ABSTRACT
Niraparib (NIRA) is a highly selective inhibitor of poly (adenosine diphosphate-ribose) polymerase, PARP1 and PARP2, which play a role in DNA repair. The phase II QUEST study evaluated NIRA combinations in patients with metastatic castration-resistant prostate cancer who were positive for homologous recombination repair gene alterations and had progressed on 1 prior line of novel androgen receptor-targeted therapy. Results from the combination of NIRA with abiraterone acetate plus prednisone, which disrupts androgen axis signaling through inhibition of CYP17, showed promising efficacy and a manageable safety profile in this patient population.
Subject(s)
Abiraterone Acetate , Prostatic Neoplasms, Castration-Resistant , Male , Humans , Abiraterone Acetate/adverse effects , Prednisone/adverse effects , Prostatic Neoplasms, Castration-Resistant/drug therapy , Prostatic Neoplasms, Castration-Resistant/pathology , Treatment Outcome , Antineoplastic Combined Chemotherapy Protocols/adverse effectsABSTRACT
PURPOSE: We sought to expand current prediction tools for lymph node invasion in patients with prostate cancer using current state-of-the-art available tumor information, including multiparametric magnetic resonance imaging based tumor stage and detailed biopsy information. MATERIALS AND METHODS: We selected patients with prostate cancer for study who had available registered information on ISUP (International Society of Urological Pathology) based biopsy grading and multiparametric magnetic resonance imaging, and who had undergone radical prostatectomy with extended pelvic lymph node dissection. We developed a lymph node invasion prediction tool in 420 patients and externally validated it in 187. A concordance index was estimated to quantify the discriminative performance of the model. RESULTS: In the development cohort a median of 21 lymph nodes were removed per patient and 71 patients (16.9%) were diagnosed with lymph node invasion. Statistically significant predictors of lymph node invasion were the initial prostate specific antigen value, multiparametric magnetic resonance imaging based T stage, maximum tumor length in 1 core in mm and ISUP grade group corresponding to the maximum tumor involvement in 1 core. The predictive accuracy of this lymph node invasion prediction tool was 79.7% after fivefold internal cross validation and 72.5% after external validation. CONCLUSIONS: We report a contemporary, externally validated prediction tool for lymph node invasion in patients with prostate cancer. This prediction tool is a response to the paradigm shift from systematic to targeted biopsies by incorporating additional core specific biopsy information instead of the percent of positive cores. This new tool will also overcome stage migration, which is a potential risk when multiparametric magnetic resonance imaging information is used in digital rectal examination based nomograms.
Subject(s)
Lymph Node Excision , Lymphatic Metastasis/diagnosis , Multiparametric Magnetic Resonance Imaging , Nomograms , Prostate/pathology , Prostatic Neoplasms/diagnostic imaging , Aged , Biopsy, Large-Core Needle , Humans , Kallikreins/blood , Lymph Nodes/pathology , Lymph Nodes/surgery , Male , Middle Aged , Neoplasm Grading , Neoplasm Staging , Patient Selection , Predictive Value of Tests , Prostate/diagnostic imaging , Prostate-Specific Antigen/blood , Prostatectomy , Prostatic Neoplasms/pathology , Retrospective StudiesABSTRACT
PURPOSE: Surgical innovation is necessary to ensure continued improvement in patient care. However, several challenges unique to the surgical craft are encountered during the development and validation of such new technology. This article highlights some of these challenges and gives an overview of existing solutions. METHODS: A Pubmed review was performed about the "introduction of new technology" to identify challenges. Cross-referencing was used to explore the possible solutions per challenge. RESULTS: Several characteristics of the surgical craft itself limit our ability to establish randomised controlled trials and hence provide clear categorical evidence. Existing certification bodies for new technology often use unstructured regulations and allow fast-track bypassing systems. Consequently the IDEAL framework (innovation, development, exploration, assessment, long-term follow-up) proposes an objective scientific approach whilst defining stakeholder responsibilities. The selection of which new modality to implement is heavily influenced by third parties unrelated to the best patient outcomes and thus professional organisations can aid in this decision-making. Appropriate training of surgeons and their teams until proficiency is achieved is essential prior to credentialling. Finally long-term surveillance of outcomes in the form of registries is an increasing responsibility of the urological community to maintain our role in directing the adoption or rejection of these innovations. CONCLUSION: Urological innovation is a dynamic and challenging process. Increasing efforts are identified within the urological community to render the process more reliable and transparent.
