Hypothermia During Partial Nephrectomy for Patients with Renal Tumors: A Randomized Controlled Trial.

PURPOSE: Surgeons induce renal hypothermia during partial nephrectomy to preserve kidney function, without strong evidence of benefit. This trial examined the effectiveness and safety of renal hypothermia during partial nephrectomy. MATERIALS AND METHODS: We conducted a parallel randomized controlled trial of hypothermia versus no hypothermia (control group) during partial nephrectomy at 6 academic hospitals. Eligible patients had a planned open partial nephrectomy for the treatment of a renal tumor. During surgery, after clamping the renal hilum, patients were randomized to the intervention or control arm in a 1:1 ratio using permuted blocks of variable lengths (2 and 4), stratified by institution, using a computer-based program. Surgeons and study coordinators were masked to treatment allocation until the renal hilum was clamped. Overall glomerular filtration rates were determined before, and 1-year after, surgery. The primary outcome was measured glomerular filtration rate (mGFR) assessed by the plasma clearance of 99mTc-DTPA. The trial (NCT01529658) was designed with 90% power to detect a minimal clinically important difference in mGFR of 10 ml/minute/1.73 m2 at a 5% significance level. RESULTS: Of the 184 patients randomized, hypothermia and control patients had similar baseline mean mGFR (87.1 vs 81.0 ml/minute/1.73 m2). One hundred and sixty-one (79 hypothermia, 82 control) were alive with primary outcome data 1 year after surgery. The change in mGFR 1 year after surgery was -6.6 ml/minute/1.73 m2 in the hypothermia group and -7.8 ml/minute/1.73 m2 in the control group (mean difference 1.2 ml/minute/1.73 m2, 95% CI -3.3 to 5.6). Operated-kidney change in mGFR was similar between groups (-5.8 vs -6.3 ml/minute/1.73 m2; mean difference 0.5 ml/minute/1.73 m2, 95% CI -2.9 to 3.8). No clinically significant difference in the mGFR was observed when patients were stratified by pre-planned subgroups. Renal hypothermia did not impact the secondary outcomes of surgical complications and patient reported quality of life. CONCLUSIONS: Renal hypothermia during partial nephrectomy does not preserve kidney function in patients with normal or mildly impaired renal function.

Development and Implementation of a Continuing Medical Education Program in Canada: Knowledge Translation for Renal Cell Carcinoma (KT4RCC).

An in-person multidisciplinary continuing medical education (CME) program was designed to address previously identified knowledge gaps regarding quality indicators of care in kidney cancer. The objective of this study was to develop a CME program and determine if the program was effective for improving participant knowledge. CME programs for clinicians were delivered by local experts (uro-oncologist and medical oncologist) in four Canadian cities. Participants completed knowledge assessment tests pre-CME, immediately post-CME, and 3-month post-CME. Test questions were related to topics covered in the CME program including prognostic factors for advanced disease, surgery for advanced disease, indications for hereditary screening, systemic therapy, and management of small renal masses. Fifty-two participants attended the CME program and completed the pre- and immediate post-CME tests. Participants attended in Ottawa (14; 27%), Toronto (13; 25%), Québec City (18; 35%), and Montréal (7; 13%) and were staff urologists (21; 40%), staff medical oncologists (9; 17%), fellows (5; 10%), residents (16; 31%), and oncology nurses (1; 2%). The mean pre-CME test score was 61% and the mean post-CME test score was 70% (p = 0.003). Twenty-one participants (40%) completed the 3-month post-CME test. Of those that completed the post-test, scores remained 10% higher than the pre-test (p value 0.01). Variability in test scores was observed across sites and between French and English test versions. Urologists had the largest specialty-specific increase in knowledge at 13.8% (SD 24.2, p value 0.02). The kidney cancer CME program was moderately effective in improving provider knowledge regarding quality indicators of kidney cancer care. These findings support continued use of this CME program at other sites.

Risk of Active Tuberculosis in Patients with Cancer: A Systematic Review and Meta-Analysis.

