Canadian Update on Surgical Procedures (CUSP) Urology Group consensus for intraoperative hemostasis during minimally invasive partial nephrectomy.

INTRODUCTION: Partial nephrectomy remains the gold standard in the management of small renal masses. However, minimally invasive partial nephrectomy (MIPN) is associated with a steep learning curve, and optimal, standardized techniques for time-efficient hemostasis are poorly described. Given the relative lack of evidence, the goal was to describe a set of actionable guiding principles, through an expert working panel, for urologists to approach hemostasis without compromising warm ischemia or oncological outcomes. METHODS: A three-step modified Delphi method was used to achieve expert agreement on the best practices for hemostasis in MIPN. Panelists were recruited from the Canadian Update on Surgical Procedures (CUSP) Urology Group, which represent all provinces, academic and community practices, and fellowship-and non-fellowship-trained surgeons. Thirty-two (round 1) and 46 (round 2) panellists participated in survey questionnaires, and 22 attended the in-person consensus meeting. RESULTS: An initial literature search of 945 articles (230 abstracts) underwent screening and yielded 24 preliminary techniques. Through sequential survey assessment and in-person discussion, a total of 11 strategies were approved. These are temporally distributed prior to tumor resection (five principles), during tumor resection (two principles), and during renorrhaphy (four principles). CONCLUSIONS: Given the variability in tumor size, depth, location, and vascularity, coupled with limitations of laparoscopic equipment, achieving consistent hemostasis in MIPN may be challenging. Despite over two decades of MIPN experience, limited evidence exists to guide clinicians. Through a three-step Delphi method and rigorous iterative review with a panel of experts, we ascertained a guiding checklist of principles for newly beginning and practicing urologists to reference.

Contemporary National Assessment of Robot-Assisted Surgery Rates and Total Hospital Charges for Major Surgical Uro-Oncological Procedures in the United States.

Background: The role of robot assistance is increasingly gaining importance among all major surgical uro-oncological procedures (MSUPs). However, contemporary analyses showed that total hospital charges (THCGs) related to robot-assisted procedures exceed those of open procedures. Based on increasing familiarity with robot-assisted surgery, we postulated that THCGs may have decreased over the past half-decade. Thus, we tested contemporary trends and THCGs related to robot-assisted vs nonrobot-assisted MSUPs. Materials and Methods: Within the National Inpatient Sample database (2009-2015), we identified patients who underwent robot-assisted vs nonrobot-assisted (open or laparoscopic) MSUPs, which included radical prostatectomy (RP), radical nephrectomy (RN), partial nephrectomy (PN), and radical cystectomy (RC). Rates of robot-assisted MSUPs were evaluated using estimated annual percentage changes (EAPCs) analyses. The t-test was used to examine statistically significant differences between mean THCGs according to either robot-assisted or nonrobot-assisted approach. Finally, linear regression analyses were tested for annual variation in the mean THCGs. Results: Of 128,367 MSUPs, 47.7% were robot-assisted. Overall, robot-assisted surgery rates among MSUPs increased from 40.3% to 57.6% (EAPC: +6.3%, p < 0.001) between 2009 and 2015. The mean THCGs for robot-assisted RP, RN, PN, and RC were $13,799, $18,789, $16,574, and $33,575, respectively. The observed mean THCGs differences between robot-assisted and nonrobot-assisted MSUPs were +$1594, +$1592, and +$1829 for RP, RN, and RC, respectively (all p < 0.05). Conversely, no statistically significant difference in the mean THCGs was reported between robot-assisted and nonrobot-assisted PN (+$367, p > 0.05). Finally, the annual observed mean THCGs linearly decreased for all robot-assisted MSUPs during the study period. Conclusions: Rates of robot-assisted MSUPs exponentially increased between 2009 and 2015. Although the mean THCGs decreased in a significant manner during the study period for all MSUPs, THCGs of robot-assisted RP, RN, and RC still exceed those of their respective nonrobot-assisted counterparts. Conversely, no differences in the mean THCGs were reported between robot-assisted vs nonrobot-assisted PN.

Error reporting from the da Vinci surgical system in robotic surgery: A Canadian multispecialty experience at a single academic centre.

