Type of treatment, symptoms and patient satisfaction play an important role in primary care contact during prostate cancer follow-up: results from the population-based PROFILES registry.

BACKGROUND: With the increasing attention for the role of General Practitioners (GPs) after cancer treatment, it is important to better understand the involvement of GPs following prostate cancer treatment. This study investigates factors associated with GP contact during follow-up of prostate cancer survivors, such as patient, treatment and symptom variables, and satisfaction with, trust in, and appraised knowledge of GPs. METHODS: Of 787 prostate cancer survivors diagnosed between 2007 and 2013, and selected from the Netherlands Cancer Registry, 557 (71%) responded to the invitation to complete a questionnaire. Multivariable logistic regression analyses were performed to investigate which variables were associated with GP contact during follow- up. RESULTS: In total, 200 (42%) prostate cancer survivors had contact with their GP during follow-up, and 76 (16%) survivors preferred more contact. Survivors who had an intermediate versus low educational level (OR = 2.0) were more likely to have had contact with their GP during follow-up. Survivors treated with surgery (OR = 2.8) or hormonal therapy (OR = 3.5) were also more likely to seek follow-up care from their GP compared to survivors who were treated with active surveillance. Patient reported bowel symptoms (OR = 1.4), hormonal symptoms (OR = 1.4), use of incontinence aids (OR = 1.6), and being satisfied with their GP (OR = 9.5) were also significantly associated with GP contact during follow-up. CONCLUSIONS: Education, treatment, symptoms and patient satisfaction were associated with GP contact during prostate cancer follow-up. These findings highlight the potential for adverse side-effects to be managed in primary care. In light of future changes in cancer care, evaluating prostate cancer follow-up in primary care remains important.

Long-term functional outcomes after robot-assisted prostatectomy compared to laparoscopic prostatectomy: Results from a national retrospective cluster study.

BACKGROUND: Despite multiple studies evaluating the effectiveness of Robot-Assisted Radical Prostatectomy (RARP), there is no definitive conclusion about the added value of RARP. A retrospective cluster study was conducted to evaluate long-term sexual and urinary functioning after RARP and Laparoscopic Radical Prostatectomy (LRP) based on real-world data from 12 Dutch hospitals. METHODS: Data was collected from patients who underwent surgery between 2010 and 2012. A mixed effect model was used to evaluate differences between groups on urinary and sexual functioning (EPIC-26). Additionally, a regression analysis was conducted to evaluate the relationship between these functional outcomes and, among others, hospital volume. RESULTS: 1370 (65.1%) patients participated, 907 underwent RARP and 463 LRP, with a median follow-up time of 7.08 years (SD = 0.98). The RARP group showed a statistically and clinically significant better urinary functioning compared to the LRP group (p = 0.002). RARP showed also a shorter procedure time (p=<0.001), reduced blood loss (p=<0.001), and a higher chance of neurovascular bundle preservation (39.8% vs 29.1%; p=<0.01). CONCLUSION: RARP resulted in better long-term urinary function compared to LRP. Based on the results from this study, guidelines concerning the preferred surgery type and the position on reimbursement may change, especially when RARP proves to be cost-effective.

Real-world Outcomes of Sequential Androgen-receptor Targeting Therapies with or Without Interposed Life-prolonging Drugs in Metastatic Castration-resistant Prostate Cancer: Results from the Dutch Castration-resistant Prostate Cancer Registry.

