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Background: Robotic-assisted hysterectomy (RAH) is a widely accepted minimally invasive approach for uterus removal. However, as RAH is typically performed in the umbilical region, it usually results in scars in cosmetically suboptimal locations. This is the first case of RAH with cervicosacropexy performed below the bikini line, using the new Dexter robotic system™. Objectives: The aim of this article is to show the surgical steps of the first RAH with cervicosacropexy performed below the bikini line with the new Dexter robotic system™ (Distalmotion), and furthermore assess the feasibility of this approach using this robotic platform. Materials and Methods: A 43-year-old woman with uterine adenomyosis and recurrent uterine prolapse underwent a robotic-assisted subtotal hysterectomy with cervicosacropexy, performed below the bikini line, using the Dexter robotic system™, at the Clinic of Gynecology and Obstetrics at Universitätsklinikum Schleswig-Holstein (UKHS) in Kiel, Germany. Main outcome measures: Perioperative data, surgical approach specifics, objective, and subjective outcomes of this new approach. Results: The procedure was performed without intra-operative complications; estimated blood loss was 10 ml. Operative time was 150 minutes, console time 120 minutes, total docking time 6 minutes. Dexter performed as expected; no device-related issues or robotic arm collisions occurred. The patient did not require pain medication and was released on the second postoperative day. Conclusion: RAH performed below the bikini line using the Dexter robotic system™ is a feasible, safe, and adequate procedure. These initial results should be confirmed and further extensively refurbished with larger patient cohorts, and functional and psychological outcomes need further investigation.
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Radiation-induced hemorrhagic cystitis is a late-onset complication of radiation therapy of the pelvis with an incidence rate of approximately 5-10%. The severity of hematuria can vary from mild hematuria to more severe bleeding with clot formation and urinary retention to intractable life-threatening bleeding when blood transfusions fail to keep pace with blood loss. Management of radiation-induced hemorrhagic cystitis is based on the presenting symptoms after ruling out urinary tract infection or a tumor. In cases with mild or moderate gross hematuria, hydration can be sufficient to prevent clot formation. In emergency cases, evacuation of clots and continuous bladder irrigation with isotonic saline is required, and in cases with persistent bleeding, transurethral fulguration is also required. Unfortunately, radiation-induced hemorrhagic cystitis can lead to persistent or intermittent hematuria. In these cases, intravesical instillation of astringent agents or hyperbaric oxygen therapy can alleviate symptoms. In emergency cases, transarterial embolization or surgical ligation of vesical arteries may be necessary. In rare refractory cases, urinary diversion with or without cystectomy should be performed.
Assuntos
Cistite , Lesões por Radiação , Administração Intravesical , Cistite/diagnóstico , Hematúria/etiologia , Hemorragia/etiologia , Humanos , Lesões por Radiação/diagnósticoRESUMO
BACKGROUND: Data from interventional studies suggest that a peritoneal flap after pelvic lymph node dissection (LND) during laparoscopic, robotic-assisted radical prostatectomy (RARP) may reduce the rate of symptomatic lymphoceles in transperitoneal approach. However, most of these studies are not conducted in a randomized controlled fashion, thus limiting their scientific value. A recent prospective, randomized, controlled trial (RCT) did not show superiority of a peritoneal flap while further trials are lacking. Therefore, the aim of the presented RCT will be to show that creating a peritoneal flap decreases the rate of symptomatic lymphoceles compared to the current standard procedure without creation of a flap. METHODS/DESIGN: PELYCAN is a parallel-group, patient- and assessor-blinded, phase III, adaptive randomized controlled superiority trial. Men with histologically confirmed prostate cancer who undergo transperitoneal RARP with pelvic LND will be randomly assigned in a 1:1 ratio to two groups-either with creating a peritoneal flap (PELYCAN) or without creating a peritoneal flap (control). Sample size calculation yielded a sample size of 300 with a planned interim analysis after 120 patients, which will be performed by an independent statistician. This provides a possibility for early stopping or sample size recalculation. Patients will be stratified for contributing factors for the development of postoperative lymphoceles. The primary outcome measure will be the rate of symptomatic lymphoceles in both groups within 6 months postoperatively. Patients and assessors will be blinded for the intervention until the end of the follow-up period of 6 months. The surgeon will be informed about the randomization result after performance of vesicourethral anastomosis. Secondary outcome measures include asymptomatic lymphoceles at the time of discharge and within 6 months of follow-up, postoperative complications, mortality, re-admission rate, and quality of life assessed by the EORTC QLQ-C30 questionnaire. DISCUSSION: The PELYCAN study is designed to assess whether the application of a peritoneal flap during RARP reduces the rate of symptomatic lymphoceles, as compared with the standard operation technique. In case of superiority of the intervention, this peritoneal flap may be suggested as a new standard of care. TRIAL REGISTRATION: German Clinical Trials Register DRKS00016794 . Registered on 14 May 2019.
