The Impact of Histologic Subtypes on Clinical Outcomes After Radiation-Based Therapy for Muscle-Invasive Bladder Cancer.

PURPOSE: Outcomes of radiation-based therapy (RT) for muscle-invasive bladder cancer (MIBC) with histologic subtypes of urothelial cancer (HS-UC) are lacking. Our objective was to compare survival outcomes of pure urothelial carcinoma (PUC) to HS-UC after RT. MATERIALS AND METHODS: A multicenter retrospective study of 864 patients with MIBC who underwent curative-intent RT to the bladder for MIBC (clinical T2-T4aN0-2M0) between 2001 and 2018 was conducted. Regression models were used to test the association between HS-UC and complete response (CR) and survival outcomes after RT. RESULTS: In total, 122 patients (14%) had HS-UC. Seventy-five (61%) had HS-UC with squamous and/or glandular differentiation. A CR was confirmed in 69% of patients with PUC and 63% with HS-UC. There were 207 (28%) and 31 (25%) patients who died of metastatic bladder cancer in the PUC and HS-UC groups, respectively. There were 361 (49%) and 58 (48%) patients who died of any cause in the PUC and HS-UC groups, respectively. Survival outcomes were not statistically different between the groups. The HS-UC status was not associated with survival outcomes in multivariable Cox regression analyses. CONCLUSIONS: In our study, HS-UC responded to RT with no significant difference in CR and survival outcomes compared to PUC. The presence of HS-UC in MIBC does not seem to confer resistance to RT, and patients should not be withheld from bladder preservation therapy options. Due to low numbers, definitive conclusions cannot be drawn for particular histologic subtypes.

Surgical Outcomes and Genomic Insights of Nonclear Cell Renal Cell Carcinoma with Synchronous and Metachronous Nodal Disease.

INTRODUCTION: Oncological outcomes in patients with nonclear cell renal cell carcinoma (non-ccRCC) treated with surgery for locoregional nodal disease (ND) remain incompletely characterized. The objective was to investigate the characteristics and outcomes of non-ccRCC patients treated with lymph node dissection (LND) and salvage-LND (S-LND). METHODS: A total of 1627 patients underwent nephrectomy for nonmetastatic non-ccRCC at Memorial Sloan Kettering Cancer Center between 2007 and 2023. Histology was grouped as papillary, chromophobe, unclassified, and rare subtypes. Retrospective evaluation identified 2.5% (n = 40) of patients with nodal disease at time of nephrectomy (synchronous-ND) and 1.1% (n = 18) with metachronous nodal disease limited to the retroperitoneum (metachronous-ND). Patients' demographics and tumor characteristics were recorded and evaluated by univariate and multivariate cox regression models. Recurrence-free survival (RFS) and overall survival (OS) were estimated by the Kaplan-Meier method. Patients who underwent tumor DNA sequencing during their clinical course were considered for genomic analysis. RESULTS: OS trended toward longer in metachronous-ND (51 vs 105 months; P = .2), though 23% of patients with synchronous-ND were recurrence-free at 45 months median follow-up. In multivariate analysis, rare histologies were associated with decreased OS (P = .030) and metachronous-ND with improved OS (P = .036). RFS and OS after S-LND was 15 and 96 months, respectively. Late onset of metachronous-ND/recurrence was associated with improved OS (P = .008). Genetic alterations in SETD2, TP53, B2M, and FGFR3 were exclusively seen in synchronous-ND, and tumor mutation burden (TMB) was also higher in patients with synchronous-ND (P = .016). CONCLUSIONS: Patients with metachronous-ND tend to have prolonged OS compared to synchronous-ND, but a substantial portion of patients with synchronous-ND still enter a durable disease-free state following LND. S-LND can likewise provide long-term survival, particularly in patients with longer time to metachronous nodal recurrence. Synchronous-ND was associated with SETD2, TP53, and NF2 alteration as well as higher TMB.

Benefit of Neoadjuvant Cisplatin-based Chemotherapy for Invasive Bladder Cancer Patients Treated with Radiation-based Therapy in a Real-world Setting: An Inverse Probability Treatment Weighted Analysis.