Background: Cancer is a known risk factor for developing active tuberculosis (TB). We determined the incidence and relative risk of active TB in cancer patients compared to the general population. Methods: Electronic databases were searched up to December 2015: Medline, Medline InProcess, EMBASE, PubMed, the Cochrane Database of Systematic Reviews, Cancerlit, and Web of Science. Studies of pathologically confirmed cancer patients were included if active TB was identified concurrently or after the diagnosis. Cumulative incidence rate/100,000 population (CIR) of new cases of TB occurring in cancer patients and comparative incidence rate ratios (IRR) to the general population from the same country of origin were estimated. A random effect meta-analysis was conducted on the CIR and IRR. Results: A total of 23 studies reporting 593 TB cases occurring in 324,041 cancer patients between 1950 and 2011 were identified. In a meta-analysis of 6 studies conducted in the US in 317,243 cancer patients (98% of all patients) the CIR of active TB decreased by 3 fold and 6.5 fold in hematologic and solid cancers respectively before and after 1980. After 1980 the CIR of active TB was highest in hematologic (219/100,000 population, IRR=26), head and neck (143; 16), lung cancers (83; 9) and was lowest in breast and other solid cancers (38; 4). Conclusions: Individuals living in the US with hematologic, head and neck, and lung cancers had a 9-fold higher rate of developing active TB compared to those without cancer and would benefit from targeted latent TB screening and therapy.

The Risks and Benefits of Cavernous Neurovascular Bundle Sparing during Radical Prostatectomy: A Systematic Review and Meta-Analysis.

PURPOSE: We summarize published data on associations between cavernous neurovascular bundle preservation (nerve sparing) during prostatectomy and positive surgical margins, erectile function, urinary function and other patient reported outcomes. MATERIALS AND METHODS: A systematic literature search of MEDLINE®, Embase® and Cochrane Reviews databases was performed for interventional or observational studies published between 2000 and 2014. English language articles that compared clinical outcomes of patients undergoing nerve sparing and nonnerve sparing radical prostatectomy were included. Meta-analyses were performed to calculate pooled relative risk estimates for positive surgical margins, erectile dysfunction and urinary incontinence in nerve sparing and nonnerve sparing groups. Sensitivity analyses compared outcomes among unilateral and bilateral nerve sparing vs nonnerve sparing groups. RESULTS: Of the 1,883 articles identified, 124 studies (73,448 patients) were included in the analysis. Nerve sparing did not increase the risk of positive surgical margins in patients with pT2 (RR 0.92, 95% CI 0.75-1.13) or pT3 disease (RR 0.83, 95% CI 0.71-0.96), potentially due to appropriate patient selection. The risk of incontinence was lower in nerve sparing cases (RR 0.75, 95% CI 0.65-0.85 and RR 0.61, 95% CI 0.44-0.84) at 3 and 12 months, respectively. The relative risk of erectile dysfunction with nerve sparing was 0.77 (95% CI 0.70-0.85) at 3 months and 0.53 (95% CI 0.39-0.71) at 12 months. Subgroup analyses of unilateral and bilateral nerve sparing approaches demonstrated similar results. CONCLUSIONS: Among cohort studies nerve sparing was not associated with worse cancer outcomes. Nerve sparing is associated with better urinary and erectile function. These results should be interpreted with caution given the potential for selection bias and unadjusted confounding factors.

Active surveillance in Canadian men with low-grade prostate cancer.