BACKGROUND: Cross resistance between androgen-receptor targeting therapies (ARTs) (abiraterone acetate plus prednisone [ABI+P] or enzalutamide [ENZ]) for treatment of metastatic castration-resistant prostate cancer (mCRPC) may affect responses to second ART (ART2). OBJECTIVE: To establish treatment duration and prostate-specific antigen (PSA) response of ART2 in real-world mCRPC patients treated with or without other life-prolonging drugs (LPDs; ie, docetaxel, cabazitaxel, or radium-223) between ART1 and ART2. DESIGN, SETTING, AND PARTICIPANTS: Castration-resistant prostate cancer patients, diagnosed between 2010 and 2016 were retrospectively registered in Castration-resistant Prostate Cancer Registry (CAPRI). Patients treated with both ARTs were clustered into two subgroups: ART1>ART2 or ART1>LPD>ART2. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Outcomes were ≥50% PSA response and treatment duration of ART2. Descriptive statistics and binary logistic regression after multiple imputations were performed. RESULTS AND LIMITATIONS: A total of 273 patients were included with a median follow-up of 8.4 mo from ART2. Patients with ART1>ART2 were older and had favourable prognostic characteristics at ART2 baseline compared with patients with ART1>LPD>ART2. No differences between ART1>ART2 and ART1>LPD>ART2 were found in PSA response and treatment duration. Multivariate analysis suggested that PSA response of ART2 was less likely in patients with visceral metastases (odds ratio [OR] 0.143, p=0.04) and more likely in patients with a relatively longer duration of androgen-deprivation treatment (OR 1.028, p=0.01) and with ABI + P before ENZ (OR 3.192, p=0.02). A major limitation of this study was missing data, a common problem in retrospective observational research. CONCLUSIONS: The effect of ART2 seems to be low, with a low PSA response rate and a short treatment duration irrespective of interposed chemotherapy or radium-223, especially in patients with short time on castration, visceral disease, and ENZ before ABI+P. PATIENT SUMMARY: We observed no differences in outcomes of patients treated with sequential abiraterone acetate plus prednisone (ABI+P) and enzalutamide (ENZ) with or without interposed chemotherapy or radium-223. In general, outcomes were lower than those in randomised trials, questioning the additional effect of second treatment with ABI+P or ENZ in daily practice.

Endoscopic transvesical adenomectomy of the prostate, a new minimally invasive approach for large benign prostatic hyperplasia. What has our experience taught us?

INTRODUCTION: Recent technical advances have made new minimally invasive techniques possible to treat large volume (>80 ml) benign prostatic hyperplasia (BPH). The endoscopic transperitoneal adenomectomy of the prostate (ETAP) is a new minimally invasive technique developed in our centre. The aim of this study was to describe the safety, efficacy and to evaluate our learning curve in ETAP. MATERIAL AND METHODS: This was a single-centre study that enrolled eighty-eight consecutive patients with large BPH who underwent ETAP. Pre-, per- and postoperative data were prospectively collected. Statistical analysis compared the first 40 patients submitted to ETAP (Group A) with the subsequent 48 patients (Group B). RESULTS: There were no significant differences in the surgical procedure between groups. The median operating time was 94 (80-110) minutes and the estimated blood loss 150 (100-300) ml. There were no perioperative blood transfusions nor any conversions to open approach needed. Median hospital stay was 3 (3-5) days and catheter was removed mainly at day 9 (5-11). The median Qmax improved from 8.0 (6.2-9.9) ml/s to 15.0 (11.5-23.0) ml/s postoperatively and the median International Prostate Symptom Score (IPSS) score decreased from 20 (15-24) to 6 (4-11) after the procedure. CONCLUSIONS: ETAP is a secure and feasible minimally invasive technique for treatment of large BPH. The functional outcomes of this technique are consistent and promising.

Utilization and Operative Influence of Renal Mass Biopsy in the Small Renal Mass: Analysis from the Clinical Research Office of the Endourological Society Small Renal Mass registry.

