Objectives
To evaluate whether pathological downstaging (pDS) was more informative in predicting overall survival (OS) than pathological complete response (pCR) in patients treated with neoadjuvant ...chemotherapy (NAC) for upper tract urothelial carcinoma (UTUC).
Patients and Methods
The National Cancer Database was queried for patients with high‐grade cN0M0 disease who had received NAC. pDS was defined as a decrease of at least one stage from cT to pT stage along with pN0, including pCR. A multivariable Cox model predicting OS was generated by fitting alternatively either pDS or pCR, and adjusted for potential confounders. The discrimination of the Cox models for predicting OS was evaluated using Harrell's C‐index. The analyses were repeated in patients diagnosed as having cT2–4N0M0 disease.
Results
Among 264 patients meeting the inclusion criteria, 72 (27%) and 39 (15%) achieved pDS and pCR, respectively. On multivariable analysis, both pDS (hazard ratio HR 0.24, 95% confidence interval CI 0.13, 0.45; P < 0.001) and pCR (HR 0.37, 95% CI 0.18, 0.79; P = 0.01) were associated with OS. The model including pDS achieved better discrimination with respect to the model including pCR: C‐index 76.4 vs 72.7, respectively.
In the 128 patients diagnosed with cT2–4 disease, both pDS (HR 0.19, 95% CI 0.09, 0.40; P < 0.001) and pCR (HR 0.31, 95% CI 0.11, 0.85; P = 0.023) were confirmed as predictors of OS. The model including pDS was confirmed to discriminate better than the model including pCR: C‐index 75 vs 68.9, respectively.
Conclusion
The study showed that pDS after NAC for UTUC was more informative than pCR when predicting OS. These findings, although requiring prospective validation, can aid in the design of clinical trials seeking to refine the use of chemotherapy and other systemic therapies in this setting.
Background
The mostly indolent natural history of prostate cancer (PCa) provides an opportunity for men to explore the benefits of lifestyle interventions. Current evidence suggests appropriate ...changes in lifestyle including diet, physical activity (PA) and stress reduction with or without dietary supplements may improve both disease outcomes and patient's mental health.
Objective
This article aims to review the current evidence on the benefits of all lifestyle programmes for PCa patients including those aimed at reducing obesity and stress, explore their affect on tumour biology and highlight any biomarkers that have clinical utility.
Evidence acquisition
Evidence was obtained from PubMed and Web of Science using keywords for each section on the affects of lifestyle interventions on (a) mental health, (b) disease outcomes and (c) biomarkers in PCa patients. PRISMA guidelines were used to gather the evidence for these three sections (15, 44 and 16 publications, respectively).
Evidence synthesis
For lifestyle studies focused on mental health, 10/15 demonstrated a positive influence, although for those programmes focused on PA it was 7/8. Similarly for oncological outcomes, 26/44 studies demonstrated a positive influence, although when PA was included or the primary focus, it was 11/13. Complete blood count (CBC)‐derived inflammatory biomarkers show promise, as do inflammatory cytokines; however, a deeper understanding of their molecular biology in relation to PCa oncogenesis is required (16 studies reviewed).
Conclusions
Making PCa‐specific recommendations on lifestyle interventions is difficult on the current evidence. Nevertheless, notwithstanding the heterogeneity of patient populations and interventions, the evidence that dietary changes and PA may improve both mental health and oncological outcomes is compelling, especially for moderate to vigorous PA. The results for dietary supplements are inconsistent, and although some biomarkers show promise, significantly more research is required before they have clinical utility.
We investigated the characteristics and outcomes of patients with muscle invasive bladder cancer treated with transurethral resection plus chemotherapy alone in a large observational cohort ...reflecting the continuum of practice settings in the United States.
In the National Cancer Database from 2004 to 2015 we identified 1,538 patients treated with transurethral resection plus multi-agent chemotherapy as definitive treatment of cT2-T4aN0M0 urothelial carcinoma of the bladder. For comparison purposes we included in study 17,866 patients treated with radical cystectomy with or without perioperative chemotherapy. Baseline characteristics were compared between the 2 groups by multivariable logistic regression. Treatment outcomes were assessed using Kaplan-Meier analysis and a Cox regression model.
