Body morphometry may predict parastomal hernia following radical cystectomy with ileal conduit.

OBJECTIVE: To investigate whether preoperative body morphometry analysis can identify patients at risk of parastomal hernia (PH), which is a common complication after radical cystectomy (RC). PATIENTS AND METHODS: All patients who underwent RC between 2010 and 2020 with available cross-sectional imaging preoperatively and at 1 and 2 years postoperatively were included. Skeletal muscle mass and total fat mass (FM) were determined from preoperative axial computed tomography images obtained at the level of the L3 vertebral body using Aquarius Intuition software. Sarcopenia and obesity were assigned based on consensus definitions of skeletal muscle index (SMI) and FM index (FMI). PH were graded using both the Moreno-Matias and European Hernia Society criteria. Binary logistic regression and recursive partitioning were used to identify patients at risk of PH. The Kaplan-Meier method with log-rank and Cox proportional hazards models included clinical and image-based parameters to identify predictors of PH-free survival. RESULTS: A total of 367 patients were included in the final analysis, with 159 (43%) developing a PH. When utilising binary logistic regression, high FMI (odds ratio [OR] 1.63, P < 0.001) and low SMI (OR 0.96, P = 0.039) were primary drivers of risk of PH. A simplified model that only relied upon FMI, SMI, and preoperative albumin improved the classification of patients at risk of PH. On Kaplan-Meier analysis, patients who were obese or obese and sarcopenic had significantly worse PH-free survival (P < 0.001). CONCLUSION: Body morphometry analysis identified FMI and SMI to be the most consistent predictors of PH after RC.

Oncologic outcomes of intravesical therapy in the management of nonmuscle invasive bladder cancer with variant histology.

PURPOSE: There is limited data on oncologic outcomes in nonmuscle invasive bladder cancer (NMIBC) with variant histology (VH) managed with intravesical therapy. We sought to evaluate oncologic outcomes for this cohort at a high-volume center. MATERIALS AND METHODS: A retrospective review of an IRB-approved bladder cancer database was performed. Patients with a history of NMIBC with VH present on transurethral resection of bladder tumor (TURBT) treated with intravesical therapy (BCG or chemotherapy) were identified. Outcomes of interest included recurrence within the bladder, progression to muscle-invasive bladder cancer (MIBC), metastatic progression, cancer-specific, and overall survival. Survival time was computed from the date of initiation of intravesical therapy to the date of event or censoring. For patients who underwent radical cystectomy, recurrence-free, cancer-specific, and overall survival were also computed. The Kaplan-Meier method with log rank was utilized to compare survival time between VH sub-groups. RESULTS: Ninety patients were included in the final cohort with a median follow-up of 38 months. The majority of patients had T1 disease (72%) and received intravesical BCG (83%) as their only form of intravesical therapy. The most commonly represented VH in this series were glandular and squamous differentiation (26%). Forty-eight patients (53%) experienced recurrence within the bladder with a median recurrence-free survival of 24 months (95% Confidence Interval [CI]: 2-46 months). Five-year rates of progression to MIBC and distant metastasis were both 14% respectively. Twenty-six patients (28%) eventually required cystectomy. When stratifying by VH, patients with sarcomatoid, plasmacytoid, and micropapillary had significantly worse oncologic outcomes. CONCLUSION: In this series of highly-selected patients with NMIBC and VH, bladder-sparing treatment with intravesical therapy demonstrated acceptable oncologic outcomes for most VHs. This may be an acceptable treatment option for patients without plasmacytoid, sarcomatoid, or micropapillary features who are not suitable cystectomy candidates or who prioritize bladder-sparing treatment.

The role of enhanced recovery after surgery protocols in the development of acute kidney injury following radical cystectomy.

PURPOSE: Recent reports have suggested that fluid restriction as part of Enhanced Recovery after Surgery (ERAS) pathways may increase the risk of AKI in radical cystectomy (RC) patients. We sought to evaluate the impact of ERAS initiation on AKI incidence at a high-volume tertiary care center. MATERIALS AND METHODS: We performed a retrospective review of our IRB approved database to identify patients receiving RC from 2010 to 2019. ERAS was initiated at our institution in October 2016. Acute kidney injuries were graded according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria and must have occurred within 7 days of indexed RC. Estimated glomerular filtration rate (eGFR) was captured at baseline, 1, 3, 6, and 12 months respectively. Categorical variables were compared with the Pearson-Chi square test. Quantitative variables were analyzed with the Wilcoxon-Rank sum test. Multivariable binary logistic regression and interaction analysis was used to identify predictors of AKI. RESULTS: Twelve hundred patients were included. Twenty-two percent of patients experienced an AKI within 7 days. Patients in the ERAS cohort experienced less AKIs after RC (18% vs. 25%, P = 0.003). When adjusting for year of surgery, ERAS was not a significant predictor for AKI on multivariable analysis (OR: 0.87, P = 0.73). On interaction analysis, during the ERAS era, intracorporeal robot-assisted radical cystectomy (iRARC) was associated with decreased odds of AKI (OR: 0.39, P = 0.034). There were no significant differences in eGFR at 12 months postoperatively (P = 0.16). CONCLUSION: Unlike previous reports, ERAS initiation was not associated with increased risk of AKI at a tertiary care high-volume center.