Assuntos
Laparoscopia , Linfocele , Neoplasias da Próstata , Procedimentos Cirúrgicos Robóticos , Humanos , Laparoscopia/efeitos adversos , Excisão de Linfonodo/efeitos adversos , Linfocele/diagnóstico , Linfocele/etiologia , Linfocele/prevenção & controle , Masculino , Pelve , Prostatectomia/efeitos adversos , Neoplasias da Próstata/cirurgia , Ensaios Clínicos Controlados Aleatórios como Assunto , Procedimentos Cirúrgicos Robóticos/efeitos adversosRESUMO
PURPOSE: The comprehensive complication index (CCI) is a new tool for reporting the cumulative burden of postoperative complications on a continuous scale. This study validates the CCI for urological surgery and its benefits over the Clavien-Dindo-Classification (Clavien). MATERIAL AND METHODS: Data from a prospectively maintained data base of all consecutive patients at a university care-center was analyzed. Complications after radical cystectomy (RC), radical prostatectomy (RP), and partial nephrectomy (PN) were classified using the CCI and Clavien system. Differences in complications between the CCI and the Clavien were assessed and correlation analyses performed. Sample size calculations for hypothetical clinical trials were compared between CCI and Clavien to evaluate whether the CCI would reduce the number of required patients in a clinical trial. RESULTS: 682 patients (172 RC, 297 RP, 213 PN) were analyzed. Overall, 9.4-46.6% of patients had > 1 complication cumulatively assessed with the CCI resulting in an upgrading in the Clavien classification for 2.4-32.4% of patients. Therefore, scores between the systems differed for RC: CCI (mean ± standard deviation) 26.3 ± 20.8 vs. Clavien 20.4 ± 16.7, p < 0.001; PN: CCI 8.4 ± 14.7 vs. Clavien 7.0 ± 11.8, p < 0.001 and RP: CCI 5.8 ± 11.7 vs. Clavien 5.3 ± 10.6, p = 0.102. The CCI was more accurate in predicting LOS after RC than Clavien (p < 0.001). Sample size calculations based in the CCI (for future hypothetical trials) resulted in a reduction of required patients for all procedures (- 25% RC, - 74% PN, - 80% RP). CONCLUSION: The CCI is more accurate to assess surgical complications and reduces required sample sizes that will facilitate the conduction of clinical trials.