Introduction and Objective: Definitive inclusion of renal mass biopsy (RMB) in small renal mass (SRM) diagnostic algorithm remains controversial. We assessed incidence and accuracy of RMB in SRMs in the CROES Renal Mass registry and the influence of preoperative RMB on perioperative complications after SRM nephron-sparing surgery (NSS). Materials and Methods: "ad hoc" description of incidence of preoperative RMB and characteristics of SRM cases with and without RMB. Accuracy of RMB was calculated in the SRM subcohort that received extirpative treatment and complication rate after NSS compared to between the two groups. Continuous variables were compared using t-test; categorical variables were compared using the chi-square test. K-statistics was used to analyze agreement between the biopsy histology and surgical pathology. Logistic regression was used to assess the association between RMB and NSS complications. All tests were two sided, and p-values <0.05 were considered statistically significant. Results: The rate of preoperative RMB in SRMs was 11.6% (175/1597) in Europe and the United States. RMB patients were more likely to have hypertension (p < 0.04), be on dialysis (p < 0.024), or smokers (p = 0.005), with multiple/bilateral tumors (0.008 and 0.010) and previous other malignancy (p = 0.021). They underwent radical nephrectomy more frequently than non-RMB group (p = 0.034). RMB was nondiagnostic in 16 cases (9%). Accuracy of RMB in distinguishing malignant from benign was 89.5%. Agreement between biopsy and final surgical pathology was 93% for malignant vs benign tumors (kappa = 0.655). Upstaging to pT3a occurred more frequently in the RMB group (12.6% vs 6.25% [p = 0.022]). Complication rate in renal mass-NSS subcohort was 15.8%, not statistically different between RMB and non-RMB groups. On logistic regression analysis, RMB was not associated with increased risk of postoperative complication after NSS (OR: 0.9, 95% CI: 0.43-1.89). Conclusion: The practice of RMB in SRM is still scarce despite high accuracy and concordance with final pathology. RMB does not seem to increase complication rate after NSS.

Second-Line Cabazitaxel Treatment in Castration-Resistant Prostate Cancer Clinical Trials Compared to Standard of Care in CAPRI: Observational Study in the Netherlands.

BACKGROUND: Cabazitaxel has been shown to improve overall survival (OS) in metastatic castration-resistant prostate cancer (mCRPC) patients after docetaxel in the TROPIC trial. However, trial populations may not reflect the real-world population. We compared patient characteristics and outcomes of cabazitaxel within and outside trials (standard of care, SOC). PATIENTS AND METHODS: mCRPC patients treated with cabazitaxel directly after docetaxel therapy before 2017 were retrospectively identified and followed to 2018. Patients were grouped on the basis of treatment within a trial or SOC. Outcomes included OS and prostate-specific antigen (PSA) response. RESULTS: From 3616 patients in the CAPRI registry, we identified 356 patients treated with cabazitaxel, with 173 patients treated in the second line. Trial patients had favorable prognostic factors: fewer symptoms, less visceral disease, lower lactate dehydrogenase, higher hemoglobin, more docetaxel cycles, and longer treatment-free interval since docetaxel therapy. PSA response (≥ 50% decline) was 28 versus 12%, respectively (P = .209). Median OS was 13.6 versus 9.6 months for trial and SOC subgroups, respectively (hazard ratio = 0.73, P = .067). After correction for prognostic factors, there was no difference in survival (hazard ratio = 1.00, P = .999). Longer duration of androgen deprivation therapy treatment, lower lactate dehydrogenase, and lower PSA were associated with longer OS; visceral disease had a trend for shorter OS. CONCLUSION: Patients treated with cabazitaxel in trials were fitter and showed outcomes comparable to registration trials. Conversely, those treated in daily practice showed features of more aggressive disease and worse outcome. This underlines the importance of adequate estimation of trial eligibility and health status of mCRPC patients in daily practice to ensure optimal outcomes.

Endoscopic Transvesical Adenomectomy of the Prostate, a New Minimal Invasive Approach for Large Benign Prostate Hyperplasia. A Description of the Technique and the Results of the First 40 Patients.