On multivariate analysis several variables, including patient demography (older age, African American race, prior malignancy and lack of insurance), tumor characteristics (higher cT stage) and facility type (nonacademic facilities and lower radical cystectomy volume) were associated with a higher probability of transurethral resection plus chemotherapy for muscle invasive bladder cancer compared to the standard of care. Two and 5-year survival rates in all patients treated with transurethral resection plus chemotherapy were 49.0% and 32.9%, and in patients with cT2 disease the rates were 52.6% and 36.2%, respectively.
This large population level cohort of unselected patients shows that long-term survival can be achieved in a subset of patients treated with transurethral resection plus chemotherapy alone for muscle invasive bladder cancer. However, the best candidates for this approach remain to be defined. Ongoing clinical trials are now being launched to evaluate the ability of biomarkers to accurately select patients who could be treated with this bladder sparing strategy.
Multiple scoring systems have been proposed for prostate MRI reporting. We sought to review the clinical impact of the new Prostate Imaging Reporting and Data System v2 (PI-RADS) and compare those ...results to our proposed Simplified Qualitative System (SQS) score with respect to detection of prostate cancers and clinically significant prostate cancers.
All patients who underwent multiparametric prostate MRI (mpMRI) had their images interpreted using PI-RADS v1 and SQS score. PI-RADS v2 was calculated from prospectively collected data points. Patients with positive mpMRIs were then referred by their urologists for enrollment in an IRB-approved prospective phase III trial of mpMRI-Ultrasound (MR/TRUS) fusion biopsy of suspicious lesions. Standard 12-core biopsy was performed at the same setting. Clinical data were collected prospectively.
1060 patients were imaged using mpMRI at our institution during the study period. 341 participants were then referred to the trial. 312 participants underwent MR/TRUS fusion biopsy of 452 lesions and were included in the analysis. 202 participants had biopsy-proven cancer (64.7%) and 206 (45.6%) lesions were positive for cancer. Distribution of cancer detected at each score produced a Gaussian distribution for SQS while PI-RADS demonstrates a negatively skewed curve with 82.1% of cases being scored as a 4 or 5. Patient-level data demonstrated AUC of 0.702 (95% CI 0.65 to 0.73) for PI-RADS and 0.762 (95% CI 0.72 to 0.81) for SQS (p< 0.0001) with respect to the detection of prostate cancer. The analysis for clinically significant prostate cancer at a per lesion level resulted in an AUC of 0.725 (95% CI 0.69 to 0.76) and 0.829 (95% CI 0.79 to 0.87) for the PI-RADS and SQS score, respectively (p< 0.0001).
mpMRI is a useful tool in the workup of patients at risk for prostate cancer, and serves as a platform to guide further evaluation with MR/TRUS fusion biopsy. SQS score provided a more normal distribution of scores and yielded a higher AUC than PI-RADS v2. However until our findings are validated, we recommend reporting of detailed sequence-specific findings. This will allow for prospectively collected data to be utilized in determining the impact of ongoing changes to these scoring systems as our understanding of mpMRI interpretation evolves.
Objective To determine anatomical variations between the prone, supine, and supine oblique positions that are likely to affect percutaneous renal access. Material and Methods Twenty patients ...underwent computed tomography urograms in the supine and prone positions. Twenty patients underwent supine oblique and prone scans. Mean nephrostomy tract length, maximum access angle, and anterior–posterior renal position were calculated. Results Mean nephrostomy tract length was shorter in the prone position (82.6 mm right kidney, 85.4 mm left kidney) compared with the supine position (108.3 mm right kidney, P <.001; 103.7 mm left kidney, P <.001). Prone tract length was also shorter than supine oblique tract length (86.1 mm vs 96.5 mm; P = .048). Mean maximum access angle was significantly greater ( P = .018 right kidney; P = .007 left kidney) in the prone position (right kidney 99.7°, left kidney 104.0°) compared with the supine position (right kidney 87.7°, left kidney 89.4°). The same was true for the prone compared with the supine oblique position (75.8° vs 58.7°; P = .004). No difference was noted in anterior–posterior renal position between the supine and prone positions (20.3 mm vs 26.7 mm; P = .094) or supine oblique and prone positions (22.8 mm vs 15.6 mm; P = .45). Conclusions The prone position is associated with a significantly shorter nephrostomy tract length and more potential access sites, which may improve ease and safety of percutaneous renal access.