Assuntos
Cistectomia/efeitos adversos , Nefrectomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Prostatectomia/efeitos adversos , Gestão de Riscos/normas , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
PURPOSE: Comorbidities and frailty are determinants of surgical outcome. The aim of the study was to examine various measures of frailty and comorbidities in predicting postoperative outcome of partial nephrectomy (PN). METHODS: We prospectively analyzed the frailty and comorbidity status of 150 patients undergoing PN between 2015 and 2018. Primary endpoint was the occurrence of major postoperative complications (MPC) and secondary endpoints were the failure of Trifecta achievement and the need for hospital readmissions. For the transfer into clinical practice the most significant frailty parameters were summarized in a multi-dimensional test. RESULTS: Median age was 67 (33-93) years, 64.7% of the patients were male. Univariable regression analysis showed, that patients with increased frailty indices (Hopkins frailty score ≥2 (OR = 3.74, p = 0.005), Groningen frailty index ≥4 (OR = 2.85, p = 0.036)) are at higher risk to develop MPC. Furthermore, poor physical performance, such as a low handgrip strength or a Full-Tandem-Stand (FTS) < 10 s were associated with MPC (OR = 4.76, p = 0.014; OR = 4.48, p = 0.018) and Trifecta failure (OR = 3.60, p = 0.037, OR = 5.50, p = 0.010). Six measures were combined to the geriatric assessment in partial nephrectomy score (GAPN). A GAPN-score ≥3 proved to be a significant predictor for MPC (OR = 4.30, p = 0.029) and for Trifecta failure (OR = 0.20, p = 0.011) in multivariable regression analysis. CONCLUSION: The frailty status and comorbidities are important determinants of the postoperative course after PN. These parameters should be assessed preoperatively and included in the treatment planning, especially in light of available alternative therapies. In this context, the GAPN-score may be a suitable tool.
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Fragilidade/complicações , Fragilidade/diagnóstico , Neoplasias Renais/cirurgia , Nefrectomia/efeitos adversos , Complicações Pós-Operatórias/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Feminino , Fragilidade/fisiopatologia , Avaliação Geriátrica/métodos , Força da Mão , Humanos , Neoplasias Renais/complicações , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente , Desempenho Físico Funcional , Medição de RiscoRESUMO
OBJECTIVES: To validate the adherence of urologists to chemotherapy recommendations given in the EAU guidelines on PeCa. The European Association of Urology (EAU) guidelines on penile cancer (PeCa) are predominantly based on retrospective studies with low level of evidence. MATERIALS AND METHODS: A 14-item-survey addressing general issues of PeCa treatment was developed and sent to 45 European hospitals. 557 urologists participated in the survey of which 43.5%, 19.3%, and 37.2% were in-training, certified, and in leading positions, respectively. Median response rate among participating departments was 85.7% (IQR 75-94%). Three of 14 questions addressed clinical decisions on neoadjuvant, adjuvant, and palliative chemotherapy. Survey results were analyzed by bootstrap-adjusted multivariate logistic-regression-analysis to identify predictors for chemotherapy recommendations consistent with the guidelines. RESULTS: Neoadjuvant, adjuvant, and palliative chemotherapy was recommended according to EAU guidelines in 21%, 26%, and 48%, respectively. For neoadjuvant chemotherapy, urologists holding leading positions or performing chemotherapy were more likely to recommend guideline-consistent treatment (OR 1.85 and 1.92 with p(bootstrap) = 0.007 and 0.003, respectively). Supporting resources (i.e., guidelines, textbooks) were used by 23% of survey participants and significantly improved consistency between treatment recommendations and Guideline recommendations in all chemotherapy settings (p(bootstrap) = 0.010-0.001). Department size and university center status were no significant predictors for all three endpoints. CONCLUSIONS: In this study, we found a very low rate of adherence to the EAU guidelines on systemic treatment for PeCa. Further investigations are needed to clarify whether this missing adherence is a consequence of limited individual knowledge level or of the low grade of guideline recommendations.