Subject(s)
Inventions , Urologic Surgical Procedures/trends , Evidence-Based Medicine/organization & administration , Humans , Inventions/legislation & jurisprudence , Inventions/standardsABSTRACT
The artificial urinary sphincter (AUS) is considered the 'gold standard' in post-prostatectomy urinary incontinence. However, in recent years, male slings have gained much popularity due to the ease of surgery, good functional results and low complications rates. This review systematically shows the evidence for the different sling systems, describes the working mechanism, and compares their efficacy against that of the AUS. Furthermore subgroups of patients are defined who are not suited to undergo sling surgery.
Subject(s)
Prostatectomy/adverse effects , Suburethral Slings/adverse effects , Urinary Incontinence/epidemiology , Urinary Incontinence/therapy , Urinary Sphincter, Artificial/adverse effects , Humans , MaleABSTRACT
ProBio is the first outcome-adaptive platform trial in prostate cancer utilizing a Bayesian framework to evaluate efficacy within predefined biomarker signatures across systemic treatments. Prospective circulating tumor DNA and germline DNA analysis was performed in patients with metastatic castration-resistant prostate cancer before randomization to androgen receptor pathway inhibitors (ARPIs), taxanes or a physician's choice control arm. The primary endpoint was the time to no longer clinically benefitting (NLCB). Secondary endpoints included overall survival and (serious) adverse events. Upon reaching the time to NLCB, patients could be re-randomized. The primary endpoint was met after 218 randomizations. ARPIs demonstrated ~50% longer time to NLCB compared to taxanes (median, 11.1 versus 6.9 months) and the physician's choice arm (median, 11.1 versus 7.4 months) in the biomarker-unselected or 'all' patient population. ARPIs demonstrated longer overall survival (median, 38.7 versus 21.7 and 21.8 months for taxanes and physician's choice, respectively). Biomarker signature findings suggest that the largest increase in time to NLCB was observed in AR (single-nucleotide variant/genomic structural rearrangement)-negative and TP53 wild-type patients and TMPRSS2-ERG fusion-positive patients, whereas no difference between ARPIs and taxanes was observed in TP53-altered patients. In summary, ARPIs outperform taxanes and physician's choice treatment in patients with metastatic castration-resistant prostate cancer with detectable circulating tumor DNA. ClinicalTrials.gov registration: NCT03903835 .
ABSTRACT
BACKGROUND: Although excellent training programs exist for acquiring the challenging skill required in laparoscopic suturing, without subsequent reinforcement, performance is prone to decay. Therefore, maintenance training is proposed to ensure better skill retention. This study aimed to elucidate the ideal timing and frequency of maintenance training as well as the best model to be used for this training. METHODS: After completing a proficiency-based laparoscopic suturing training, 39 medical students attended different maintenance programs represented by four groups: a control group without additional training (group 1), a massed training group with one supervised training session (150 min) after 2.5 months (group 2), and two distributed training groups with five monthly unsupervised training sessions of 30 min on a box trainer (group 3) or the LapMentor(®) (group 4). Retention testing, after 5 months, included suturing on a box trainer and on a cadaver porcine Nissen model. Performance scores (time and errors) were expressed in seconds. Afterward, time needed to regain proficiency was measured. RESULTS: On the box trainer, the median performance scores were 233 s (interquartile range [IQR] 27 s) for group 1, 180 s (IQR 55 s) for group 2, 169 s (IQR 26 s) for group 3, and 226 s (IQR 66 s) for group 4 (p = 0.03). No difference was seen between groups 2 and 3, both of which significantly outperformed groups 1 and 4. On the porcine Nissen model, no differences were detected between the groups (p = 0.53). Group 3 reached proficiency more quickly than the other groups. CONCLUSIONS: Maintenance training is a valuable and necessary addendum to proficiency-based training programs for laparoscopic suturing. A maintenance-training interval of 1 month with unsupervised training sessions on simple box trainers seems ideal. The LapMentor(®) did not show any benefit. Performance differences between groups did not translate to a clinically relevant model, indicating that transfer of training is not perfect.