BACKGROUND: Recent guidelines recommend against routine screening for prostate cancer, partly because of the risks associated with overtreatment of clinically indolent tumours. We aimed to determine the proportion of patients whose low-grade prostate cancer was managed by active surveillance instead of immediate treatment. METHODS: We reviewed data for patients who were referred to the Ottawa regional Prostate Cancer Assessment Clinic with abnormal results for prostate-specific antigen (PSA) or prostate examination between Apr. 1, 2008, and Jan. 31, 2013. Patients with subsequent biopsy-proven low-grade (Gleason score 6) cancer were included. Active surveillance was defined a priori as monitoring by means of PSA, digital rectal examination and repeat biopsies, with the potential for curative-intent treatment in the event of disease progression. RESULTS: Of 477 patients with low-grade cancer, active surveillance was used for 210 (44.0%), and the annual proportion increased from 32% (11/34) in 2008 to 67% (20/30) in 2013. Factors associated with immediate treatment were palpable tumour, PSA density above 0.2 ng/mL(2) and more than 2 positive biopsy cores. Factors associated with surveillance were age over 70 years and higher Charlson comorbidity index. Of 173 men who received immediate surgical treatment, 103 (59.5%) had higher-grade or advanced-stage disease on final pathologic examination. Of the 210 men with active surveillance, 62 (29.5%) received treatment within a median of 1.3 years, most commonly (52 [84%]) because of upgrading of disease on the basis of surveillance biopsy. INTERPRETATION: Active surveillance has become the most common management strategy for men with low-grade prostate cancer at our regional diagnostic centre. Factors associated with immediate treatment reflected those that increase the risk of higher-grade tumours.

Expression of chemokine decoy receptors and their ligands at the porcine maternal-fetal interface.

Successful pregnancy requires coordinated maternal-fetal cross-talk to establish vascular connections that support conceptus growth. In pigs, two waves of spontaneous fetal loss occur and 30-40% of conceptuses are lost before parturition. Previous studies associated these losses with decreased angiogenic and increased inflammatory cytokines. Chemokines, a sub-category of cytokines, and decoy receptors control leukocyte trafficking, angiogenesis and development. The availability of chemokines is regulated by three non-signalling decoy receptors: chemokine decoy receptor (D6), Duffy antigen receptor for chemokines (DARC) and Chemocentryx decoy receptor (CCX CKR). We hypothesized that the expression of these receptors and their chemokine ligands regulate the porcine pregnancy success or failure. Here, we describe for the first time the transcription and translation of all three decoy receptors and several chemokine ligands in endometrium and trophoblast associated with healthy and arresting conceptuses at gestation day (gd) 20 and gd50. Among decoy receptors, transcripts for DARC were significantly reduced in endometrium, whereas that for CCX CKR were significantly increased in endometrium and trophoblast at gd50 arresting compared with healthy sites. However, western blot analysis revealed no differences in decoy receptor expression between healthy and arresting tissues. Transcripts for decoy receptor ligands CCL2, CCL3, CCL4, CCL5, CCL11, CCL19, CCL21, CXCL2 and CXCL8 were stable between healthy and arresting littermates. Quantification by SearchLight chemiluminescent protein array confirmed ligand expression at the protein level. These data indicate that decoy receptors and ligands are expressed at the porcine maternal-fetal interface and dysregulation of decoy receptor (DARC and CCX CKR) transcripts occurs at sites of fetal arrest.

Angiogenic DC-SIGN(+) cells are present at the attachment sites of epitheliochorial placentae.

Spontaneous early and mid-gestation fetal losses occur in swine. At both stages, endometrial lymphocytes associated with smaller, paler conceptuses have fewer pro-angiogenic and more pro-inflammatory cytokine transcripts compared with robust conceptuses. We hypothesized that similar differences occur in conceptus-associated dendritic cells (DCs). Using laser capture-microdissection, dendritic cell-specific intercellular adhesion molecule-grabbing non-integrin (DC-SIGN)(+) cells were isolated from attachment sites of healthy and arresting conceptuses at gestation day (gd)20 and 50. DC-SIGN(+) cells were screened using real-time PCR for vascular endothelial cell growth factor (Vegf), its receptors, semaphorins (Sema) and plexins (Plxn), and for toll-like receptor (Tlr) transcripts to address potential activation pathways. Homogenized endometrial and trophoblast biopsies were quantified for type 1/type 2 cytokine transcripts/proteins. DC-SIGN(+) cells from healthy and arresting conceptuses had more Vegf transcripts at early than mid gestation whereas transcripts for Vegfr1 and Vegfr2 were stable. In gd20 arresting site DC-SIGN(+) cells, Neuropilin-2 transcripts were elevated, whereas at gd50 arresting sites, Plxn-A2 increased and Sema3A transcripts were lost. Tlr-1, Tlr-4 and Tlr-6 transcript abundance was independent of conceptus health. At gd20, type 1 cytokines were prevalent, whereas at gd50 type 2 cytokines predominated in endometrium and trophoblast. Thus, gestational features, characteristic of haemochorial placentation, are present in species with distinctly different placentation.