OBJECTIVE: The objective of this study is to present the results in the first 40 patients treated with a new minimal invasive technique in the treatment of large-volume benign prostate hyperplasia: the endoscopic transvesical adenomectomy of the prostate (ETAP). PATIENTS AND METHODS: From 2014 to 2016 we performed the ETAP in 40 patients with large volume benign prostate hyperplasia (>80 cc). The mean volume on ultrasound was 117 cc. The mean baseline Qmax was 8.1 ml/s and the International Prostate Symptom Score was 20.5. Seventeen patients (43%) had a urinary retention preoperatively. A cystotomy through a small infraumbilical incision was performed and a camera port was placed through the bladder dome. A pneumovesicum was created and 2 instrument ports were placed into the bladder. The prostate was transected and removed in 1 piece through the umbilical incision. RESULTS: The operation was completed in all 40 patients, without need for conversion. The mean operation time was 102 minutes with a mean blood loss of 185 ml. The average hospital stay was 5 days. There were no grade V complications and 1 grade IV complication. The transfusion rate was 2.5%. After the procedure, all 40 patients were able to void spontaneous. The Qmax increased to 21.2 ml/s (+13.1 ml/s) and the International Prostate Symptom Score decreased to 7.5 (-13 pts). CONCLUSION: This study shows that the ETAP is a feasible, safe, and truly minimal invasive procedure. The functional outcomes are promising as well. We believe the ETAP is good alternative to open surgery.

Cancer survivors' preference for follow-up care providers: a cross-sectional study from the population-based PROFILES-registry.

BACKGROUND: The best practice for the organization of follow-up care in oncology is under debate, due to growing numbers of cancer survivors. Understanding survivors' preferences for follow-up care is elementary for designing patient-centred care. Based on data from prostate cancer and melanoma survivors, this study aims to identify: 1) preferences for follow-up care providers, for instance the medical specialist, the oncology nurse or the general practitioner; 2) characteristics associated with these preferences and 3) the preferred care provider to discuss cancer-related problems. MATERIAL AND METHODS: Survivors diagnosed with prostate cancer (N = 535) and melanoma (N = 232) between 2007 and 2013 as registered in The Netherlands Cancer Registry returned a questionnaire (response rate was 71% and 69%, respectively). A latent class cluster model analysis was used to define preferences and a multinomial logistic regression analysis was used to identify survivor-related characteristics associated with these preferences. RESULTS: Of all survivors, 29% reported no preference, 40% reported a preference for the medical specialist, 20% reported a preference for both the medical specialist and the general practitioner and 11% reported a preference for both the medical specialist and the oncology nurse. Survivors who were older, lower/intermediate educated and women were more likely to have a preference for the medical specialist. Lower educated survivors were less likely to have a preference for both the medical specialist and the general practitioner. Overall, survivors prefer to discuss diet, physical fitness and fatigue with the general practitioner, and hereditary and recurrence with the medical specialist. Only a small minority favored to discuss cancer-related problems with the oncology nurse. CONCLUSION: Survivors reported different preferences for follow-up care providers based on age, education level, gender and satisfaction with the general practitioner, showing a need for tailored follow-up care in oncology. The results indicate an urgency to educate patients about transitions in follow-up care.

Laparoscopic Radical Cystectomy in the Elderly - Results of a Single Center LRC only Series

ABSTRACT Objective: To compare outcome of laparoscopic radical cystectomy (LRC) with ileal conduit in 22 elderly ( (≥75 years) versus 51 younger (<75 years) patients. patients. Materials and Methods: Analysis of prospectively gathered data of a single institution LRC only series was performed. Selection bias for LRC versus non-surgical treatments was assessed with data retrieved from the Netherlands Cancer Registry. Results: Median age difference between LRC groups was 9.0 years. (77.0 versus 68.0 years). Both groups had similar surgical indications, body mass index and gender distribution. Charlson Comorbidity Index score was 3 versus 4 in ≥50% of younger and elderly patients. Median operative time (340 versus 341 min) and estimated blood loss (<500 versus >500mL) did not differ between groups. Median total hospital stay was 12.0 versus 14.0 days for younger and elderly patients. Grade I-II 90-d complication rate was higher for elderly patients (68 versus 43%, p=0.05). Grade III-V 90-d complication rate was equal for both groups (23 versus 29%, p=0.557). 90-d mortality rate was higher for elderly patients (14 versus 4%, p=0.157). Median follow-up was 40.0 months for younger and 57.0 months for elderly patients. Estimated overall and cancer-specific survival at 5years. was 46% versus 35% and 64% versus 64% for younger and elderly patients respectively. Conclusions: Our results suggest that LRC is feasible in elderly patients, where a non-surgical treatment is usually favoured.