Subject(s)
Education, Medical, Undergraduate/methods , Laparoscopy/education , Models, Structural , Suture Techniques/education , Animals , Educational Measurement , Female , Fundoplication/education , Fundoplication/methods , Humans , Learning Curve , Male , Students, Medical , Swine , Task Performance and Analysis , User-Computer Interface , Young AdultABSTRACT
In this review, the role of surgery in patients with adverse tumor characteristics and a high risk of tumor progression are discussed. In the current PSA era the proportion of patients presenting with high risk prostate cancer (PCa) is estimated to be between 15% and 25% with a 10-year cancer specific survival in the range of 80-90% for those receiving active local treatment. The treatment of high risk prostate cancer is a contemporary challenge. Surgery in this group is gaining popularity since 10-year cancer specific survival data of over 90% has been described. Radical prostatectomy should be combined with extended lymphadenectomy. Adjuvant or salvage therapies may be needed in more than half of patients , guided by pathologic findings and postoperative PSA. Unfortunately there are no randomized controlled trials comparing radical prostatectomy to radiotherapy and no single treatment can be universally recommended. This group of high risk prostate cancer patients should be considered a multi-disciplinary challenge; however, for the properly selected patient, radical prostatectomy either as initial or as the only therapy can be considered an excellent treatment.
Subject(s)
Prostate-Specific Antigen , Prostatic Neoplasms , Humans , Male , Prostatectomy , Prostatic Neoplasms/surgery , Salvage TherapyABSTRACT
BACKGROUND: Quality control indicators (QCIs) can be used to objectively evaluate guideline adherence and benchmark quality among urologists and centers. OBJECTIVE: To assess six QCIs for non-muscle-invasive bladder cancer (NMIBC) using a prospective registry of transurethral resection of bladder tumor (TURBT) procedures. DESIGN, SETTING, AND PARTICIPANTS: Clinical data for TURBT cases were prospectively collected using electronic case report forms (eCRFs) embedded in the electronic medical record in three centers during 2013-2017. Pathological data were collected retrospectively. Patients with T0 disease or prior T2 disease were excluded. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We assessed six QCIs: complete resection (CR) status, presence of detrusor muscle (DM), re-TURBT, single instillation of mitomycin C (MMC), start of bacillus Calmette-Guérin (BCG) therapy, and therapy ≤6 wk after diagnosis. We assessed the quality of reporting on QCIs and compliance with QCIs, compared compliance between centers and over time, and investigated correlation between compliance and recurrence-free survival (RFS). RESULTS AND LIMITATIONS: Data for 1350 TURBT procedures were collected, of which 1151 were included for 907 unique patients. The distribution of European Association of Urology risk categories after TURBT was 271 with low risk, 464 with intermediate risk, and 416 with high risk. The quality of reporting for two QCIs was suboptimal, at 35% for DM and 51% for BCG. QCI compliance was 97% for CR, 31% for DM, 65% for MMC, 33% for re-TURBT, 39% for BCG, and 88% for therapy ≤6 wk after diagnosis. Compliance with all QCIs differed significantly among centers. Compliance with MMC and re-TURBT increased significantly over time, which could be attributed to one center. Compliance with MMC was significantly correlated with RFS. The main study limitation is the retrospective collection of pathology data. CONCLUSIONS: A TURBT registry consisting of eCRFs to collect pathology and outcome data allowed assessment of QCIs for NMIBC. Our study illustrates the feasibility of this approach in a real-life setting. Differences in performance on QCIs among centers can motivate urologists to improve their day-to-day care for patients with NMIBC, and can thus improve clinical outcomes. PATIENT SUMMARY: Our study demonstrates that quality control indicators for treatment of bladder cancer not invading the bladder muscle can be evaluated using electronic medical records. We assessed results for 1151 procedures in 907 individual patients to remove bladder tumors between 2013 and 2017 at three centers in Belgium. Compliance with the quality control indicators differed between centers, increased over time, and was correlated with recurrence of disease.