BACKGROUND: Neoadjuvant chemotherapy (NAC) improves survival for patients with muscle-invasive bladder cancer (MIBC) treated with radical cystectomy. Studies on the potential benefit of NAC before radiation-based therapy (RT) are conflicting. OBJECTIVE: To evaluate the effect of NAC on patients with MIBC treated with curative-intent RT in a real-world setting. DESIGN, SETTING, AND PARTICIPANTS: The study cohort consisted of 785 patients with MIBC (cT2-4aN0-2M0) who underwent RT at academic centers across Canada. Patients were classified into two treatment groups based on the administration of NAC before RT (NAC vs no NAC). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The inverse probability of treatment weighting (IPTW) with absolute standardized differences (ASDs) was used to balance covariates across treatment groups. The impact of NAC on complete response, overall, and cancer-specific survival (CSS) after RT in the weighted cohort was analyzed. RESULTS AND LIMITATIONS: After applying the exclusion criteria, 586 patients were included; 102 (17%) received NAC before RT. Patients in the NAC subgroup were younger (mean age 65 vs 77 yr; ASD 1.20); more likely to have Eastern Cooperative Oncology Group performance status 0-1 (87% vs 78%; ASD 0.28), lymphovascular invasion (32% vs 20%; ASD 0.27), higher cT stage (cT3-4 in 29% vs 20%; ASD 0.21), and higher cN stage (cN1-2 in 32% vs 4%; ASD 0.81); and more commonly treated with concurrent chemotherapy (79% vs 67%; ASD 0.28). After IPTW, NAC versus no NAC cohorts were well balanced (ASD <0.20) for all included covariates. NAC was significantly associated with improved CSS (hazard ratio [HR] 0.28; 95% confidence interval [CI] 0.14-0.56; p < 0.001) and overall survival (HR 0.56; 95% CI 0.38-0.84; p = 0.005). This study was limited by potential occult imbalances across treatment groups. CONCLUSIONS: If tolerated, NAC might be associated with improved survival and should be considered for eligible patients with MIBC planning to undergo bladder preservation with RT. Prospective trials are warranted. PATIENT SUMMARY: In this study, we showed that neoadjuvant chemotherapy might be associated with improved survival in patients with muscle-invasive bladder cancer who elect for curative-intent radiation-based therapy.

Radiation-based Therapy for Muscle-invasive Bladder Cancer: Contemporary Outcomes Across Tertiary Centers.

BACKGROUND: Radiation therapy (RT) is an alternative to radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC). OBJECTIVE: To analyze predictors of complete response (CR) and survival after RT for MIBC. DESIGN, SETTING, AND PARTICIPANTS: This was a multicenter retrospective study of 864 patients with nonmetastatic MIBC who underwent curative-intent RT from 2002 to 2018. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Regression models were used to explore prognostic factors associated with CR, cancer-specific survival (CSS), and overall survival (OS). RESULTS AND LIMITATIONS: The median patient age was 77 yr and median follow-up was 34 mo. Disease stage was cT2 in 675 patients (78%) and cN0 in 766 (89%). Neoadjuvant chemotherapy (NAC) was given to 147 patients (17%) and concurrent chemotherapy to 542 (63%). A CR was experienced by 592 patients (78%). cT3-4 stage (odds ratio [OR] 0.43, 95% confidence interval [CI] 0.29-0.63; p < 0.001) and hydronephrosis (OR 0.50, 95% CI 034-0.74; p = 0.001) were significantly associated with lower CR. The 5-yr survival rates were 63% for CSS and 49% for OS. Higher cT stage (HR 1.93, 95% CI 1.46-2.56; p < 0.001), carcinoma in situ (HR 2.10, 95% CI 1.25-3.53; p = 0.005), hydronephrosis (HR 2.36, 95% CI 1.79-3.10; p < 0.001), NAC use (HR 0.66, 95% CI 0.46-0.95; p = 0.025), and whole-pelvis RT (HR 0.66, 95% CI 0.51-0.86; p = 0.002) were independently associated with CSS; advanced age (HR 1.03, 95% CI 1.01-1.05; p = 0.001), worse performance status (HR 1.73, 95% CI 1.34-2.22; p < 0.001), hydronephrosis (HR 1.50, 95% CI 1.17-1.91; p = 0.001), NAC use (HR 0.69, 95% CI 0.49-0.97; p = 0.033), whole-pelvis RT (HR 0.64, 95% CI 0.51-0.80; p < 0.001), and being surgically unfit (HR 1.42, 95% CI 1.12-1.80; p = 0.004) were associated with OS. The study is limited by the heterogeneity of different treatment protocols. CONCLUSIONS: RT for MIBC yields a CR in most patients who elect for curative-intent bladder preservation. The benefit of NAC and whole-pelvis RT require prospective trial validation. PATIENT SUMMARY: We investigated outcomes for patients with muscle-invasive bladder cancer treated with curative-intent radiation therapy as an alternative to surgical removal of the bladder. The benefit of chemotherapy before radiotherapy and whole-pelvis radiation (bladder plus the pelvis lymph nodes) needs further study.

Prophylactic tamsulosin and urinary retention rates following elective colorectal surgery: a retrospective cohort study.