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Antineoplásicos/administração & dosagem , Fidelidade a Diretrizes/estatística & dados numéricos , Pesquisas sobre Atenção à Saúde , Neoplasias Penianas/tratamento farmacológico , Urologia , Europa (Continente) , Humanos , Masculino , Guias de Prática Clínica como Assunto , Sociedades MédicasRESUMO
PURPOSE: Fatty acid-binding protein 5 (FABP5), a transport protein for lipophilic molecules, has been proposed as protein marker in prostate cancer (PCa). The role of FABP5 gene expression is merely unknown. METHODS: In two cohorts of PCa patients who underwent radical prostatectomy (n = 40 and n = 57) and one cohort of patients treated with palliative transurethral resection of the prostate (pTUR-P; n = 50) FABP5 mRNA expression was analyzed with qRT-PCR. Expression was correlated with clinical parameters. BPH tissue samples served as control. To independently validate findings on FABP5 expression, three microarray and sequencing datasets were reanalyzed (MSKCC 2010 n = 216; TCGA 2015 n = 333; mCRPC, Nature Medicine 2016 n = 114). FABP5 expression was correlated with ERG-fusion status, TCGA subtypes, cancer driver mutations and the expression of druggable downstream pathway components. RESULTS: FABP5 was overexpressed in PCa compared to BPH in the cohorts analyzed by qRT-PCR (radical prostatectomy p = 0.003, p = 0.010; pTUR-P p = 0.002). FABP5 expression was independent of T stage, Gleason Score, nodal status and PSA level. FABP5 overexpression was associated with the absence of TMPRSS2:ERG fusion (p < 0.001 in TCGA and MSKCC). Correlation with TCGA subtypes revealed FABP5 overexpression to be associated with SPOP and FOXA1 mutations. FABP5 was positively correlated with potential drug targets located downstream of FABP5 in the PPAR-signaling pathway. CONCLUSION: FABP5 overexpression is frequent in PCa, but seems to be restricted to TMPRESS2:ERG fusion-negative tumors and is associated with SPOP and FOXA1 mutations. FABP5 overexpression appears to be indicative for increased activity in PPAR signaling, which is potentially druggable.
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Carcinoma/genética , Proteínas de Ligação a Ácido Graxo/genética , Expressão Gênica , Neoplasias da Próstata/genética , RNA Mensageiro/metabolismo , Idoso , Idoso de 80 Anos ou mais , Carcinoma/patologia , Carcinoma/secundário , Carcinoma/cirurgia , Estudos de Casos e Controles , Fator 3-alfa Nuclear de Hepatócito/genética , Humanos , Masculino , Pessoa de Meia-Idade , Mutação , Gradação de Tumores , Metástase Neoplásica , Estadiamento de Neoplasias , Proteínas Nucleares/genética , Proteínas de Fusão Oncogênica/genética , Cuidados Paliativos , Receptores Ativados por Proliferador de Peroxissomo/metabolismo , Prostatectomia , Hiperplasia Prostática/genética , Neoplasias da Próstata/patologia , Neoplasias da Próstata/cirurgia , Proteínas Repressoras/genética , Reação em Cadeia da Polimerase Via Transcriptase Reversa , Transdução de Sinais , Ressecção Transuretral da PróstataRESUMO
PURPOSE: To systematically analyze the impact of prophylactic abdominal or retroperitoneal drain placement or omission in uro-oncologic surgery. METHODS: This systematic review follows the Cochrane recommendations and was conducted in line with the PRISMA and the AMSTAR-II criteria. A comprehensive database search including Medline, Web-of-Science, and CENTRAL was performed based on the PICO criteria. All review steps were done by two independent reviewers. Risk of bias was assessed with the Cochrane tool for randomized trials and the Newcastle-Ottawa Scale. RESULTS: The search identified 3427 studies of which eleven were eligible for qualitative and ten for quantitative analysis reporting on 3664 patients. Six studies addressed radical prostatectomy (RP), four studies partial nephrectomy (PN) and one study radical cystectomy. For RP a reduction in postoperative complications was found without drainage (odds ratio (OR)[95% confidence interval (CI)]: 0.62[0.44;0.87], p = 0.006), while there were no differences for re-intervention (OR[CI]: 0.72[0.39;1.33], p = 0.300), lymphocele OR[CI]: 0.60[0.22;1.60], p = 0.310), hematoma (OR[CI]: 0.68[0.18;2.53], p = 0.570) or urinary retention (OR[CI]: 0.57[0.26;1.29], p = 0.180). For partial nephrectomy no differences were found for overall complications (OR[CI]: 0.99[0.65;1.51], p = 0.960) or re-intervention (OR[CI]: 1.16[0.31;4.38], p = 0.820). For RC, there were no differences for all parameters. The overall-quality of evidence was assessed as low. CONCLUSION: The omission of drains can be recommended for standardized RP and PN cases. However, deviations from the standard can still mandate the placement of a drain and remains surgeon preference. For RC, there is little evidence to recommend the omission of drains and future research should focus on this issue. REVIEW REGISTRATION NUMBER (PROSPERO): CRD42019122885.