Subject(s)
BCG Vaccine , Urinary Bladder Neoplasms , Humans , Retrospective Studies , Belgium/epidemiology , BCG Vaccine/therapeutic use , Transurethral Resection of Bladder , Administration, Intravesical , Urinary Bladder Neoplasms/pathology , Mitomycin/therapeutic use , Quality ControlABSTRACT
BACKGROUND: The optimal treatment for patients with pathological node-positive (pN1) prostate cancer (PCa) is unclear. OBJECTIVE: To evaluate whether whole-pelvis radiotherapy (WPRT) improves clinical relapse-free survival (cRFS) in comparison to prostate-only radiotherapy (PORT) in pN1 PCa. DESIGN, SETTING, AND PARTICIPANTS: PROPER was a phase 3 trial randomizing patients to WPRT or PORT. All patients had pN1cM0 PCa with fewer than five lymph nodes involved. INTERVENTION: All patients underwent pelvic lymph node dissection followed by radical prostatectomy/primary radiotherapy + 2 yr of androgen deprivation therapy (ADT). Patients were randomized to PORT (arm A) or WPRT (arm B). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was cRFS. The secondary endpoints were overall survival (OS), biochemical relapse-free survival (bRFS), and toxicity. The study was stopped because of poor accrual in June 2021 after the inclusion of 69 patients. We report on OS, bRFS, cRFS, and acute and late toxicity. RESULTS AND LIMITATIONS: The median follow-up was 30 mo in arm A (n = 33) and 36 mo in arm B (n = 31). The 3-yr OS rate was 92% ± 5% in arm A and 93% ± 5% in arm B (p = 0.61). None of the patients died of PCa. The 3-yr bRFS was 79% ± 9% in arm A and 92% ± 5% in arm B (p = 0.08). The 3-yr cRFS rate was 88% ± 6% in arm A and 92% ± 5% in arm B (p = 0.31). No pelvic recurrence was observed in arm B. Acute grade 2 gastrointestinal toxicity was higher with WPRT (15% in arm A vs 45% in arm B; p = 0.03). Limitations are the early closure because of poor accrual and the limited follow-up. CONCLUSIONS: The results of our trial are hypothesis-generating but add evidence supporting the recommendation to offer WPRT to patients with pN1 PCa. However, WPRT is associated with more acute gastrointestinal toxicity. PATIENT SUMMARY: We looked at the impact of radiotherapy to the whole pelvis (WPRT) for patients with prostate cancer that had spread to the lymph nodes. Although the trial was closed early because of poor enrolment, we found that WPRT improves survival free from relapse, and no recurrences were observed in the pelvis. WPRT is associated with more acute side effects on the gastrointestinal system in comparison to radiotherapy to just the prostate.
Subject(s)
Prostatic Neoplasms , Male , Humans , Prostatic Neoplasms/radiotherapy , Prostatic Neoplasms/surgery , Prostatic Neoplasms/drug therapy , Prostate/pathology , Androgen Antagonists/therapeutic use , Disease-Free Survival , Neoplasm Recurrence, Local/pathologyABSTRACT
Lutetium-177 prostate-specific membrane antigen radioligands (177Lu-PSMA) are new therapeutic agents for the treatment of metastatic castration-resistant prostate cancer (mCRPC). We evaluated the prognostic value of circulating tumour DNA (ctDNA) profiling in patients with mCRPC starting treatment with 177Lu-PSMA I&T. Between January 2020 and October 2022, patients with late-stage mCRPC (n = 57) were enrolled in a single-centre observational cohort study. Genomic alterations in the AR gene, PI3K signalling pathway, TP53, and TMPRSS2-ERG were associated with progression-free survival (PFS) on Kaplan-Meier and multivariable Cox regression analyses. Median PFS of 3.84 mo (95% confidence interval [CI] 3.3-5.4) was observed, and 21/56 (37.5%) evaluable patients experienced a prostate-specific antigen response of ≥50% during treatment. Among 46 patients who provided a blood sample for profiling before 177Lu-PSMA treatment. ctDNA was detected in 39 (84.8%); higher ctDNA was correlated with shorter PFS. Genomic structural rearrangements in the AR gene (hazard ratio [HR] 9.74, 95% confidence interval [CI] 2.4-39.5; p = 0.001) and alterations in the PI3K signalling pathway (HR 3.58, 95% CI 1.41-9.08; p = 0.007) were independently associated with poor 177Lu-PSMA prognosis on multivariable Cox regression. Prospective evaluation of these associations in biomarker-driven trials is warranted. Patient summary: We examined cell-free DNA in blood samples from patients with advanced metastatic prostate cancer who started treatment with lutetium-177-PSMA, a new radioligand therapy. We found that patients with genetic alterations in the androgen receptor gene or PI3K pathway genes did not experience a lasting benefit from lutetium-177-PSMA.