Renal hypothermia during partial nephrectomy for patients with renal tumours: a randomised controlled clinical trial protocol.

INTRODUCTION: Partial nephrectomy is a standard of care for non-metastatic renal tumours when technically feasible. Despite the increased use of partial nephrectomy, intraoperative techniques that lead to optimal renal function after surgery have not been rigorously studied. Clamping of the renal hilum to prevent bleeding during resection causes temporary renal ischaemia. The internal temperature of the kidney may be lowered after the renal hilum is clamped (renal hypothermia) in an attempt to mitigate the effects of ischaemia. Our objective is to determine if renal hypothermia during open partial nephrectomy results in improved postoperative renal function at 12 months following surgery as compared with warm ischaemia (no renal hypothermia). METHODS AND ANALYSES: This is a multicentre, randomised, single-blinded controlled trial comparing renal hypothermia versus no hypothermia during open partial nephrectomy. Due to the nature of the intervention, complete blinding of the surgical team is not possible; however, surgeons will be blinded until the time of hilar clamping. Glomerular filtration will be based on plasma clearance of a radionucleotide, and differential renal function will be based on renal scintigraphy. The primary outcome is overall renal function at 12 months measured by the glomerular filtration rate (GFR). Secondary outcomes include change in GFR, GFR of the affected kidney, change in GFR of the affected kidney, serum creatinine, haemoglobin, spot urine albumin to creatinine ratio, quality of life and postoperative complications. Data will be collected at baseline, immediately postoperatively and at 3, 6, 9 and 12 months postoperatively. ETHICS AND DISSEMINATION: Ethics approval was obtained for all participating study sites. Results of the trial will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT01529658; Pre-results.

Immunological mechanisms affecting angiogenesis and their relation to porcine pregnancy success.

Prenatal mortality due to loss of lymphocyte-promoted endometrial angiogenesis is being investigated as a major cause of litter reductions during pregnancy in pigs. This review discusses immune mechanisms influencing porcine endometrial angiogenesis as well as additional signalling molecules that may play important roles in the compromise of peri-implantation and mid-gestation fetal pig survival. These include dendritic cells, signalling molecules such as toll-like receptors, chemokines and ficolins. Together these cells and molecules regulate immune responses and, ideally, protect the mother and prevent immune-based conceptus losses. Dendritic cells were recently shown to be angiogenic. Their tolerogenic role at the maternal-fetal interface coupled with the ability to secrete and respond to angiogenic factors suggests that dendritic cells are the key coordinators of angiogenesis at the porcine maternal-fetal interface. Chemokines coordinate the localization of immune effector and endothelial cells. The balance between pro-angiogenic and anti-angiogenic chemokines is addressed in relation to conceptus viability. Ficolins, components of the lectin-mediated complement activation pathway, are used for self/non-self recognition. Together, these components of the immune system could regulate lymphocyte- and non-lymphocyte-promoted endometrial angiogenesis to determine conceptus survival.

Female radical cystectomy patients have a higher risk of surgical site infections.