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Cistectomia/métodos , Drenagem/métodos , Nefrectomia/métodos , Complicações Pós-Operatórias/prevenção & controle , Procedimentos Cirúrgicos Profiláticos , Prostatectomia/métodos , Neoplasias Urológicas/cirurgia , Abdome , Humanos , Masculino , Espaço RetroperitonealRESUMO
Prostate-specific membrane antigen (PSMA) positron emission tomography-computed tomography (PET-CT) imaging for the localization of prostate cancer is increasingly available in Germany. The advances and limitations in different disease stages are reviewed. As the clinical relevance of oligometastatic disease in primary cancer detected by PSMA PET-CT imaging is not yet completely understood, it should only be used in clinical trials. In recurrent prostate cancer after therapy with curative intent, PSMA PET-CT shows encouraging potential for the planning of salvage therapy. In metastatic castration-resistant prostate cancer evidence for its use is not available.
Assuntos
Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Neoplasias da Próstata , Alemanha , Humanos , Masculino , Recidiva Local de Neoplasia , Antígeno Prostático Específico , Neoplasias da Próstata/diagnóstico por imagemRESUMO
Prostate-specific membrane antigen (PSMA) positron emission tomography-computed tomography (PET-CT) imaging for the localization of prostate cancer is increasingly available in Germany. The advances and limitations in different disease stages are reviewed. As the clinical relevance of oligometastatic disease in primary cancer detected by PSMA PET-CT imaging is not yet completely understood, it should only be used in clinical trials. In recurrent prostate cancer after therapy with curative intent, PSMA PET-CT shows encouraging potential for the planning of salvage therapy. In metastatic castration-resistant prostate cancer evidence for its use is not available.
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Antígenos de Superfície/análise , Glutamato Carboxipeptidase II/análise , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada/métodos , Neoplasias da Próstata/diagnóstico por imagem , Neoplasias da Próstata/patologia , Progressão da Doença , Humanos , Masculino , Invasividade Neoplásica , Recidiva Local de Neoplasia/diagnóstico por imagem , Recidiva Local de Neoplasia/patologia , Recidiva Local de Neoplasia/terapia , Estadiamento de Neoplasias , Prognóstico , Neoplasias da Próstata/terapia , Neoplasias de Próstata Resistentes à Castração/diagnóstico por imagem , Neoplasias de Próstata Resistentes à Castração/patologia , Neoplasias de Próstata Resistentes à Castração/terapia , Terapia de SalvaçãoRESUMO
PURPOSE: To evaluate the possible association between bladder tumor location and the laterality of positive lymph nodes (LN) in a prospectively collected multi-institutional radical cystectomy (RC) series. METHODS: The study population included 148 node-positive bladder cancer (BC) patients undergoing RC and pelvic lymph node dissection in 2011 without neoadjuvant chemotherapy and without distant metastasis. Tumor location was classified as right, left or bilateral and compared to the laterality of positive pelvic LN. A logistic regression model was used to identify predictors of ipsilaterality of lymphatic spread. Using multivariate Cox regression analyses (median follow-up: 25 months), the effect of the laterality of positive LN on cancer-specific mortality (CSM) was estimated. RESULTS: Overall, median 18.5 LN [interquartile range (IQR), 11-27] were removed and 3 LN (IQR 1-5) were positive. There was concordance of tumor location and laterality of positive LN in 82% [95% confidence interval (CI), 76-89]. Patients with unilateral tumors (n = 78) harbored exclusively ipsilateral positive LN in 67% (95% CI 56-77). No criteria were found to predict ipsilateral positive LN in patients with unilateral tumors. CSM after 3 years in patients with ipsilateral, contralateral, and bilateral LN metastasis was 41, 67, and 100%, respectively (p = 0.042). However, no significant effect of the laterality of positive pelvic LN on CSM could be confirmed in multivariate analyses. CONCLUSIONS: Our prospective cohort showed a concordance of tumor location and laterality of LN metastasis in BC at RC without any predictive criteria and without any influence on CSM. It is debatable, whether these findings may contribute to a more individualized patient management.