Optimizing prediction of new-baseline glomerular filtration rate after radical nephrectomy: are algorithms really necessary?

INTRODUCTION: Radical nephrectomy (RN) is an important consideration for the management of localized renal-cell-carcinoma (RCC) whenever the tumor appears aggressive, although reduced renal function is a concern. Split-renal-function (SRF) in the contralateral kidney and postoperative renal functional compensation (RFC) are fundamentally important for the accurate prediction of new baseline GFR (NBGFR) post-RN. SRF can be estimated either from nuclear renal scans (NRS) or from preoperative imaging using parenchymal-volume-analysis (PVA). We compare two SRF-based models for predicting NBGFR after RN with a subjective prediction of NBGFR by an experienced urologic-oncologist. METHODS: 187 RCC patients managed with RN (2006-16) were included based on the availability of preoperative CT/MRI and NRS, and preoperative/postoperative eGFR. NBGFR was defined as the final GFR 3-12 months post-RN. For the SRF-based approaches, SRF was derived from either NRS or PVA, and RFC was estimated at 25% based on previous independent analyses. Thus, the formula (Global GFRPre-RN × SRFcontralateral) × 1.25 was used to predict NBGFR after RN. For subjective-assessment, a blinded, independent urologic oncologist provided NBGFR predictions based on preoperative eGFR, CT/MRI, and clinical/tumor characteristics. Predictive accuracies were assessed by correlation coefficients (r). RESULTS: The r values for subjective-assessment, NRS/SRF-based, and PVA/SRF-based approaches were 0.72/0.72/0.85, respectively (p < 0.05). The PVA/SRF-based model also demonstrated significant improvement across other performance parameters. CONCLUSIONS: The PVA/SRF-based model more accurately predicts NBGFR post-RN than NRS/SRF-based and Subjective Estimation. PVA software (Fujifilm-medical-systems) is readily available and affordable and provides accurate SRF estimations from routine preoperative imaging. This novel approach may inform clinical management regarding RN/PN for complex RCC cases.

Comparing Pathologic and Survival Outcomes Between Primary and Secondary Muscle Invasive Bladder Cancer When Treated by Radical Cystectomy With or Without Neoadjuvant Chemotherapy.

OBJECTIVE: To compare pathologic and survival outcomes between primary muscle invasive (pMIBC) and secondary muscle invasive (sMIBC) bladder cancer patients who were treated with or without cisplatin-based neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC). METHODS: We reviewed cT2-T4/N0 MIBC patients at our institution between 2010-2019. pMIBC was defined as presenting with > cT2 disease on initial or restaging TURBT with no prior history of bladder cancer. sMIBC was defined as prior history of NMIBC that was treated with at least one induction course of BCG that progressed to MIBC. Outcomes analyzed included pathologic downstaging rates defined as pT2 and N+ disease were predictors of poorer CSS and OS. Separate analysis of sMIBC patients whom underwent RC only (N = 61), demonstrated inferior oncologic outcomes to other cohorts (P < .01). CONCLUSION: There were no differences in pathologic response or survival between pMIBC and sMIBC patients when managed with NAC and RC.

Split Renal Function Is Fundamentally Important for Predicting Functional Recovery After Radical Nephrectomy.

While partial nephrectomy (PN) is generally preferred for localized renal cell carcinoma (RCC), radical nephrectomy (RN) is occasionally required. A new-baseline glomerular filtration rate (NBGFR) >45 ml/min/1.73 m2 after kidney cancer surgery is associated with strong survival outcomes. If NBGFR after RN will be above this threshold and the tumor has increased oncologic potential, RN may be a relevant consideration. Predicting NBGFR, defined as the GFR at 3-12 mo after RN, has been challenging owing to omission of two important parameters: split renal function (SRF) and renal function compensation (RFC). Our objective was to evaluate a simple SRF-based model in comparison to five published non-SRF-based models using data from a retrospective cohort of 445 RN patients. SRF was obtained via readily available semiautomated software (FUJIFILM Medical Systems) that provides differential parenchymal volume analysis on the basis of preoperative imaging. Our conceptually simple and clinically implementable SRF-based model more accurately predicts NBGFR after RN than five published non-SRF-based models (all p < 0.01). The SRF-based model also improved prediction of the clinically relevant threshold of NBGFR >45 ml/min/1.73 m2 (all p < 0.05). Patient summary: We validated a novel approach for more accurate prediction of kidney function after removal of one kidney. Our approach can be used in clinical and practice and will help in making decisions on full or partial removal of a kidney for kidney cancer.