INTRODUCTION: The goal of the study is to evaluate and report on the third-generation da Vinci surgical (Si) system malfunctions. METHODS: A total of 1228 robotic surgeries were performed between January 2012 and December 2015 at our academic centre. All cases were performed by using a single, dual console, four-arm, da Vinci Si robot system. The three specialties included urology, gynecology, and thoracic surgery. Studied outcomes included the robotic surgical error types, immediate consequences, and operative side effects. Error rate trend with time was also examined. RESULTS: Overall robotic malfunctions were documented on the da Vinci Si systems event log in 4.97% (61/1228) of the cases. The most common error was related to pressure sensors in the robotic arms indicating out of limit output. This recoverable fault was noted in 2.04% (25/1228) of cases. Other errors included unrecoverable electronic communication-related in 1.06% (13/1228) of cases, failed encoder error in 0.57% (7/1228), illuminator-related in 0.33% (4/1228), faulty switch in 0.24% (3/1228), battery-related failures in 0.24% (3/1228), and software/hardware error in 0.08% (1/1228) of cases. Surgical delay was reported only in one patient. No conversion to either open or laparoscopic occurred secondary to robotic malfunctions. In 2015, the incidence of robotic error rose to 1.71% (21/1228) from 0.81% (10/1228) in 2014. CONCLUSIONS: Robotic malfunction is not infrequent in the current era of robotic surgery in various surgical subspecialties, but rarely consequential. Their seldom occurrence does not seem to affect patient safety or surgical outcome.

Biopsy Based Proteomic Assay Predicts Risk of Biochemical Recurrence after Radical Prostatectomy.

PURPOSE: Current clinicopathological parameters are insufficient to predict the likelihood of biochemical recurrence in patients with prostate cancer after radical prostatectomy. Such information may help identify patients who would likely benefit from adjuvant radiotherapy rather than active surveillance. A multiplex proteomic assay, previously tested on biopsies and found to be predictive of favorable or unfavorable pathology at radical prostatectomy, was assessed for its predictive value to identify patients at higher risk for biochemical relapse. MATERIALS AND METHODS: Proteomic assays from core needle biopsies of 288 men who subsequently underwent radical prostatectomy at CHUM (Centre hospitalier de l'Université de Montréal) were evaluated for the prediction of subsequent biochemical recurrence. RESULTS: Of the 288 men, biochemical relapse was observed in 47 (16.3%) and metastases were found in 5 (1.7%). Median followup was 68.5 months. The proteomic assay clearly separated patients into 3 categories, including those at low, intermediate and high risk for biochemical relapse (p = 0.0007). Assay scores predicted biochemical relapse on univariate analysis (HR 1.724, p = 0.0002 per 20% change in score), significantly better than other preoperative prognostic parameters. Additionally, the assay score had a significantly higher p value when combined with clinical National Comprehensive Cancer Network® stage compared to stage alone (HR 1.579, p = 0.0017 per 20% change in score). CONCLUSIONS: A protein based assay score derived from diagnostic needle biopsy has strong predictive ability for biochemical relapse after surgery. These results suggest that this assay score can be used at the diagnostic stage to identify patients in whom prostate cancer is potentially more biologically aggressive and active treatment should be considered.

Differences in Patient Characteristics among Men Choosing Open or Robot-Assisted Radical Prostatectomy in Contemporary Practice - Analysis of Surveillance, Epidemiology, and End Results Database.

OBJECTIVE: To examine characteristics of robot-assisted (RARP) and open radical prostatectomy (ORP) patients. PATIENTS AND METHODS: We relied on the Surveillance, Epidemiology, and End Results-Medicare-linked database and focused on prostate cancer patients between 2008 and 2009. In multivariable logistic regression analyses, we predicted RARP. RESULTS: Of 5,915 patients, 3,476 (58.8%) underwent RARP and 2,439 (41.2%) ORP. Patients within intermediate (OR 1.4, p = 0.01) or highest (OR 1.5, p = 0.02) education strata and those treated by surgeons with a high volume (OR 2.2, p < 0.001) were more likely to undergo RARP. Conversely, those residing in rural areas (OR 0.7, p = 0.005) and those with clinical stage T2 or higher (OR 0.7, p = 0.006) were less likely to undergo RARP. Additionally, patients from the Southwest were less likely to undergo RARP (OR 0.4, p < 0.001), but those from the Northern Plains were more likely to undergo RARP (OR 1.4, p = 0.02) than their counterparts from the East. Finally, RARP patients were neither younger nor healthier than ORP patients. CONCLUSIONS: Several patient characteristics such as education, region of residence and population density affect the likelihood of RARP vs. ORP treatment. Similarly, clinical stage and surgeon characteristics also affect the assignment to one or other treatment modality.

Suboptimal use of pelvic lymph node dissection: Differences in guideline adherence between robot-assisted and open radical prostatectomy.