INTRODUCTION: Surgical site infections (SSI) are common after radical cystectomy. The objectives of this study were to evaluate if female sex is associated with postoperative SSI and if experiencing an SSI was associated with subsequent adverse events. METHODS: This was a historical cohort study of radical cystectomy patients from the American College of Surgeons' National Surgical Quality Improvement Program database between 2006 and 2016. The primary outcome was development of a SSI (superficial, deep, or organ/abdominal space) within 30 days of surgery. Multivariable logistic regression analyses were performed to determine the association between sex and other patient/procedural factors with SSI. Female patients with SSI were also compared to those without SSI to determine risk of subsequent adverse events. RESULTS: A total of 9,275 radical cystectomy patients met the inclusion criteria. SSI occurred in 1,277(13.7%) patients, 308 (16.4%) females and 969 (13.1%) males (odds ratio = 1.27; 95% confidence interval 1.10-1.47; P = 0.009). Infections were superficial in 150 (8.0%) females versus 410 (5.5%) males (P < 0.0001), deep in 40 (2.1%) females versus 114 (1.5%) males (P = 0.07), and organ/abdominal space in 118 (6.2%) females versus 445 (6.0%) males (P = 0.66). On multivariable analysis, female sex was independently associated with SSI (odds ratio = 1.21 confidence interval 1.01-1.43 P = 0.03). Females who experience SSI had higher probability of developing other complications including wound dehiscence, septic shock, and need for reoperation (all P < 0.05). CONCLUSIONS: Female sex is an independent risk factor for SSI following radical cystectomy. More detailed study of patient factors, pathogenic microbes, and treatment factors are needed to prescribe the best measures for infection prophylaxis.

Age-stratified perioperative mortality after urological surgeries.

INTRODUCTION: More elderly patients are presenting for surgical consultation. Understanding the risk of mortality by age group after urological surgery is important for patient selection and counselling. METHODS: A historical cohort study of The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2006-2015 was performed. Current procedural terminology (CPT) codes for similar surgical procedures were grouped for analyses. Urological procedures commonly performed in elderly patients were identified and stratified by patient age and surgical approach (open vs. laparoscopic/robotic). The primary outcome was the absolute risk of death by 30 days stratified by age for each surgical procedure. The secondary outcome was risk of death by surgical approach (open vs. laparoscopic/robotic). RESULTS: Twelve urological procedures were reviewed including 124 262 patients. A total of 1011 (0.8%) deaths occurred by 30 days after surgery. The procedure with the highest incidence of mortality by 30 days was open nephroureterectomy (2.9 %). In patients 80 years and over, the procedure with the highest incidence of death was open radical nephrectomy (5.32%). There was an increased risk of mortality with increasing age group for all procedures. Unadjusted risk of mortality was consistently higher in patients who receive open compared to laparoscopic surgery. CONCLUSIONS: There is an increasing risk of mortality with age and with open surgical approach in urology. Knowledge regarding the absolute risk of mortality in patients receiving common urological surgeries may improve patient selection and counselling.

Tranexamic Acid versus Placebo to Prevent Blood Transfusion during Radical Cystectomy for Bladder Cancer (TACT): Study Protocol for a Randomized Controlled Trial.

BACKGROUND: Radical cystectomy for bladder cancer is associated with a high risk of needing red blood cell transfusion. Tranexamic acid reduces blood loss during cardiac and orthopedic surgery, but no study has yet evaluated tranexamic acid use during cystectomy. METHODS: A randomized, double-blind (surgeon-, anesthesiologist-, patient-, data-monitor-blinded), placebo-controlled trial of tranexamic acid during cystectomy was initiated in June 2013. Prior to incision, the intervention arm participants receive a 10 mg/kg loading dose of intravenously administered tranexamic acid, followed by a 5 mg/kg/h maintenance infusion. In the control arm, the patient receives an identical volume of normal saline that is indistinguishable from the intervention. The primary outcome is any blood transfusion from the start of surgery up to 30 days post operative. There are no strict criteria to mandate the transfusion of blood products. The decision to transfuse is entirely at the discretion of the treating physicians who are blinded to patient allocation. Physicians are allowed to utilize all resources to make transfusion decisions, including serum hemoglobin concentration and vital signs. To date, 147 patients of a planned 354 have been randomized to the study. DISCUSSION: This protocol reviews pertinent data relating to blood transfusion during radical cystectomy, highlighting the need to identify methods for reducing blood loss and preventing transfusion in patients receiving radical cystectomy. It explains the clinical rationale for using tranexamic acid to reduce blood loss during cystectomy, and outlines the study methods of our ongoing randomized controlled trial. TRIAL REGISTRATIONS: Canadian Institute for Health Research (CIHR) Protocol: MOP-342559; ClinicalTrials.gov, ID: NCT01869413. Registered on 5 June 2013.

Current guidelines do not sufficiently discriminate venous thromboembolism risk in urology.