Rare urological manifestation of Henoch-Schönlein purpura: testicular torsion.

The Henoch-Schönlein purpura (HSP) is a systemic vasculitis that mostly occurs in children. Besides the most common clinical manifestations such as palpable purpura, arthralgia, abdominal pain and renal disease, it can have urological manifestations. We report a rare case of a 2-year-old boy with the HSP who developed a testicular torsion under corticosteroid treatment.

Variations in pelvic lymph node dissection in invasive bladder cancer: A Dutch nationwide population-based study during centralization of care.

OBJECTIVES: To assess temporal trends in radical cystectomy (RC) and pelvic lymph node dissection (PLND) and the effect of centralization of care in the Netherlands between 2006 and 2012. PATIENTS AND METHODS: This nationwide population-based study included 3524 patients from the Netherlands Cancer Registry who underwent RC as the primary treatment for cT1-4a, N0 or Nx, M0 urothelial carcinoma. Annual application rates of PLND, median LNC, and rates of node-positive disease (pN+) were compared by linear-by-linear association. Multivariable logistic regression was performed to identify patients׳ and hospital characteristics associated with PLND and LNC≥10, and to study associations between LNC and pN+disease. RESULTS: In total, 3,191 (91%) patients had PLND during RC and the use increased from 84% in 2006 to 96% in 2012 (P<0.001). Owing to centralization of care in 2010 (at least 10RCs/y/hospital), significantly more patients were treated in high-volume hospitals (≥20RC per year) in 2011 and 2012. PLND use was highest in males, younger patients and in academic, teaching, and high-volume hospitals (≥20RC per year). In 2012, PLND application rates were comparable for academic, teaching, and nonteaching hospitals (P = 0.344). Median LNC increased from 7 in 2006 to 13 in 2012 (P<0.001), 55% had an LNC≥10 (63% in 2012). Furthermore, lymph node count (LNC)≥10 was associated with cT3-4a and, pN+disease, R0 and treatment in academic, teaching, or high-volume hospitals (≥20RC per year). Rate of pN+disease increased from 18% to 24% between 2006 and 2012 (P = 0.014). This trend was significantly associated with increased LNC on a continuous scale (odds ratio = 1.03). CONCLUSIONS: After centralization of care, PLND during RC for cT1-4a, N0 or Nx, M0 urothelial carcinoma has become standard in all types of Dutch hospitals. The increase in LNC between 2006 and 2012 was associated with a higher incidence of pN+disease and suggests more adequate template extension and adherence to contemporary guidelines in recent years.

Laparoscopic Radical Cystectomy in the Elderly - Results of a Single Center LRC only Series.

OBJECTIVE: To compare outcome of laparoscopic radical cystectomy (LRC) with ileal conduit in 22 elderly (≥75 years.) versus 51 younger (< 75 years.) patients. MATERIALS AND METHODS: Analysis of prospectively gathered data of a single institution LRC only series was performed. Selection bias for LRC versus non-surgical treatments was assessed with data retrieved from the Netherlands Cancer Registry. RESULTS: Median age difference between LRC groups was 9.0 years (77.0 versus 68.0 years). Both groups had similar surgical indications, body mass index and gender distribution. Charlson Comorbidity Index score was 3 versus 4 in ≥50% of younger and elderly patients. Median operative time (340 versus 341 min) and estimated blood loss (< 500 versus >500mL) did not differ between groups. Median total hospital stay was 12.0 versus 14.0 days for younger and elderly patients. Grade I-II 90-d complication rate was higher for elderly patients (68 versus 43%, p=0.05). Grade III-V 90-d complication rate was equal for both groups (23 versus 29%, p=0.557). 90-d mortality rate was higher for elderly patients (14 versus 4%, p=0.157). Median follow-up was 40.0 months for younger and 57.0 months for elderly patients. Estimated overall and cancer-specific survival at 5years. was 46% versus 35% and 64% versus 64% for youn¬ger and elderly patients respectively. CONCLUSIONS: Our results suggest that LRC is feasible in elderly patients, where a non¬-surgical treatment is usually favoured.