INTRODUCTION: Our aim was to assess adherence to National Comprehensive Cancer Network (NCCN) and American Urological Association (AUA) guidelines for pelvic lymph node dissection (PLND) at the time of either robot-assisted (RARP) or open radical prostatectomy (ORP). METHODS: We relied on the Surveillance, Epidemiology, and End Results-Medicare linked database and focused on localized prostate cancer (PCa) patients who were treated with either RARP or ORP between October 2008 and December 2009. Categorical and multivariable logistic regression analyses targeted two endpoints: 1) probability of guideline-recommended PLND; and 2) probability of no PLND, when not guideline-recommended. RESULTS: Among 5268 PCa patients, adherence to NCCN PLND guideline was 56.9% during RARP and 76.5% during ORP (odds ratio [OR] 0.4, 95% confidence interval [CI] 0.3‒0.6). AUA PLND guideline adherence was 68.1% during RARP and 82.4% during ORP (OR 0.7, 95% CI 0.5‒0.9). When PLND was not recommended, it was more frequently performed during ORP according to either NCCN (OR 3.7, 95% CI 3.5‒3.9) or AUA (OR 2.7, 95% CI 2.6‒2.8). According to the NCCN guideline, at recommended PLND in ORP patients, 6.3% harboured lymph node invasion (LNI) (number needed to treat [NNT] 16) vs. 3.2% at RARP (NNT 31). According to the AUA guideline, at recommended PLND in ORP patients, 12.3% harboured LNI (NNT 8) vs. 5.1% RARP (NNT 19). CONCLUSIONS: Adherence to NCCN and AUA PLND guidelines was lower during RARP than during ORP when PLND was recommended. The rate of non-recommended PLND was also higher during ORP than during RARP. Technical considerations may be at play.

Cardiovascular mortality in patients with metastatic prostate cancer exposed to androgen deprivation therapy: a population-based study.

INTRODUCTION: The aim of our study was to reexamine the prevalence of baseline cardiovascular (CV) morbidity and the rates of CV mortality in a contemporary cohort of patients with prostate cancer (PCa) exposed to androgen deprivation therapy (ADT). MATERIALS AND METHODS: Records of patients aged 65 years and older with metastatic PCa who received ADT were abstracted from the Surveillance, Epidemiology, and End Results-Medicare database between 1991 and 2009. The primary end points comprised 5-year CV mortality rates. Survival rates were stratified according to age and Charlson comorbidity index (CCI). Competing-risks Poisson regression methodologies were performed. RESULTS: Overall, 9596 patients with metastatic PCa treated with ADT were identified. At baseline, 3049 patients (31.8%) had preexisting CV disease. The 5-year CV mortality rates were 9.8% and 14.8% in the overall population and in patients with preexisting CV disease, respectively. The 5-year CV mortality rates increased with advanced age and higher CCI score. In multivariate competing-risks regression analyses, age, year of diagnosis, CV comorbidities, CCI, and marital status represented independent predictors of CV mortality, after accounting for the risk of dying from other causes (all P ≤ .04). Of those, preexisting CV disease contributed to the highest risk of CV mortality. Our study is limited by its retrospective nature. CONCLUSION: CV mortality represents a common event in patients with metastatic PCa treated with ADT. Preexisting CV disease represented the strongest risk factor.

Oncological and functional outcomes of 722 robot-assisted radical prostatectomy (RARP) cases: The largest Canadian 5-year experience.

INTRODUCTION: While RARP (robotic-assisted radical prostatectomy) has become the predominant surgical approach to treat localized prostate cancer, there is little Canadian data on its oncological and functional outcomes. We describe the largest RARP experience in Canada. METHODS: Data from 722 patients who underwent RARP performed by 7 surgeons (AEH performed 288, TH 69, JBL 23, SB 17, HW 15, QT 7, and KCZ 303 patients) were collected prospectively from October 2006 to December 2013. Preoperative characteristics, as well as postoperative surgical and pathological outcomes, were collected. Functional and oncological outcomes were also assessed up to 72 months postoperative. RESULTS: The median follow-up (Q1-Q3) was 18 months (9-36). The D'Amico risk stratification distribution was 31% low, 58% intermediate and 11% high-risk. The median operative time was 178 minutes (142-205), blood loss was 200 mL (150-300) and the postoperative hospital stay was 1 day (1-23). The transfusion rate was only 1.0%. There were 0.7% major (Clavien III-IV) and 10.1% minor (Clavien I-II) postoperative complications, with no mortality. Pathologically, 445 men (70%) were stage pT2, of which 81 (18%) had a positive surgical margin (PSM). In addition, 189 patients (30%) were stage pT3 and 87 (46%) with PSM. Urinary continence (0-pads/day) returned at 3, 6, and 12 months for 68%, 80%, and 90% of patients, respectively. Overall, the potency rates (successful penetration) for all men at 6, 12, and 24 months were 37%, 52%, and 59%, respectively. Biochemical recurrence was observed in 28 patients (4.9%), and 14 patients (2.4%) were referred for early salvage radiotherapy. In total, 49 patients (8.4%) underwent radio-therapy and/or hormonal therapy. CONCLUSIONS: This study shows similar results compared to other high-volume RARP programs. Being the largest RARP experience in Canada, we report that RARP is safe with acceptable oncologic outcomes in a Canadian setting.