PURPOSE: Venous thromboembolism (VTE) is the leading cause of noncancer death following major cancer surgery. Current thromboprophylaxis guidelines do not address procedure-specific risk of venous thromboembolism for urological patients. This project was created to determine the risk and timing of VTE after major urological surgery and to evaluate if surgical procedure was an independent risk factor for VTE after adjusting for previously established risk factors. MATERIAL AND METHODS: The American College of Surgeons׳ National Surgical Quality Improvement Program was used to create a cohort of patients who received major abdominal or pelvic urologic surgery between 2006 and 2014. The primary outcome was postoperative VTE. A Caprini score was calculated for each patient in our study to determine the risk of VTE. Multivariable logistic regression analyses were performed to determine the association between patient and procedural factors with venous thromboembolism. RESULTS: During the study period, 65,100 patients were eligible and 956 patients (1.5%) developed a venous thromboembolism. More than half of VTE events occurred after hospital discharge (n = 570; 60%). Radical cystectomy had the highest risk of VTE (299/5,976; 5.0%) and laparoscopic nephrectomy had the lowest risk (56/8,475; 0.7%). Most patients (58,782; 90%) were classified as high risk for VTE using the Caprini score. After adjusting for known risk factors, the risk of venous thromboembolism was significantly greater for radical cystectomy compared to laparoscopic nephrectomy (relative risk = 7.0; 95% CI: 5.0-9.2). CONCLUSIONS: This study reports procedure-specific venous thromboembolism risk adjusting for known risk factors. These data demonstrate that procedure-specific thromboprophylaxis guidelines are needed in urology.

Are renal tumour scoring systems better than clinical judgement at predicting partial nephrectomy complexity?

INTRODUCTION: We aimed to determine how renal tumour scoring systems, such as RENAL, PADUA, and Centrality (C)-index, compare to clinical judgement at predicting time required for tumour removal and kidney reconstruction during partial nephrectomy. METHODS: A consecutive cohort of partial nephrectomy patients treated at The Ottawa Hospital, a tertiary care uro-oncological centre, was retrospectively reviewed. Preoperative axial images were reviewed by four experienced urological oncologists who independently rated the complexity of a partial nephrectomy from 1-10 to generate a clinical judgement score. Two independent reviewers determined the RENAL, PADUA, and C-index scores. The time to complete tumour resection and renal reconstruction during partial nephrectomy was prospectively recorded. RESULTS: During the study period, 104 partial nephrectomies were performed. The mean partial nephrectomy complexity score based on clinical judgement was 3.4 (standard deviation [SD] 2.1) out of 10. There was good agreement between surgeons in assessing tumour complexity (intraclass correlation coefficient 0.72; 95% confidence interval [CI] 0.65, 0.78). The mean RENAL score was 6.7 (SD 1.6) out of a maximum of 12, the mean PADUA score was 8.5 (SD 1.5) out of a maximum of 14, and the mean C-index score was 3.8 (SD 2). Mean resection and reconstruction time was 24 minutes (SD 10 minutes). The correlation between clinical judgement score and time was 0.27 (p=0.005). The correlation between renal tumour scoring systems and time was 0.20 (p=0.04) for RENAL, 0.21 (p=0.03) for C-index, and 0.26 (p=0.007) for PADUA. RENAL and PADUA scores were significantly associated with surgical and total complications. CONCLUSIONS: The majority of variance in ischemia time is not explained by clinical judgement or renal tumour scoring systems. Renal tumour scoring systems were not better than the clinical judgement of urological oncologists at predicting ischemia time during partial nephrectomy.

An assessment of Prostate Cancer Research International: Active Surveillance (PRIAS) criteria for active surveillance of clinically low-risk prostate cancer patients.