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Carcinoma de Células de Transição , Cistectomia , Excisão de Linfonodo/métodos , Vasos Linfáticos/patologia , Pelve/patologia , Neoplasias da Bexiga Urinária , Bexiga Urinária , Adulto , Idoso , Carcinoma de Células de Transição/mortalidade , Carcinoma de Células de Transição/patologia , Carcinoma de Células de Transição/cirurgia , Cistectomia/efeitos adversos , Cistectomia/métodos , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Alemanha/epidemiologia , Humanos , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Avaliação de Processos e Resultados em Cuidados de Saúde , Análise de Sobrevida , Bexiga Urinária/patologia , Bexiga Urinária/cirurgia , Neoplasias da Bexiga Urinária/mortalidade , Neoplasias da Bexiga Urinária/patologia , Neoplasias da Bexiga Urinária/cirurgiaRESUMO
Cross-sectional imaging modalities including multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) are the diagnostic standard in detection, characterization, and staging of renal masses due to their high sensitivity and specificity. Currently, most renal masses are incidentally diagnosed by imaging for other medical reasons. Recent developments have improved image acquisition with high resolution, while simultaneously reducing radiation dose. CT imaging is the most accessible cross-sectional imaging method and is, therefore, the standard technique. MRI is indicated in patients who are allergic to intravenous CT contrast medium, in patients with renal insufficiency, or in younger patients. Further characterization of renal masses is possible with functional imaging including dual energy CT, perfusion CT, or diffusion-weighted MRI. Contrast-enhanced ultrasound allows detection of even subtle enhancement in hypovascular lesions with high sensitivity and can add valuable information to CT and MRI studies.
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Anatomia Transversal/métodos , Neoplasias Renais/diagnóstico , Imageamento por Ressonância Magnética/métodos , Tomografia Computadorizada Multidetectores/métodos , Ultrassonografia/métodos , Anatomia Transversal/tendências , Técnicas de Diagnóstico Urológico/tendências , Humanos , Imageamento por Ressonância Magnética/tendências , Tomografia Computadorizada Multidetectores/tendências , Ultrassonografia/tendênciasRESUMO
PURPOSE: Radical cystectomy (RC) and pelvic lymph node dissection (LND) are standard treatments for muscle-invasive urothelial carcinoma of the bladder. Lymph node staging is a prerequisite for clinical decision-making regarding adjuvant chemotherapy and follow-up regimens. Recently, the clinical and pathological nodal staging scores (cNSS and pNSS) were developed. Prior to RC, cNSS determines the minimum number of lymph nodes required to be dissected; pNSS quantifies the accuracy of negative nodal staging based on pT stage and dissected LNs. cNSS and pNSS have not been externally validated, and their relevance for prediction of cancer-specific mortality (CSM) has not been assessed. METHODS: In this retrospective study of 2,483 RC patients from eight German centers, we externally validated cNSS and pNSS and determined their prediction of CSM. All patients underwent RC and LND. Median follow-up was 44 months. cNSS and pNSS sensitivities were evaluated using the original beta-binominal models. Adjusted proportional hazards models were calculated for pN0 patients to assess the predictive value of cNSS and pNSS for CSM. RESULTS: cNSS and pNSS both pass external validation. Adjusted for other clinical parameters, cNSS can predict outcome after RC. pNSS has no independent impact on prediction of CSM. The retrospective design is the major limitation of the study. CONCLUSIONS: In the present external validation, we confirm the validity of both cNSS and pNSS. cNSS is an independent predictor of CSM, thus rendering it useful as a tool for planning the extent of LND.