Prospective randomized trial of barbed polyglyconate suture to facilitate vesico-urethral anastomosis during robot-assisted radical prostatectomy: time reduction and cost benefit.

UNLABELLED: Study Type - RCT (randomized trial) Level of Evidence 2b. What's known on the subject? and What does the study add? In a previous randomized controlled trial, barbed polyglyconate suture for vesico-urethral anastomosis was associated with more frequent cystogram leaks, longer mean catheterization times and greater suture costs per case. In the current randomized controlled trial, we show that barbed polyglyconate suture is associated with decreased anastomosis time, decreased need to readjust suture tension, cost reduction, and equal continence and early/late urinary complication rates. OBJECTIVE: To examine the effectiveness of barbed polyglyconate suture (V-Loc 180; Covidien, Mansfield, MA, USA) compared with standard monofilament for posterior reconstruction (PR) and vesico-urethral anastomosis (VUA) during robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: A prospective randomized controlled trial was conducted in 70 consecutive RARP cases by a single surgeon (K.C.Z.). Standard VUA was performed using three 4-0 poliglecaprone 25 (Monocryl; Ethicon Endosurgery, Cincinnati, OH, USA) sutures secured with absorbable suture clips (LapraTy, Ethicon; one single 6-inch [15.2 cm] for PR and two attached 6-inch [15.2 cm] for VUA). Barbed suture VUA was performed using two 3-0 6-inch (15.2 cm) barbed polyglyconate sutures. Time to complete the suture set-up by the nursing team, anastomosis time and need to adjust suture tension were recorded. Suture-related complications, validated-questionnaire continence and cost were also examined. RESULTS: Compared with a conventional reconstruction technique, there was a significant reduction in mean nurse set-up time (31 vs. 294 s; P < 0.01) and reconstruction time (13.1 vs. 20.8 min; P < 0.01) for the barbed suture technique. Need to readjust suture tension or to place additional suture clips for watertight closure was greater in the standard monofilament group than in the barbed suture group (6% vs. 24%; P= 0.03). • A cost reduction was recorded at our institution (48.05 vs. 70.25 $CAN) with the barbed suture technique. • With a mean follow-up of 6.2 months, no delayed anastomotic leak or bladder neck contracture was observed in either group. • Pad-free continence outcomes for the monofilament suture vs the barbed suture groups at 1 (64 vs. 69%, P= 0.6), 3 (76 vs. 81%, P= 0.5) and 6 months (88 vs. 92%, P= 0.7) were similar. CONCLUSIONS: • Compared with standard monofilament suture, the unidirectional barbed polyglyconate suture appears to provide safe, efficient and cost-effective PR and VUA during RARP. • Use of the interlocked barbed polyglyconate suture technique prevents slippage, precluding the need for assistance, knot-tying and constant reassessment of anastomosis integrity.

Cytoreductive nephrectomy in the elderly: a population-based cohort from the USA.