Among the many milestones in the last several decades in the management of muscle-invasive bladder cancer and high-risk nonmuscle-invasive bladder cancer including the extension of the standard lymph ...node dissection and the use of neoadjuvant chemotherapy, minimally invasive techniques have gained traction as an attractive option for radical cystectomy. Open radical cystectomy is plagued with high rates of perioperative and postoperative morbidity and mortality, and as robotic assistance has demonstrated benefits in other arenas of surgery and urology, the evolution of the approach to radical cystectomy has likewise incorporated robotic assistance. We thus sought to critically review the literature comparing open radical cystectomy with robotic-assisted radical cystectomy. Perioperative and oncologic outcomes as well as cost analyses and health-related quality of life were compared between the two approaches, and identified manuscripts were categorized according to level of evidence.
What's known on the subject? and What does the study add?
Off‐clamp laparoscopic partial nephrectomy (LPN) is thought to preserve renal function by limiting warm ischaemia time (WIT) and consequently ...reperfusion injury. To date, studies using the off‐clamp technique represent a heterogeneous group, with limited follow‐up showing feasibility and safety in a restricted number of cases.
We report the largest experience of off‐clamp vs on‐clamp LPN with perioperative outcomes and intermediate follow‐up of renal functional outcomes with stratification by WIT.
OBJECTIVE
•
To evaluate perioperative and 6‐month renal functional outcomes of patients undergoing off‐clamp vs complete hilar control laparoscopic partial nephrectomy (LPN).
PATIENTS AND METHODS
•
A retrospective review of 489 patients undergoing LPN was completed.
•
Preoperative imaging assessed tumour characteristics.
•
Patient demographics, perioperative parameters, and postoperative outcomes were documented.
•
Multivariable regression analysis was used to assess factors contributing to changes in postoperative renal function between off‐clamp and clamped LPN.
RESULTS
•
In all, 289 LPNs were performed on‐clamp and 150 were performed off‐clamp.
•
Tumours in the on‐clamp group were larger than those in the off‐clamp group (mean range 3.3 0.5–13.5 vs 2.7 0.4–9 cm, P= 0.003).
•
Univariable analysis comparing off‐clamp to on‐clamp cohorts showed that estimated glomerular filtration rate (eGFR) was better preserved in the off‐clamp cohort at 6 months (−5.8% vs –11.4%, P= 0.046). Multivariable analysis of the groups showed that estimate blood loss (P= 0.015) and warm ischaemia time (WIT, P< 0.001) were the only significant predictors of decreased eGFR in the postoperative period.
•
Difference in eGFR at 6 months was not significant when WIT was limited to 30 min. The complication rate was greater in the clamped cohort (10% vs 20%, P= 0.012).
•
There was no difference in transfusion rate or positive margin status.
CONCLUSIONS
•
LPN without hilar clamping is feasible, safe and associated with less renal injury as assessed by postoperative GFR in select patients.
•
With experience, it can be applied to complex renal lesions.
We aimed to compare perioperative and oncologic outcomes for patients undergoing robotic-assisted radical cystectomy (RARC) with intracorporeal ileal conduit (IC) and neobladder (NB) urinary ...diversion.
Patients undergoing RARC with intracorporeal urinary diversion between January 2017 and January 2022 at the Icahn School of Medicine at Mount Sinai, New York, NY, USA were indexed. Baseline demographics, clinical characteristics, perioperative, and oncologic outcomes were analyzed. Survival was estimated with Kaplan-Meier plots.
Of 261 patients (206 78.9% male), 190 (72.8%) received IC while 71 (27.2%) received NB diversion. Median age was greater in the IC group (71 interquartile range, IQR 65–78 years vs. 64 IQR 59–67 years, p<0.001) and BMI was 26.6 (IQR 23.2–30.4) kg/m2. IC group was more likely to have prior abdominal or pelvic radiation (15.8% vs. 2.8%, p=0.014). American Association of Anesthesiologists scores were comparable between groups. The IC group had a higher proportion of patients with pathological tumor stage 2 (pT2) tumors (34 17.9% vs. 10 14.1%, p=0.008) and pathological node stages pN2–N3 (28 14.7% vs. 3 4.2%, p<0.001). IC group had less median operative time (272 IQR 246–306 min vs. 341 IQR 303–378 min, p<0.001) and estimated blood loss (250 150–500 mL vs. 325 200–575 mL, p=0.002). Thirty- and 90-day complication rates were 44.4% and 50.2%, respectively, and comparable between groups. Clavien-Dindo grades 3–5 complications occurred in 27 (10.3%) and 34 (13.0%) patients within 30 and 90 days, respectively, with comparable rates between groups. Median follow-up was 324 (IQR 167–552) days, and comparable between groups. Kaplan-Meier estimate for overall survival at 24 months was 89% for the IC cohort and 93% for the NB cohort (hazard ratio 1.23, 95% confidence interval 1.05–2.42, p=0.02). Kaplan-Meier estimate for recurrence-free survival at 24 months was 74% for IC and 87% for NB (hazard ratio 1.81, 95% confidence interval 0.82–4.04, p=0.10).