Critical Analysis of Early Recurrence after Laparoscopic Radical Cystectomy in a Large Cohort by the ESUT.

PURPOSE: We analyze patients with early progression after laparoscopic radical cystectomy in a large cohort by the ESUT (European Association of Urology Section of Uro-Technology). More specifically we focus on patients with favorable pathology (pT2 N0 R0 or less) who experienced an unexpected recurrence and analyze possible causes for such early recurrence, discussing the surgical technique including pneumoperitoneum. MATERIALS AND METHODS: Since 2000 the ESUT has been constructing a large, multicenter, prospective database of patients undergoing laparoscopic radical cystectomy. All procedures were performed via a standard laparoscopic approach without robotic assistance. We specifically analyzed patients with favorable pathological characteristics, in particular pT2 N0 R0 or less, and evaluated those with progression despite these favorable characteristics. Univariate and multivariate logistic regression was performed to evaluate risk factors for early recurrence. RESULTS: A total of 627 patients were available for final analysis with a median followup of 46 months (mean 57). Of these patients 311 had favorable pathological characteristics of pT2 N0 R0 or less. During followup 27 (8.7%) patients experienced disease progression during the first 24 months. Surgical negligence was found in only 1 case. Most of these patients with early recurrence had progression to high tumor volume disseminated metastatic disease. On multivariate logistic regression tumor stage was the only factor significantly associated with early recurrence (p=0.027). CONCLUSIONS: We report early unexpected recurrences after laparoscopic radical cystectomy in nearly 5% of our entire cohort, all in patients with favorable pathological characteristics (pT2 N0 R0 or less). Pneumoperitoneum may have had a role in the development of these relapses. Specifically designed studies are necessary to investigate the possible role of pneumoperitoneum in urothelial cancer recurrence.

The morbidity of laparoscopic radical cystectomy: analysis of postoperative complications in a multicenter cohort by the European Association of Urology (EAU)-Section of Uro-Technology.

PURPOSE: To analyze postoperative complications after laparoscopic radical cystectomy (LRC) and evaluate its risk factors in a large prospective cohort built by the ESUT across European centers involved in minimally invasive urology in the last decade. METHODS: Patients were prospectively enrolled, and data were retrospectively analyzed. Only oncologic cases were included. There were no formal contraindications for LRC: Also patients with locally advanced tumors (pT4a), serious comorbidities, and previous major abdominal surgery were enrolled. All procedures were performed via a standard laparoscopic approach, with no robotic assistance. Early and late postoperative complications were graded according to the modified Clavien-Dindo classification. Multivariate logistic regression was performed to explore possible risk factors for developing complications. RESULTS: A total of 548 patients were available for final analysis, of which 258 (47%) experienced early complications during the first 90 days after LRC. Infectious, gastrointestinal, and genitourinary were, respectively, the most frequent systems involved. Postoperative ileus occurred in 51/548 (9.3%) patients. A total of 65/548 (12%) patients underwent surgical re-operation, and 10/548 (2%) patients died in the early postoperative period. Increased BMI (p = 0.024), blood loss (p = 0.021), and neoadjuvant treatment (p = 0.016) were significantly associated with a greater overall risk of experiencing complications on multivariate logistic regression. Long-term complications were documented in 64/548 (12%), and involved mainly stenosis of the uretero-ileal anastomosis or incisional hernias. CONCLUSIONS: In this multicenter, prospective, large database, LRC appears to be a safe but morbid procedure. Standardized complication reporting should be encouraged to evaluate objectively a surgical procedure and permit comparison across studies.

Presence and Number of Positive Surgical Margins after Radical Prostatectomy for Prostate Cancer: Effect on Oncological Outcome in a Population-Based Cohort.