UNLABELLED: Study Type - Therapy (cohort) Level of Evidence 2b What's known on the subject? and What does the study add? While cytoreductive nephrectomy is associated with a survival benefit in the context of metastatic renal cell carcinoma, the rates of morbidity and perioperative mortality remain non-negligible. For example, perioperative mortality may be as high as 21% in elderly patients. The study shows that perioperative death amongst the elderly was substantially lower than what was previously reported from a single institutional report. Nonetheless, postoperative adverse outcomes were non-negligible in elderly patients relative to their younger counterparts. In consequence, these rates should be discussed at informed consent and a rigorous patient selection remains essential. OBJECTIVE: • To examine the rate of perioperative mortality (PM), and other adverse outcomes in 'elderly' patients treated with cytoreductive nephrectomy (CNT). MATERIAL AND METHODS: • Patients who underwent CNT for metastatic renal cell carcinoma were abstracted from the Nationwide Inpatient Sample (1998-2007). 'Elderly' was defined as ≥ 75 years, according to previous definition. • Endpoints consisted of PM, intraoperative and postoperative complications, blood transfusions and length of stay. • We adjusted for the effect of elderly status within five separate logistic regression models. Covariates consisted of comorbidity, race, gender, year of surgery and hospital region. RESULTS: • Overall, CNT was performed in 504 (15.3%) elderly patients and in 2796 (84.7%) 'younger' patients (<75 years). • The rate of PM was 4.8% in elderly patients vs 1.9% in the younger patients (P < 0.001). Similarly, the rates of blood transfusions (29.8 vs 21.5%), postoperative complications (27.8 vs 22.8%), and prolonged length of stay (≥ 8 days) were higher in the elderly (45.0 vs 32.0%; all P < 0.001). • In multivariable analyses, elderly patients were 2.2-, 1.5-, and 1.6 fold more likely to experience PM, to receive a blood transfusion and to be hospitalized ≥ 8 days than the younger patients. CONCLUSIONS: • Although the rate of PM was substantially lower than 21%, elderly patients are significantly more likely to die after this type of surgery, to receive a transfusion, and to experience a prolonged length of stay. • These facts and figures should be discussed at informed consent and a rigorous patient selection is essential.

A stage-for-stage and grade-for-grade analysis of cancer-specific mortality rates in renal cell carcinoma according to age: a competing-risks regression analysis.

BACKGROUND: The association of advanced age and cancer control outcomes shows discordant findings. OBJECTIVE: To evaluate the effect of age on cancer control outcomes in a large population-based cohort of patients diagnosed with renal cell carcinoma (RCC) of all stages. DESIGN, SETTING, AND PARTICIPANTS: Using the Surveillance Epidemiology and End Results database, 36 333 patients with RCC were identified. The population was stratified according to age:<50, 50-59, 60-69, 70-79, and ≥80 yr. The effect of age on cancer control outcomes was evaluated using competing-risks regression models. Analyses were repeated stage for stage and grade for grade. MEASUREMENTS: Cancer-specific mortality (CSM) was measured. RESULTS AND LIMITATIONS: Age categories 50-59, 60-69, 70-79, and ≥80 yr respectively portended a 1.4-, 1.5-, 1.6-, and 1.9-fold higher risk of CSM than age category <50 yr (all p < 0.001). The effect of advanced age was particularly detrimental in patients with stage I disease: 1.8-, 2.3-, 3.2-, and 3.8-fold higher CSM risk for the same age groups, respectively (all p<0.001). The effect of age on CSM was at its peak in patients with stage I, low-grade RCC (1.6-, 2.2-, 3.6-, and 4.3-fold, respectively; all p<0.001) and remained elevated in stage I, high-grade RCC (2.2-, 2.6-, 2.4-, and 3.0-fold higher, respectively; all p<0.05). Conversely, its effect was virtually absent in patients with stage II-IV RCC. CONCLUSIONS: Our data suggest that stage I RCC may behave in a more aggressive fashion in elderly patients. Further studies are required to confirm the current findings.

Phenotypic characterization and functional analysis of human tumor immune infiltration after mechanical and enzymatic disaggregation.

Multi-parametric flow cytometry analysis is a reliable method for phenotypic and functional characterization of tumor infiltrating immune cells (TIIC). The isolation of infiltrating leukocytes from solid tumors can be achieved through various methods which can be both enzymatic and mechanical; however, these methods may alter cell biology. The aim of this study was to compare the effects of three tissue disaggregation techniques on TIIC biology in breast, kidney and lung tumor specimens. We therefore compared two enzymatic treatments using either collagenase type IA alone or in combination with collagenase type IV and DNase I type II, and one mechanical system (Medimachine™). We evaluated the impact of treatments on cell viability, surface marker integrity and proliferative capacity. We show that cell viability was not significantly altered by treatments. However, enzymatic treatments decreased cell proliferation; specifically collagenases and DNase provoked a significant decrease in detection of surface markers such as CD4, CD8, CD45RA and CD14, indicating that results of phenotypic studies employing these techniques could be affected. In conclusion, mechanical tissue disaggregation by Medimachine™ appears to be optimal to maintain phenotypic and functional TIIC features.

Novel method of knotless vesicourethral anastomosis during robot-assisted radical prostatectomy: feasibility study and early outcomes in 30 patients using the interlocked barbed unidirectional V-LOC180 suture.