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Carcinoma de Células de Transição/patologia , Excisão de Linfonodo/métodos , Linfonodos/patologia , Neoplasias da Bexiga Urinária/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células de Transição/terapia , Quimioterapia Adjuvante , Estudos de Coortes , Cistectomia , Intervalo Livre de Doença , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Pelve , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Resultado do Tratamento , Neoplasias da Bexiga Urinária/terapiaRESUMO
AIM: The outcome of patients with urothelial carcinoma of the bladder (UCB) after radical cystectomy (RC) shows remarkable variability. We evaluated the ability of artificial neural networks (ANN) to perform risk stratification in UCB patients based on common parameters available at the time of RC. METHODS: Data from 2111 UCB patients that underwent RC in eight centers were analysed; the median follow-up was 30 months (IQR: 12-60). Age, gender, tumour stage and grade (TURB/RC), carcinoma in situ (TURB/RC), lymph node status, and lymphovascular invasion were used as input data for the ANN. Endpoints were tumour recurrence, cancer-specific mortality (CSM) and all-cause death (ACD). Additionally, the predictive accuracies (PA) of the ANNs were compared with the PA of Cox proportional hazards regression models. RESULTS: The recurrence-, CSM-, and ACD- rates after 5 years were 36%, 33%, and 46%, respectively. The best ANN had 74%, 76% and 69% accuracy for tumour recurrence, CSM and ACD, respectively. Lymph node status was one of the most important factors for the network's decision. The PA of the ANNs for recurrence, CSM and ACD were improved by 1.6% (p = 0.247), 4.7% (p < 0.001) and 3.5% (p = 0.007), respectively, in comparison to the Cox models. CONCLUSIONS: ANN predicted tumour recurrence, CSM, and ACD in UCB patients after RC with reasonable accuracy. In this study, ANN significantly outperformed the Cox models regarding prediction of CSM and ACD using the same patients and variables. ANNs are a promising approach for individual risk stratification and may optimize individual treatment planning.
Assuntos
Carcinoma de Células de Transição/patologia , Cistectomia , Diagnóstico por Computador , Redes Neurais de Computação , Neoplasias da Bexiga Urinária/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células de Transição/cirurgia , Intervalo Livre de Doença , Feminino , Alemanha , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Modelos de Riscos Proporcionais , Medição de Risco , Sensibilidade e Especificidade , Análise de Sobrevida , Neoplasias da Bexiga Urinária/cirurgiaRESUMO
PURPOSE: To perform the first external validation of a recently identified association between disease-free survival at two years (DFS2) or three years (DFS3) and overall survival at five years (OS5) in patients after radical cystectomy (RC) for muscle-invasive urothelial carcinoma of the bladder (UCB). METHODS AND METHODS: Records of 2483 patients who underwent RC for UCB at eight European centers between 1989 and 2008 were reviewed. The cohort included 1738 patients with pT2-4a tumors and negative soft tissue surgical margins (STSM) according to the selection criteria of the previous study (study group (SG)). In addition, 745 patients with positive STSM or other tumor stages (pT0-T1, pT4b) that were excluded from the previous study (excluded patient group (EPG)) were evaluated. Kappa statistic was used to measure the agreement between DFS2 or DFS3 and OS5. RESULTS: The overall agreement between DFS2 and OS5 was 86.5% (EPG: 88.7%) and 90.1% (EPG: 92.1%) between DFS3 and OS5. The kappa values for comparison of DFS2 or DFS3 with OS5 were 0.73 (SE: 0.016) and 0.80 (SE: 0.014) respectively for the SG, and 0.67 (SE: 0.033) and 0.78 (SE: 0.027) for the EPG (all p-values <0.001). CONCLUSIONS: We externally validated a correlation between DFS2 or DFS3 and OS5 for patients with pT2-4a UCB with negative STSM that underwent RC. Furthermore, this correlation was found in patients with other tumor stages regardless of STSM status. These findings indicate DFS2 and DFS3 as valid surrogate markers for survival outcome with RC.