ABSTRACT
Purpose: We hypothesized that two-tier re-classification of the "M" (metastasis) domain of the Tumor-Node-Metastasis (TNM) staging of Renal Cell Carcinoma (RCC) may improve staging accuracy than the current monolithic classification, as advancements in the understanding of tumor biology have led to increased recognition of the heterogeneous potential of metastatic RCC (mRCC). Methods: Multicenter retrospective analysis of patients from the REMARCC (REgistry of MetAstatic RCC) database. Patients were stratified by number of metastases into two groups, M1 (≤3, "Oligometastatic") and M2 (>3, "Polymetastatic"). Primary outcome was overall survival (OS). Secondary outcomes were cancer-specific survival (CSS). Cox-regression and Kaplan-Meier (KMA) analysis were utilized for outcomes, and receiver operating characteristic analysis (ROC) was utilized to assess diagnostic accuracy compared to current "M" staging. Results: 429 patients were stratified into proposed M1 and M2 groups (M1 = 286/M2 = 143; median follow-up 19.2 months). Cox-regression revealed M2 classification as an independent risk factor for worsened all-cause mortality (HR=1.67, p=0.001) and cancer-specific mortality (HR=1.74, p<0.001). Comparing M1-oligometastatic vs. M2-polymetastatic groups, KMA revealed significantly higher 5-year OS (36% vs. 21%, p<0.001) and 5-year CSS (39% vs. 17%, p<0.001). ROC analyses comparing OS and CSS, for M1/M2 reclassification versus unitary M designation currently in use demonstrated improved c-index for OS (M1/M2 0.635 vs. unitary M 0.500) and CSS (M1/M2 0.627 vs. unitary M 0.500). Conclusion: Subclassification of Stage "M" domain of mRCC into two clinical substage categories based on metastatic burden corresponds to distinctive tumor groups whose oncological potential varies significantly and result in improved predictive capability compared to current staging.
ABSTRACT
BACKGROUND: In Belgium, bladder cancer is the fifth most common cancer in males (5.2%) and the sixth most frequent cause of death from cancer in males (3.8%). Previous epidemiological studies have consistently reported that selenium concentrations were inversely associated with the risk of bladder cancer. This suggests that selenium may also be suitable for chemoprevention of recurrence. METHOD: The SELEBLAT study opened in September 2009 and is still recruiting all patients with non-invasive transitional cell carcinoma of the bladder on TURB operation in 15 Belgian hospitals. Recruitment progress can be monitored live at http://www.seleblat.org. Patients are randomly assigned to selenium yeast (200 µg/day) supplementation for 3 years or matching placebo, in addition to standard care. The objective is to determine the effect of selenium on the recurrence of bladder cancer. Randomization is stratified by treatment centre. A computerized algorithm randomly assigns the patients to a treatment arm. All study personnel and participants are blinded to treatment assignment for the duration of the study. DESIGN: The SELEnium and BLAdder cancer Trial (SELEBLAT) is a phase III randomized, placebo-controlled, academic, double-blind superior trial. DISCUSSION: This is the first report on a selenium randomized trial in bladder cancer patients. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00729287.
Subject(s)
Neoplasm Recurrence, Local/epidemiology , Neoplasm Recurrence, Local/prevention & control , Selenium/therapeutic use , Urinary Bladder Neoplasms/drug therapy , Urinary Bladder Neoplasms/mortality , Adolescent , Adult , Aged , Aged, 80 and over , Antioxidants/therapeutic use , Belgium/epidemiology , Female , Humans , Male , Middle Aged , Prevalence , Risk Assessment , Risk Factors , Survival Analysis , Survival Rate , Treatment Outcome , Young AdultABSTRACT
BACKGROUND: Treatment paradigms for management of metastatic renal cell carcinoma (mRCC) are evolving. We examined impact of surgical metastasectomy on survival across in mRCC stratified by risk-group. METHODS: Multicenter retrospective analysis from the Registry of Metastatic RCC database. The cohort was subdivided utilizing Motzer criteria (favorable-, intermediate-, high-risk). Primary outcome was all-cause mortality (ACM)/overall survival (OS); secondary outcome was cancer-specific mortality (CSM)/cancer-specific survival (CSS). Impact of metastasectomy was analyzed via Cox-Regression analysis adjusting for potential prognostic variables and Kaplan-Meier analysis (KMA) within each risk-group. RESULTS: Four hundred thirty-one patients (59 favorable-risk, 274 intermediate-risk, 98 high-risk; median follow-up 27.2 months) were analyzed. Metastasectomy was performed in 22 (37%), 66 (24%), and 32 (16%) of favorable-, intermediate- and high-risk groups (P = .012). Median number of metastases at diagnosis differed significantly (favorable-risk 2, intermediate-risk 3.4, high-risk 5.1, P < .001). On Cox-regression, high-risk (HR = 1.72, P = .002) was associated with worsened ACM, while metastasectomy was associated with improved ACM (HR = 0.56, P = .005). On KMA, median OS (months) was longer with metastasectomy in favorable- (92.7 vs. 25.8, P = .003) and intermediate-risk (26.3 vs. 20.1, P = .038), but not high-risk (P = .911) groups. Metastasectomy was associated with longer CSS in favorable- (76.1 vs. 32.8, P = .004) but not intermediate- (P = .06) and high-risk (P = .595) groups. CONCLUSIONS: Metastasectomy was independently associated with improved ACM and CSM, as well as improved CSS and OS in favorable- and intermediate-risk mRCC patients. Metastasectomy may be considered as component of multimodal management strategy in favorable and intermediate-risk subgroups. In high-risk patients, metastasectomy should be deferred except in select circumstances.