PURPOSE: : Our purpose was to describe the safety and feasibility of a running posterior reconstruction (PR) integrated with continuous vesicourethral anastomosis (VUA) using a novel self-cinching unidirectional barbed suture in robot-assisted radical prostatectomy (RARP). METHODS: : Between March and October 2010, 30 consecutive patients with organ-confined prostate cancer underwent RARP by an experienced single surgeon (KCZ). Upon completion of radical prostatectomy, urinary reconstruction was carried out using 2 knotless, interlocked 6-inches 3-0 V-Loc-180 suture. The left tail of the suture was initially used for PR (starting at 5-o'clock and ran to re-approximate the retrotrigonal layer to the rectourethralis) followed by left-sided VUA (from 6- to 12-o'clock), while the right-sided suture completed the right-sided VUA. Assurance of watertight closure with an intraoperative 300 cc saline visual cystogram was performed in all cases prior to case completion. Perioperative outcomes and 30-day complications were recorded. RESULTS: : All anastamoses were performed without assistance and without knot tying. Median time for nurse setup and urinary reconstruction was 40 seconds (interquartile range [IQR] 25-60) and 14.6 min (IQR 10-18), respectively. The need to readjust suture tension or place Lapra-Ty clips (Ethicon Endo-Surgery, Cincinnati, OH) to establish watertight closure was observed in 2 cases (7%). No patient had clinical urinary leak and there was no urinary retention after catheter removal on mean postoperative day 5 (IQR 4-6). CONCLUSIONS: : Our clinical experience with a novel technique using the interlocked V-Loc suture during RARP for both PR and anastomosis appears to be safe and efficient. Using the barbed suture prevents slippage and eliminates the need for bedside assistance to maintain suture tension or knot tying, thus assuring watertight tissue closure.

Perioperative mortality is significantly greater in septuagenarian and octogenarian patients treated with radical cystectomy for urothelial carcinoma of the bladder.

OBJECTIVES: To revisit whether the perioperative mortality differs between septuagenarian and octogenarian patients and younger patients in a large contemporary population-based cohort. The data from tertiary care centers have suggested that perioperative mortality after radical cystectomy is not considerably different in septuagenarian or octogenarian patients compared with younger patients. However, population-based data have stated otherwise. METHODS: From 1988 to 2006, 12,722 radical cystectomies were performed for urothelial carcinoma of the urinary bladder in 17 Surveillance, Epidemiology, and End Results registries. Of those 12,722 patients, 4480 (35.2%) were aged 70-79 years and 1439 (11.3%) were aged ≥80 years. Univariate and multivariate logistic regression models tested the 90-day mortality after radical cystectomy. Covariates consisted of sex, race, year of surgery, Surveillance, Epidemiology, and End Results registry, and histologic grade and stage. RESULTS: The overall 90-day mortality rate was 4% for the entire population, 2% for patients aged ≤69 years, 5.4% for septuagenarian patients, and 9.2% for octogenarian patients. In the multivariate logistic regression analyses, septuagenarian (odds ratio 2.80; P < .001) and octogenarian (odds ratio 5.02; P < .001) age increased the risk of 90-day mortality after radical cystectomy. CONCLUSIONS: In the present population-based analysis, the perioperative mortality after radical cystectomy was three- and fivefold greater in the septuagenarian and octogenarian patients, respectively, which was greater than that in tertiary care centers. This information should be included in informed consent considerations.

Radical cystectomy for patients with pT4 urothelial carcinoma in a large population-based study.

OBJECTIVE: • To examine cancer-specific mortality (CSM) in patients with pT4N0₋3 M0 urothelial carcinoma of the urinary bladder (UCUB) and to compare it to patients with pT3N0₋3 M0, in a population-based cohort treated with radical cystectomy (RC). PATIENTS AND METHODS: • RCs were performed in 5625 pT3-T4b0₋3 M0 patients with UCUB within 17 Surveillance, Epidemiology and End Results (SEER) registries between 1988 and 2006. • Univariable and multivariable models tested the effect of pT4a vs pT4b vs pT3 stages on CSM. • Covariates consisted of age, gender, race, lymph node status and SEER registries. • All analyses were repeated in 3635 pN(0) patients. RESULTS: • Of 5625 patients, 2043 (36.3%) had pT4aN0₋3 , 248 (4.4%) had pT4bN0₋3 and 3334 had pT3N0₋3 (59.3%) UCUB. • The 5-year CSM was 57.6% vs 81.7% vs 53.9% for, respectively, pT4aN0₋3 vs pT4bN0₋3 vs pT3N0₋3 patients (all log-rank P= 0.008). • In multivariable analyses the rate of CSM was 2.3-fold higher in pT4b vs pT3 (P < 0.001), 1.1-fold higher in pT4a vs pT3 (P= 0.002) and 2.0-fold higher in pT4a vs pT4b patients. • After restriction to pN0 stage, pT4b patients had a 2.3-fold higher rate of CSM than pT3 patients (P < 0.001) and pT4b patients had a 2.1-fold higher rate of CSM than pT4a patients (P < 0.001). • The CSM rate was the same for pT4a and pT3 patients (P= 0.1). CONCLUSIONS: • Our findings indicate that patients with pT4a UCUB have similar CSM as those with pT3 UCUB. • Consequently, RC should be given equal consideration in patients with pT3 and pT4a UCUB.