INTRODUCTION: Additional insight in the occurrence and number of positive surgical margins (PSM) and the potential consequences is needed, since earlier studies show divergent results. This study aims at investigating the effect of the presence and number of PSM on oncological outcomes. METHODS: Retrospective population-based cohort study including 648 consecutive prostate cancer patients who underwent RP in the Southern Netherlands in 2006-2008. The effect of PSM on risk of treatment failure, defined by either biochemical recurrence or necessity of any additional therapy (Cox regression), was evaluated. RESULTS: PSM were observed in 39%; 11% had multiple PSM. Treatment failure was observed in 26% of all patients. Multivariably, the presence (hazard ratio 2.5) and number of PSM (hazard ratios: single 2.3; multiple 3.1) were independently associated with higher treatment failure rates, unlike location of PSM. CONCLUSIONS: Treatment failure rates are high among patients with PSM, especially in those with multiple PSM. This needs to be taken into account when decisions are made on the applicability of the adjuvant and salvage therapy.

Effect of surgical margin status after radical prostatectomy on health-related quality of life and illness perception in patients with prostate cancer.

OBJECTIVE: The aim of the study was to evaluate the effect of positive surgical margins (PSM) on health-related quality of life and illness perception after radical prostatectomy in patients with prostate cancer. METHODS: Of all patients with prostate cancer diagnosed between 2006 and 2009 in 7 participating hospitals in the Eindhoven region of the Netherlands Cancer Registry, 197 patients who underwent radical prostatectomy were invited to fill in a questionnaire. Data from the Netherlands Cancer Registry were combined with questionnaire data (including European Organization for Research and Treatment of Cancer quality of life questionnaire-C30, quality of life questionnaire-Prostate Module 25, and the Brief Illness Perception Questionnaire). Mean scores per margin status group were compared in multivariate linear regression. RESULTS: Of the addressed patients, 166 (84%) responded to the questionnaire. At time of questioning, their surgery was 1.7 to 6.4 years ago. The prevalence of PSM was 34%. On most scales, patients with PSM reported more favorable scores than patients with negative surgical margins. However, differences were mostly trivial (<5 points on 100-point scales), or of small (5-10) to medium (10-20) clinical importance. Only differences on hormonal complaints and illness comprehensibility were statistically significant. Effect of PSM on scores did not vary between patients who were at different time points after surgery. CONCLUSION: Although patients with PSM showed a trend toward more favorable scores, these differences were of little or no clinical importance. Additional research is needed to evaluate how patients value these differences with respect to oncological outcomes.

Long-term analysis of oncological outcomes after laparoscopic radical cystectomy in Europe: results from a multicentre study by the European Association of Urology (EAU) section of Uro-technology.

OBJECTIVE: To report long-term outcomes of laparoscopic radical cystectomy (LRC) in a multicentre European cohort, and explore feasibility and safety of LRC. PATIENTS AND METHODS: This study was coordinated by European Association of Urology (EAU)-section of Uro-technology (ESUT) with nine centres enrolling 503 patients undergoing LRC for bladder cancer prospectively between 2000 and 2013. Data were retrospectively analysed. Descriptive statistics were used to explore peri- and postoperative characteristics of th ecohort. Kaplan-Meier curves were constructed to evaluate recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS). Outcomes were also stratified according to tumour stage, lymph node (LN) involvement and surgical margin status. RESULTS: Minor complications (Clavien I-II) occurred in 39% and major (IIIa-IVb) in 17%. In all, 10 (2%) postoperative deaths were recorded. The median (interquartile, IQR) LN retrieval was 14 (9-17) and positive surgical margins were detected in 29 (5.8%) patients. The median (mean, IQR) follow-up was 50 (60, 19-90), during which 134 (27%) recurrences were detected. Actuarial RFS, CSS and OS rates were 66%, 75% and 62% at 5 years and 62%, 55%, 38% at 10 years. Significant differences in RFS, CSS and OS were found according to tumour stage, LN involvement and margin status (log-rank P < 0.001). On multivariate Cox analysis, T stage and LN involvement (both P < 0.001) were significant predictors of RFS, CSS and OS. Positive margins were significant predictors of RFS (P = 0.016) and CSS (P = 0.043). CONCLUSIONS: In this European LRC multicentre study, the largest to date, long-term RFS, CSS and OS rates after LRC appear comparable to those reported in current open RC series. Further randomised controlled trials are necessary to assess the global impact of LRC.