Patients undergoing intracorporeal IC urinary diversion had higher postoperative cancer stage, increased nodal involvement, similar complications outcomes, decreased overall survival, and similar recurrence-free survival compared to patients undergoing RARC with intracorporeal NB urinary diversion.
Objective
To present outcomes of a randomized, patient‐blinded controlled trial on Pfannenstiel laparoendoscopic single‐site (LESS) vs conventional multiport laparoscopic live donor nephrectomy.
...Patients and Methods
Patients presenting as left kidney donors between January 2009 and November 2011 were randomized to LESS donor nephrectomy (LESS‐DN: n = 15) or conventional laparoscopic donor nephrectomy (LDN: n = 14).
Patients were blinded to the surgical approach preoperatively and attempts to continue patient blinding postoperatively were made by applying dressings consistent with multiple conventional laparoscopic incisions for all patients.
De‐identified data related to the operation, peri‐operative course and postoperative follow‐up were prospectively collected and compared between the two groups with an intention‐to‐treat analysis.
Results
There were no significant differences between the groups when comparing operating time, estimated blood loss (EBL), i.v. fluid administration, renal allograft warm ischaemia time (WIT), length of hospital stay (LOS) and total inpatient analgesic requirements.
Quantitative pain assessment was not significantly different on postoperative day (POD) #0, however, it was significantly lower in the LESS‐DN group, beginning on POD #1 (P < 0.05).
The changes in haematocrit and serum creatinine in the two groups were not significantly different, and there were no blood transfusions in either group, nor was there a decline in estimated glomerular filtration rate to <60 mL/min per 1.73 m2 of body surface area in any patients.
Two patients in the LESS‐DN group were converted to conventional LDN, both because of failure to progress effectively.
All allografts were functional at the time of transplantation and revascularization, with no cases of hyperacute rejection.
Conclusions
Peri‐operative variables including EBL, WIT and LOS were equivalent when comparing Pfannenstiel LESS‐DN with conventional LDN.
Patient‐reported visual analogue pain scale scores were significantly lower in the LESS‐DN group beginning on the first postoperative day.
Pelvic organ-preserving robot-assisted radical cystectomy with orthotopic neobladder or ileal conduit allows return to sexual activity after surgery while not compromising oncological outcome. This ...approach should be considered in sexually active female undergoing cystectomy.
For females undergoing cystectomy and urinary diversion, decreases in sexual and urinary functions can have a significant impact on quality of life. Pelvic organ–preserving (POP) radical cystectomy (RC) has been proposed as an approach to improve postoperative functional outcomes.
To evaluate postoperative functional outcomes of a robotic approach for female POP RC with intracorporeal urinary diversion.
This was a multicenter retrospective study evaluating sexual, urinary, and oncological outcomes for sexually active females undergoing POP robot-assisted RC for ≤T2 bladder cancer. Exclusion criteria included multifocal, trigonal, or locally advanced tumors.
We describe a step-by-step technique for POP robot-assisted RC with intracorporeal urinary diversion.
The primary outcome of the study was evaluation of sexual and urinary functions following surgery. Oncological outcomes were evaluated as a secondary endpoint.
Our study included 23 females who underwent POP robot-assisted RC between 2008 and 2020 with intracorporeal neobladder (87%) or ileal conduit (13%) reconstruction. The median follow-up was 20 mo. A postoperative sexual function questionnaire was completed by 15 patients (65%). Of those, 13 (87%) resumed sexual activity at a median of 6 mo after surgery. Of the patients with a neobladder, 14 (70%) achieved daytime continence and 16 (80%) achieved nighttime continence. Cancer-specific and overall survival were both 91%. The results are limited by their retrospective nature.
POP robot-assisted RC with orthotopic neobladder allows a majority of female patients to return to sexual activity after surgery. This approach should be considered for selected sexually active women.
We evaluated 23 women with bladder cancer who underwent surgical removal of the bladder with preservation of their reproductive organs. Following this surgery, a majority of patients resumed sexual activity. For selected patients, this technique can be performed without compromising cancer control.
PDF