A population-based comparison of cancer-control rates between radical and partial nephrectomy for T1A renal cell carcinoma.

OBJECTIVES: To complement existing data with population-based cancer control outcomes that account for the effect of other-cause mortality (OCM). Cancer control rates are virtually equivalent between partial (PN) and radical nephrectomy (RN) for patients with T1aN0M0 renal cell carcinoma (RCC). To date, only 6 studies from centers of excellence examined cancer control rates after PN vs RN for T1aN0M0 RCC. OCM was unaccounted for in those studies, which may introduce a bias. We relied on the surveillance, epidemiology, and end results (SEER) database and assessed cancer-specific mortality (CSM) after either PN or RN for T1aN0M0 RCC, in competing-risks models. METHODS: Between 1988 and 2004, the SEER-9 database identified 1622 PN (22.3%) and 5658 RN (77.7%) T1aN0M0 RCC. Competing-risks regression models, controlling for OCM and matched for age, year of surgery, tumor size, and Fuhrman grade, addressed the effect of nephrectomy type (PN vs RN) on CSM. RESULTS: At 5 years, in a PN and RN matched-population controlling for OCM, CSM after PN and RN was respectively 1.8% vs 2.5% (P = .5). The CSM rates in this cohort for patients aged ≥ 70 years were respectively 1.0% and 3.4% (P = .7). CONCLUSIONS: This competing-risks population-based analysis confirmed the CSM equivalence between PN and RN for T1aN0M0 RCC and showed virtually perfect CSM-free rates (97.5% or better) even in older patients.

Highly predictive survival nomogram after upper urinary tract urothelial carcinoma.

BACKGROUND: Nephroureterectomy is the surgical standard of care for patients with upper urinary-tract urothelial carcinoma. The objectives of the current study were to identify the most informative predictors of cancer-specific mortality after nephroureterectomy, to devise an algorithm capable of predicting the individual probability of cancer-specific mortality, and to compare its prognostic accuracy to that of the International Union Against Cancer (UICC) staging system. METHODS: Within the Surveillance, Epidemiology, and End Results database, the authors identified 5918 patients who had been treated with nephroureterectomy. Within the development cohort (n=2959), multivariate Cox regression models predicting cancer-specific mortality were fitted by using age, stage, nodal status, sex, grade, race, type of surgery (nephroureterectomy with or without bladder-cuff removal), and tumor location (renal pelvis vs ureter). Backward variable elimination according to the Akaike information criterion identified the most accurate and parsimonious model. Model validation and calibration were performed within the external validation cohort (n=2959). External validation was also applied to the UICC staging system. RESULTS: The 5-year freedom from cancer-specific mortality rates in both the development and external validation cohorts was 77.3%. The most informative and parsimonious nomogram for cancer-specific-mortality-free survival relied on age, pT and pN stages, and tumor grade. In external validation, nomogram prediction of 5-year cancer-specific-mortality-free rate was 75.4% accurate and was significantly better (P<.001) than the UICC staging system (64.8%). CONCLUSIONS: The current nomogram is capable of predicting the prognosis in patients with upper urinary-tract urothelial carcinoma treated by nephroureterectomy with better accuracy than the UICC staging system. The authors recommend the application of this nomogram to routine clinical practice when counseling or making clinical decisions.

Segmental ureterectomy can safely be performed in patients with transitional cell carcinoma of the ureter.