INTRODUCTION: Active surveillance is a strategy to delay or prevent treatment of indolent prostate cancer. The Prostate Cancer Research International: Active Surveillance (PRIAS) criteria were developed to select patients for prostate cancer active surveillance. The objective of this study was to compare pathological findings from PRIAS-eligible and PRIAS-ineligible clinically low-risk prostate cancer patients. METHODS: A D'Amico low-risk cohort of 1512 radical prostatectomy patients treated at The Ottawa Hospital or Memorial Sloan Kettering Cancer Centre between January 1995 and December 2007 was reviewed. Pathological outcomes (pT3 tumours, Gleason sum ≥7, lymph node metastases, or a composite) and clinical outcomes (prostate-specific antigen [PSA] recurrence, secondary cancer treatments, and death) were compared between PRIAS-eligible and PRIAS-ineligible cohorts. RESULTS: The PRIAS-eligible cohort (n=945) was less likely to have Gleason score ≥7 (odds ratio [OR] 0.61; 95% confidence interval [CI] 0.49-0.75), pT3 (OR 0.41; 95% CI 0.31-0.55), nodal metastases (OR 0.37; 95% CI 0.10-1.31), or any adverse feature (OR 0.56; 95% CI 0.45-0.69) compared to the PRIAS-ineligible cohort. The probability of any adverse pathology in the PRIAS-eligible cohort was 41% vs. 56% in the PRIAS-ineligible cohort. At median follow-up of 3.7 years, 72 (4.8%) patients had a PSA recurrence, 24 (1.6%) received pelvic radiation, and 13 (0.9%) received androgen deprivation. No difference was detected for recurrence-free and overall survival between groups (recurrence hazard ratio [HR] 0.71; 95% CI 0.46-1.09 and survival HR 0.72; 95% CI 0.36-1.47). CONCLUSIONS: Low-risk prostate cancer patients who met PRIAS eligibility criteria are less likely to have higher-risk cancer compared to those who did not meet at least one of these criteria.

The Safety and Efficacy of Lysine Analogues in Cancer Patients: A Systematic Review and Meta-Analysis.

Lysine analogues are effective agents used for the reduction of blood loss and transfusion. However, the safety of lysine analogues in cancer patients remains in question due to a potential risk of venous thromboembolism (VTE). The objective of our review is to investigate safety and efficacy of lysine analogue administration in the patients with cancer. Medline, Embase, and The Cochrane Library were searched from inception to June, 2016. Reference lists of retrieved studies were searched to identify additional publications. We included randomized clinical trials in adult cancer patients for which a lysine analogue was administered for the purpose of blood loss reduction. Abstract and full-text selection as well as data extraction and risk of bias assessment was done by 2 independent reviewers. The primary outcome was venous thromboembolic events. Secondary outcomes were other adverse events, blood transfusion, and blood loss. Overall, 11studies involving 1177 patients evaluated at least one of the primary or secondary outcomes. Nine studies evaluated the effects of tranexamic acid, one study evaluated the effects of aminocaproic acid and one study examined both agents. No increased risk of venous thromboembolism was observed for patients who received lysine analogues compared to control (Peto OR 0.58; 95% CI 0.26-1.28). The administration of a lysine analogue significantly decreased both transfusion risk (pooled RR 0.52, 95% CI 0.34-0.80) and blood loss (SMD -1.57, 95% CI -2.21 to -0.92). Among 3 eligible studies, no increased risk was observed for mortality (Peto OR 1.01; 95% CI 0.14-7.18) or infection (OR 0.58; 95% CI 0.27-1.27). The safety of lysine analogues in cancer patients has not been extensively studied. Based on the available literature, lysine analogue use has not been associated with increased risk of venous thromboembolism or other adverse events, while being effective in reducing blood loss and subsequent transfusion.

Needs Assessment Survey for the Management of Kidney Cancer.

