional HRs were calculated for overall survival, skeletal related events and cancer specific survival.
After exclusions the cohort consisted of 87,344 patients, including 61% with no diabetes mellitus, 22% with diabetes mellitus and no metformin, and 17% with diabetes mellitus on metformin. Cox proportional hazard analysis of overall survival showed improved survival in men with diabetes mellitus on metformin (HR 0.82, 95% CI 0.78–0.86) compared to those with diabetes mellitus who were not on metformin (HR 1.03, 95% CI 0.99–1.08). The reference group was men with no diabetes mellitus. Cox proportional hazard analysis of predictors of skeletal related events revealed a HR of 0.82 (95% CI 0.72–0.93) in men with diabetes mellitus on metformin. Cox proportional hazard analysis of cancer specific survival showed improved survival in men with diabetes mellitus on metformin (HR 0.70, 95% CI 0.64–0.77) vs those with diabetes mellitus without metformin (HR 0.93, 95% CI 0.85– 1.00). The reference group was men with no diabetes mellitus.
Metformin use in veterans with prostate cancer who receive androgen deprivation therapy is associated with improved oncologic outcomes. This association should be evaluated in a prospective clinical trial.
To examine the historical trends and factors underlying the current state of racial/ethnic representation within the urology workforce at each stage of the educational pipeline.
Using data from the ...US Census Bureau and the Association of American Medical Colleges, trends in racial/ethnic distribution for 2007−2008 to 2019−2020 were tracked in the educational pipeline for academic urologists. This pipeline was defined as progressively diminishing cohorts, starting with the US population, leading to medical school application, acceptance, and graduation, through to urology residency application, matching, and graduation, and ending with urology faculty appointment. A comparative cohort analysis was performed for academic year 2018−2019 for differences in racial/ethnic distribution across cohorts by binomial tests.
From 2007−2008 to 2019−2020, while the proportion of Latinx/Hispanic urology applicants increased by 0.38% per year (95% CI 0.24, 0.52), their proportion in the urology resident population remained unchanged (0.07% per year, 95% CI -0.20, 0.06) from 2011−2012 to 2019−2020. There was a decrease in the proportion of Black urology applicants (−0.13% per year, 95% CI −0.24, −0.02) and no change in the resident population (−0.03% per year, 95% CI −0.11, 0.05), despite an increase in total number of residents (n = 1043 to n = 1734) from 2009−2010 to 2019−2020. In 2018−2019, there were step-wise decreases in proportion of Black and Latinx/Hispanic members represented at critical stages of the educational pipeline (P <0.0001).
Attrition in URM urologists occur at key educational stages. This paper offers opportunities for the design of interventions to diversify the urology workforce.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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