PURPOSE: To date no study to our knowledge has compared cancer control outcomes of segmental ureterectomy relative to nephroureterectomy, which represents the standard of care for ureteral transitional cell carcinoma. We compared cancer specific mortality rates according to surgery type (nephroureterectomy vs segmental ureterectomy) in a large population based cohort of patients with ureteral transitional cell carcinoma. MATERIALS AND METHODS: Our analyses involved 2,044 patients with pathological T1-T4 N0M0 ureteral transitional cell carcinoma from the Surveillance, Epidemiology and End Results database. Survival plots and Cox regression models compared cancer specific mortality after segmental ureterectomy, or nephroureterectomy with or without bladder cuff removal. Covariates consisted of pathological stage and grade, age, race, gender and year of surgery. RESULTS: Median followup of censored patients was 30.0 months. Overall 569 (27.8%) patients underwent segmental ureterectomy vs 1,222 (59.8%) nephroureterectomy with bladder cuff removal and 253 (12.4%) nephroureterectomy without bladder cuff removal. At 5 years cancer specific mortality-free rates for segmental ureterectomy vs nephroureterectomy with bladder cuff removal vs nephroureterectomy without bladder cuff removal were 86.6% vs 82.2% vs 80.5%, respectively (all pairwise log rank comparisons p >or=0.05). On univariable and multivariable analyses of the entire cohort, as well as after stratification according to pT1-2 vs pT3-4 stage, the type of surgery (segmental ureterectomy vs nephroureterectomy with bladder cuff removal vs nephroureterectomy without bladder cuff removal) failed to affect cancer specific mortality rates (p >or=0.2). CONCLUSIONS: In patients with ureteral transitional cell carcinoma segmental ureterectomy does not undermine cancer control outcomes relative to nephroureterectomy (with or without bladder cuff removal). Therefore, segmental ureterectomy may be offered to virtually all patients with ureteral transitional cell carcinoma when it is technically feasible, which also includes carefully selected patients with T3 or even T4 lesions.

A comparative population-based analysis of the rate of partial vs radical nephrectomy for clinically localized renal cell carcinoma.

STUDY TYPE: Prevalence (prospective cohort with good follow up). LEVEL OF EVIDENCE: 1a. OBJECTIVE: To examine contemporary (1989-2004) trends in partial nephrectomy (PN) within the Surveillance, Epidemiology and End Results (SEER) database, as among other considerations, a survival benefit due to avoidance of surgically induced renal insufficiency distinguishes PN from radical nephrectomy (RN). PATIENTS AND METHODS: Diagnostic, stage and surgical codes of patients with T1-2N0M0 renal cell carcinoma treated with either PN or RN were assessed. Proportions, trends and multivariable logistic regression models tested the predictors of the use of PN. RESULTS: Of 19 733 assessable patients, 2614 (13.2%) and 17 119 (86.8%), respectively, had PN or RN. The use of PN decreased with increasing tumour size, was more frequent in younger patients and increased with more contemporary years of surgery (all P < 0.001). Intriguingly, there was important geographical variability (P < 0.001), e.g. in the San Francisco-Oakland Metropolitan Area the absolute PN rate was 16.4%, vs 7.6% in New Mexico (P < 0.001). In multivariable analyses, tumour size, age, year of surgery, gender and SEER registries were independent predictors of PN use. CONCLUSION: Although as expected the rate of PN use increased over time, unexplained variability remained. For example, gender and SEER registries affected the likelihood of PN. These variables warrant further analyses to reduce unnecessary variability and to maximize PN use and its benefit.

Gender-related differences in patients with stage I to III upper tract urothelial carcinoma: results from the Surveillance, Epidemiology, and End Results database.

OBJECTIVES: To examine the effect of gender in upper tract urothelial carcinoma (UTUC) stage at nephroureterectomy (NU), as well as on cancer-specific mortality (CSM) after NU in patients with American Joint Committee on Cancer stages I-III UTUC. METHODS: Our analyses relied on 2903 (59.9%) males and 1947 (40.1%) females who underwent an NU for pT(1-3)N(0/x)M(0) UTUC between 1988 and 2006, within 17 Surveillance, Epidemiology, and End Results registries. Univariable and multivariable logistic regression models examined the effect of gender on stage and grade distribution at NU. Subsequently, cumulative incidence plots explored the impact of gender on CSM rates, after accounting for other-cause mortality (OCM). Finally, competing-risks regression models tested the independent predictor status of gender in CSM analyses. Covariates consisted of pT stage, pN stage, tumor grade, primary tumor location, type and year of surgery, age, and race. RESULTS: Relative to males, females had a higher proportion of pT(3) UTUC (43.1% vs 39%; P = .02) and a higher proportion of grade III/IV UTUC (63.8% vs 59.8%; P = .04) at NU. The female gender represented an independent predictor of pT(3) UTUC at NU (hazard ratio [HR]: 1.15; P = .03). After accounting for OCM, CSM rates in females were higher than those in males (HR: 1.18; P = .03). However, in multivariable competing-risks regression models, no statistically significant differences in survival were recorded between males and females (HR: 1.07; P = .4). CONCLUSIONS: Females are more likely to have more advanced pathologic T stage and higher tumor grade at NU than males. After accounting for OCM, stage, grade, and noncancer characteristics, gender no longer affects CSM.