Oncologic outcome after laparoscopic radical cystectomy without neoadjuvant or adjuvant therapy with a median follow-up of 32 months.

INTRODUCTION: We report the oncological outcome after laparoscopic radical cystectomy (LRC) and standard laparoscopic pelvic lymph node dissection (PLND) without neoadjuvant or adjuvant therapy in the treatment of bladder cancer with a median follow-up of 32 months. MATERIALS AND METHODS: From September 2006 to January 2011, 40 consecutive patients underwent an LRC and standard laparoscopic PLND, and were included in this prospective observational cohort study. No patient received neoadjuvant or adjuvant therapy. Demographic, perioperative, complication, histopathologic and survival data were collected and analyzed. RESULTS: The 2002 TNM staging for the tumors were: pT0, 4 cases; pTis, 5 cases; pT1, 4 cases; pT2, 7 cases; pT3, 13 cases; pT4, 7 cases. Positive surgical margins were reported in 3 patients (7.5%) and lymph node involvement in 9 patients (23.7%). No patient was lost to follow-up. The overall, cancer-specific and recurrence-free survival rates were 53, 73 and 70% with a median follow-up of 32 months. Eleven patients (27.5%) died of metastatic disease or local recurrence. Nonorgan-confined disease (≥pT3) and primary lymph node involvement (pN+) were significantly associated with worse overall, cancer-specific and recurrence-free survival rates. CONCLUSION: We report acceptable mid-term and promising long-term oncological outcome after LRC and standard laparoscopic PLND without neoadjuvant or adjuvant therapy.

What about conventional laparoscopic radical cystectomy? Cost-analysis of open versus laparoscopic radical cystectomy.

PURPOSE: To assess direct healthcare costs for open radical cystectomy (ORC) vs laparoscopic radical cystectomy (LRC) with ileal conduit. PATIENTS AND METHODS: A series of 44 and 42 patients undergoing ORC and LRC with ileal conduit were retrospectively analyzed at a single institution from January 2005 to January 2012. The ORC and LRC procedures were performed by two independent surgical teams; there was no selection in patients. Data on patient demographics, perioperative outcome parameters, complications, and readmissions were gathered retrospectively in the ORC series and prospectively in the LRC series. Direct healthcare costs were evaluated for operating room occupation, disposable surgical equipment, blood transfusions, hospital stay according to intensity of care, and readmission days. RESULTS: Mean and median evaluated total direct healthcare costs per patient did not differ significantly and were 17,534€ and 16,511€ in the LRC group and 22,284€ and 15,909€ in the ORC group. Excess costs for disposable surgical equipment and operating room occupation within the LRC group were compensated for as a result of shorter hospital stay, lower number of blood transfusions, and intensive-care admissions. Minor and major complication rates were comparable between groups. CONCLUSION: Within our series, LRC is a cost neutral minimally invasive alternative to ORC without comprising quality of care and with beneficial perioperative outcomes.

Transperitoneal laparoscopic radical nephrectomy in a patient with severe scoliosis.

OBJECTIVE: To report the first case of a left transperitoneal laparoscopic nephrectomy in a patient with a severe left convex lumbar scoliosis and to elaborate on the technical difficulties of this procedure. METHODS: The surgical procedure was performed by an experienced laparoscopic surgeon after rigorous pre-operative visualization of the altered visceral and vascular abdominal anatomy. A transperitoneal laparoscopic approach with an open introduction technique according to Hasson and a caudo-cranial dissection of the left renal hilum were performed to prevent major vascular and visceral injury in this challenging surgical procedure. RESULTS: The operation time was 102 minutes and the estimated blood loss was 100 mL. The surgeon was able to complete the transperitoneal laparoscopic radical nephrectomy without complications. CONCLUSION: Transperitoneal laparoscopic radical nephrectomy in patients with severe spinal deformities is feasible, but should only be performed by experienced laparoscopic surgeons to ensure patient safety and cancer control.