Subject(s)
Carcinoma, Renal Cell , Kidney Neoplasms , Metastasectomy , Carcinoma, Renal Cell/pathology , Humans , Kidney Neoplasms/pathology , Prognosis , Registries , Retrospective Studies , Survival RateABSTRACT
BACKGROUND: Selection of patients for upfront cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (mRCC) has to be improved. OBJECTIVE: To evaluate a new scoring system for the prediction of overall mortality (OM) in mRCC patients undergoing CN. DESIGN, SETTING, AND PARTICIPANTS: We identified a total of 519 patients with synchronous mRCC undergoing CN between 2005 and 2019 from a multi-institutional registry (Registry for Metastatic RCC [REMARCC]). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Cox proportional hazard regression was used to test the main predictors of OM. Restricted mean survival time was estimated as a measure of the average overall survival time up to 36 mo of follow-up. The concordance index (C-index) was used to determine the model's discrimination. Decision curve analyses were used to compare the net benefit from the REMARCC model with International mRCC Database Consortium (IMDC) or Memorial Sloan Kettering Cancer Center (MSKCC) risk scores. RESULTS AND LIMITATIONS: The median follow-up period was 18 mo (interquartile range: 5.9-39.7). Our models showed lower mortality rates in obese patients (p = 0.007). Higher OM rates were recorded in those with bone (p = 0.010), liver (p = 0.002), and lung metastases (p < 0.001). Those with poor performance status (<80%) and those with more than three metastases had also higher OM rates (p = 0.026 and 0.040, respectively). The C-index of the REMARCC model was higher than that of the MSKCC and IMDC models (66.4% vs 60.4% vs 60.3%). After stratification, 113 (22.0%) patients were classified to have a favorable (no risk factors), 202 (39.5%) an intermediate (one or two risk factors), and 197 (38.5%) a poor (more than two risk factors) prognosis. Moreover, 72 (17.2%) and 51 (13.9%) patients classified as having an intermediate and a poor prognosis according to MSKCC and IMDC categories, respectively, would be reclassified as having a good prognosis according to the REMARCC score. CONCLUSIONS: Our findings confirm the relevance of tumor and patient features for the risk stratification of mRCC patients and clinical decision-making regarding CN. Further prospective external validations are required for the scoring system proposed herein. PATIENT SUMMARY: Current stratification systems for selecting patients for kidney removal when metastatic disease is shown are controversial. We suggest a system that includes tumor and patient features besides the systems already in use, which are based on blood tests.
Subject(s)
Carcinoma, Renal Cell , Kidney Neoplasms , Carcinoma, Renal Cell/surgery , Cytoreduction Surgical Procedures , Humans , Kidney Neoplasms/drug therapy , Kidney Neoplasms/surgery , Nephrectomy , Registries , Retrospective Studies , Risk FactorsABSTRACT
OBJECTIVES: The REWIND study sought to describe the real-world clinical and prescribing practices for the management of urinary tract infection (UTI) in Italy, Belgium, Russia and Brazil in order to compare current practices with international, European and national guidelines. METHODS: An integrated mixed-methods approach was adopted that used information from primary care electronic medical records in longitudinal patient databases available in Italy and Belgium, and surveys of physicians in Russia (general practitioners) and Brazil (gynaecologists). RESULTS: In total, 49 548 female patients were included in the study. Antibiotics were the most common management option for UTI in Italy (71.1%, n=27 600), Belgium (92.4%, n=7703), Russia (81.9%, n=1231) and Brazil (82.4%, n=740). Fosfomycin trometamol was the first-choice antibiotic for the treatment of UTI in all countries. Ciprofloxacin was also commonly prescribed in Italy (24.6%, n=6796), Belgium (17.8%, n=1373), Russia (14.9%, n=184) and Brazil (9.6%, n=71), while prescription of nitrofurantoin was common in Belgium (24.5%, n=1890) alone. CONCLUSIONS: Despite differences in study designs and data sources, fosfomycin trometamol was found to be the most commonly prescribed treatment for UTI in all participating countries. In Belgium, real-world prescribing practices for UTI adhered more closely to European guidelines than national guidelines. Although not recommended in international and European guidelines for lower UTI management, the use of fluoroquinolones was still widespread.