Assuntos
Carcinoma/mortalidade , Carcinoma/cirurgia , Cistectomia , Neoplasias da Bexiga Urinária/mortalidade , Neoplasias da Bexiga Urinária/cirurgia , Urotélio , Adulto , Idoso , Carcinoma/secundário , Estudos de Coortes , Cistectomia/métodos , Intervalo Livre de Doença , Determinação de Ponto Final , Europa (Continente) , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Prognóstico , Reprodutibilidade dos Testes , Fatores de Tempo , Resultado do Tratamento , Neoplasias da Bexiga Urinária/patologia , Urotélio/patologia , Urotélio/cirurgiaRESUMO
Systemic therapy of metastatic renal cell carcinoma has completely changed in the last 5 years. Although a cure for the disease is still not achieved with systemic treatment in the majority of cases immunotherapy is no longer used. The therapeutic regiments are mainly based on angiogenic inhibitors such as sunitinib, sorafenib, pazopanib, everolimus and temsirolimus as well as the combination of bevacizumab with interferon. This article gives an overview of these treatment options and the clinical setting for their usage. To achieve a prolonged progression-free survival, a continuous therapy based on the new drugs is necessary. The major goal of the treatment remains to keep the disease stable as complete remission is only seen in 2-4% of cases. With these lengthy treatment regimes a schedule for sequenced administration of drugs is necessary for most of the patients. The optimal treatment sequence is unknown and should be chosen based on the individual course of the disease and the side effects as well as comorbidities. The role of neoadjuvant and adjuvant therapies remains unclear.
Assuntos
Inibidores da Angiogênese/administração & dosagem , Antineoplásicos/administração & dosagem , Carcinoma de Células Renais/tratamento farmacológico , Neoplasias Renais/tratamento farmacológico , Esquema de Medicação , Humanos , Injeções Intra-ArteriaisRESUMO
Changes in the methylation pattern in particular gene promoters as well as genetic sequence mutations play an important role in carcinogenesis. Molecular methods like pyrosequencing provide the specific analysis of these epigenetic and genetic modifications. In this review the relevance of these alterations for prostate cancer and the function of pyrosequencing will be described and explained on the basis of a search of the PubMed literature database. At present, in uro-oncology only a few studies outlining methylation in prostate cancer and pyrosequencing have been published. Nevertheless, it becomes evident that epigenetic mechanisms as well as specific gene sequence alterations have an impact on the carcinogenesis of prostate cancer and knowledge of these factors might open perspectives in diagnostic approaches of the future.
Assuntos
Biomarcadores Tumorais/genética , Análise Mutacional de DNA/tendências , Marcadores Genéticos/genética , Testes Genéticos/tendências , Neoplasias da Próstata/diagnóstico , Neoplasias da Próstata/genética , Análise de Sequência de DNA/tendências , Predisposição Genética para Doença/genética , Humanos , Masculino , Oncologia/tendências , Urologia/tendênciasRESUMO
Management of kidney injuries is an uncommon challenge to urologists. Therapy has evolved in recent years from mainly surgical to predominantly conservative treatment. Immediate surgical intervention for renal trauma is now only necessary in rare instances. This overview is based on the guidelines of the European Association of Urology and the Societé International d'Urologie as well as clinical experience and is intended to provide practical advice for treatment of renal trauma.
Assuntos
Contusões/cirurgia , Rim/lesões , Rim/cirurgia , Ferimentos não Penetrantes/cirurgia , Ferimentos Penetrantes/cirurgia , Contusões/diagnóstico , Árvores de Decisões , Hemorragia/diagnóstico , Hemorragia/cirurgia , Humanos , Nefrectomia , Complicações Pós-Operatórias/etiologia , Guias de Prática Clínica como Assunto , Radiologia Intervencionista , Cateterismo Urinário , Ferimentos não Penetrantes/diagnóstico , Ferimentos Penetrantes/diagnósticoRESUMO
Chronic inflammation seems of importance in multiple types of cancer. Numerous reports have revealed a potential link between chronic prostatatic inflammation and prostate cancer. The aim of this paper is to review the epidemiological, moprphological, molecular and clinical aspects of prostattic inflammation and prostate cancer.