PURPOSE: Postoperative urinary retention (POUR) is a known morbidity after colorectal surgery. This study investigated the effect of prophylactic tamsulosin on urinary retention rates after colorectal surgery. METHODS: A retrospective cohort study of male patients 50 years or older undergoing elective colonic and rectal resections from May 2014 to November 2019 was performed. The intervention assessed was prophylactic tamsulosin use. POUR, defined by requiring intermittent or reinsertion of urinary catheter, was compared using chi-squared analysis. RESULTS: A total of 332 patients were included, 131 received no tamsulosin, and 201 received prophylactic tamsulosin. Overall POUR was significantly reduced (16.8% vs. 9.5%, p = 0.047). Subgroup analysis for age 50-59 revealed no difference (9.1% vs. 9.4%, p = 0.96), but POUR risk was significantly lower in age 60 and older (20.7% vs. 9.5%, p = 0.02). No significant difference was found in rectal resections alone (18.2% vs. 13.2%, p = 0.34). CONCLUSION: Prophylactic tamsulosin reduced POUR after colorectal surgery with the greatest effect in men 60 years or older and colonic resections.

Renal Lymphangiectasia in the Transplanted Kidney: Case Series and Literature Review.

BACKGROUND: Renal lymphangiectasia is a rare and poorly understood lymphatic disease associated with lymphatic dilation and leakage. To our knowledge, no cases have been described in the context of a transplanted kidney. METHODS: We describe 2 cases of renal lymphangiectasia in transplanted kidneys, both from pediatric donors. RESULTS: The cases of allograft lymphangiectasia are characterized by severe, symptomatic ascites refractory to attempts at medical and surgical management, and ultimately requiring allograft nephrectomy. CONCLUSIONS: While lymphatic complications, particularly lymphoceles, are not uncommon in renal transplantation, lymphangiectasia is a distinct condition which should be considered in renal transplant patients with ascites, after all other sources have been ruled out.

Assessing Time of Full Renal Recovery Following Minimally Invasive Partial Nephrectomy.

OBJECTIVE: To assess renal function in the operated kidney at different time points post partial nephrectomy (PN) and establish the time in which optimal recovery occurs. Recovery of renal function post-PN has received significant attention. However, the optimal time to determine full recovery has not been clearly established. MATERIALS AND METHODS: Renal function following minimally invasive (laparoscopic and robotic) PNs performed between 2002 and 2015 was reviewed. Patients included in this study had renal function assessed preoperatively as well as 3 days, 6-12 weeks, and 1 year post-PN, using a combination of estimated glomerular filtration rate (eGFR) from serum creatinine and relative renal uptake (RRU) from Tc99m-MAG3 renal scintigraphy. Together, eGFR and RRU provide the ipsilateral renal function (IRF) of the operated organ. RESULTS: At 6-12 weeks postoperatively, percent preserved eGFR, RRU, and IRF (relative to preoperative baselines) were 92.1%, 83.3%, and 77.4% respectively. %IRF at 6-12 weeks was significantly improved from %IRF at 3 days postoperatively, but did not differ significantly from 1 year postoperatively. Furthermore, 89% of patients had RRU values at 6-12 weeks which differed by less than 5% from RRU values at 1 year. CONCLUSION: Our data suggest that renal function recovery at 6-12 weeks was equivalent to long-term recovery at 1 year in the majority of post-PN patients. This has important implications for post-PN follow-up, particularly in assessing the functional outcomes utilizing novel minimally invasive PN strategies, as well as in planning staged procedures for bilateral synchronous renal masses.

Changing the Learning Curve in Novice Laparoscopists: Incorporating Direct Visualization into the Simulation Training Program.

OBJECTIVE: A major challenge in laparoscopic surgery is the lack of depth perception. With the development and continued improvement of 3D video technology, the potential benefit of restoring 3D vision to laparoscopy has received substantial attention from the surgical community. Despite this, procedures conducted under 2D vision remain the standard of care, and trainees must become proficient in 2D laparoscopy. This study aims to determine whether incorporating 3D vision into a 2D laparoscopic simulation curriculum accelerates skill acquisition in novices. DESIGN: Postgraduate year-1 surgical specialty residents (n = 15) at the Schulich School of Medicine and Dentistry, at Western University were randomized into 1 of 2 groups. The control group practiced the Fundamentals of Laparoscopic Surgery peg-transfer task to proficiency exclusively under standard 2D laparoscopy conditions. The experimental group first practiced peg transfer under 3D direct visualization, with direct visualization of the working field. Upon reaching proficiency, this group underwent a perceptual switch, changing to standard 2D laparoscopy conditions, and once again trained to proficiency. RESULTS: Incorporating 3D direct visualization before training under standard 2D conditions significantly (p < 0.0.5) reduced the total training time to proficiency by 10.9 minutes or 32.4%. There was no difference in total number of repetitions to proficiency. Data were also used to generate learning curves for each respective training protocol. CONCLUSIONS: An adaptive learning approach, which incorporates 3D direct visualization into a 2D laparoscopic simulation curriculum, accelerates skill acquisition. This is in contrast to previous work, possibly owing to the proficiency-based methodology employed, and has implications for resource savings in surgical training.