INTRODUCTION: In this study we determined self-perceived knowledge gaps and continuing medical education preferences among Canadian urologists and medical oncologists related to the treatment of patients with kidney cancer. METHODS: A needs assessment survey was created by the Quality Initiative group of the Kidney Cancer Research Network of Canada using an iterative feedback process. The survey determined knowledge gaps and continuing medical education preferences pertaining to 23 previously validated quality indicators of kidney cancer care. Topics included screening, diagnosis, prognosis, surgical management, systemic therapies and followup care. The survey was distributed via e-mail to Canadian urologists and medical oncologists. RESULTS: Among the 164 respondents 121 (74%) were urologists and 43 (26%) were medical oncologists. The majority of respondents practice in academic (72, 57%) or large urban community centers (40, 32%). Of the 23 quality indicators examined 14 were designated as priority continuing medical education topics based on perceived inadequate knowledge or high interest in the topic. Priority topics were similar for urologists and medical oncologists, and covered the spectrum of kidney cancer care with an emphasis on hereditary kidney cancer and management of advanced disease. Most respondents preferred that continuing medical education be delivered through in person, case based group discussions. CONCLUSIONS: Canadian urologists and medical oncologists report similar knowledge gaps and continuing medical education preferences regarding kidney cancer care. Priority topics include screening for hereditary kidney cancer and management of advanced disease.

The effect of wide resection during radical prostatectomy on surgical margins.

INTRODUCTION: The impact of nerve-sparing on positive surgical margins during radical prostatectomy (RP) remains unclear. The objective of this study was to determine the incidence of positive surgical margins with a wide resection compared to a nerve-sparing technique. METHODS: A consecutive, single-surgeon patient cohort treated between August 2010 and November 2014 was reviewed. A standardized surgical approach of lobe-specific nerve-spare or wide resection was performed. Lobe-specific margin status and tumour stage were obtained from pathology reports. Univariable and multivariable associations between nerve management technique and lobe-specific positive surgical margin were determined. RESULTS: Of 388 prostate lobes, wide resection was performed in 105 (27%) and nerve-sparing in 283 (73%). In 273 lobes without extra-prostatic extension (EPE), 0 of 52 (0%) had a positive margin when wide resection was performed compared to 20 of 221 (9%) if nerve-sparing was performed (p=0.02). In 115 lobes with EPE, 11 of 53 (21%) had a positive margin if wide resection was performed compared to 28 of 62 (45%) if nerve-sparing was performed (p=0.006). In multivariable analysis, the risk of a positive margin was decreased among patients who received wide resection as compared to nerve-spare (RR 0.43, 95% CI 0.26-0.71; p=0.001). CONCLUSIONS: Surgical techniques to reduce positive surgical margins have become increasingly important as more patients with high-risk cancer are selecting surgery. The risk of a positive margin was greatly reduced using a standardized wide resection technique compared to nerve-sparing.

Change in Adverse Events After Enrollment in the National Surgical Quality Improvement Program: A Systematic Review and Meta-Analysis.

BACKGROUND: The American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) is the first nationally validated, risk-adjusted, outcomes-based program to measure and compare the quality of surgical care across North America. Participation in this program may provide an opportunity to reduce the incidence of adverse events related to surgery. STUDY DESIGN: A systematic review of the literature was performed. MedLine, EMBASE and PubMed were searched for studies relevant to NSQIP. Patient characteristics, intervention, and primary outcome measures were abstracted. The intervention was participation in NSQIP and monitoring of Individual Site Summary Reports with or without implementation of a quality improvement program. The outcomes of interest were change in peri-operative adverse events and mortality represented by pooled risk ratios (pRR) and 95% confidence intervals (CI). RESULTS: Eleven articles reporting on 35 health care institutions were included. Nine (82%) of the eleven studies implemented a quality improvement program. Minimal improvements in superficial (pRR 0.81; 95% CI 0.72-0.91), deep (pRR 0.82; 95% CI0.64-1.05) and organ space (pRR 1.15; 95% CI 0.96-1.37) infections were observed at centers that did not institute a quality improvement program. However, centers that reported formal interventions for the prevention and treatment of infections observed substantial improvements (superficial pRR 0.55, 95% CI 0.39-0.77; deep pRR 0.61, 95% CI 0.50-0.75, and organ space pRR 0.60, 95% CI 0.50-0.71). Studies evaluating other adverse events noted decreased incidence following NSQIP participation and implementation of a formal quality improvement program. CONCLUSIONS: These data suggest that NSQIP is effective in reducing surgical morbidity. Improvement in surgical quality appears to be more marked at centers that implemented a formal quality improvement program directed at the reduction of specific morbidities.