Subject(s)
Anti-Bacterial Agents/therapeutic use , Fosfomycin/therapeutic use , Practice Patterns, Physicians'/statistics & numerical data , Urinary Tract Infections/drug therapy , Adult , Ambulatory Care , Belgium , Brazil , Ciprofloxacin/therapeutic use , Female , Guidelines as Topic , Humans , Italy , Middle Aged , Nitrofurantoin/therapeutic use , RussiaABSTRACT
BACKGROUND: Cytoreductive nephrectomy (CN) plays an important role in the treatment of a subgroup of metastatic renal cell carcinoma (mRCC) patients. OBJECTIVE: We aimed to evaluate morbidity associated with this procedure and identify potential predictors thereof to aid patient selection for this procedure and potentially improve patient outcomes. DESIGN, SETTING, AND PARTICIPANTS: Data from 736 mRCC patients undergoing CN at 14 institutions were retrospectively recorded in the Registry for Metastatic RCC (REMARCC). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Logistic regression analysis was used to identify predictors for intraoperative, any-grade (AGCs), low-grade, and high-grade (HGCs) postoperative complications (according to the Clavien-Dindo classification) as well as 30-d readmission rates. RESULTS AND LIMITATIONS: Intraoperative complications were observed in 69 patients (10.9%). Thrombectomy (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.08-1.75, p = 0.009) and adjacent organ removal (OR 2.7, 95% CI 1.38-5.30) were significant predictors of intraoperative complications at multivariable analysis. Two hundred seventeen patients (29.5%) encountered AGCs, while 45 (6.1%) encountered an HGC, of whom 10 (1.4%) died. Twenty-four (3.3%) patients had multiple postoperative complications. Estimated blood loss (EBL; OR 1.49, 95% CI 1.08-2.05, p = 0.01) was a significant predictor of AGCs at multivariable analysis. CN case load (OR 0.13, 95% CI 0.03-0.59, p = 0.009) and EBL (OR 2.93, 95% CI 1.20-7.15, p = 0.02) were significant predictors solely for HGCs at multivariable analysis. Forty-one patients (11.5%) were readmitted within 30 d of surgery. No significant predictors were identified. Results were confirmed in a subanalysis focusing solely on patients treated in the contemporary targeted therapy era. CONCLUSIONS: Morbidity associated with CN is not negligible. Predictors of high-grade postoperative morbidity are predominantly indicators of complex surgery. EBL is a strong predictor of postoperative complications. CN case load correlates with lower high-grade morbidity and highlights the benefit of centralization of complex surgery. However, risks and benefits should be balanced when considering CN in mRCC patients. PATIENT SUMMARY: We studied patients with metastatic renal cancer to evaluate the outcomes associated with the surgical removal of the primary kidney tumor. We found that this procedure is often complex and adverse events are not uncommon. High intraoperative blood loss and a small number of cases performed at the treating center are associated with a higher rate of postoperative complications.
Subject(s)
Carcinoma, Renal Cell/surgery , Cytoreduction Surgical Procedures , Kidney Neoplasms/surgery , Nephrectomy/methods , Postoperative Complications/epidemiology , Aged , Carcinoma, Renal Cell/secondary , Female , Humans , Kidney Neoplasms/pathology , Male , Middle Aged , Prognosis , Registries , Retrospective StudiesABSTRACT
INTRODUCTION: Because of the complex nature of laparoscopic suturing, numerous curricula have been developed to overcome the steep learning curve in a patient-free environment. Distributed training leads to better acquisition and retention of skill compared with massed training. However, this requires considerable time commitment of experts that supervise these training sessions. This study investigates the possibility of replacing expert supervision by structured training with video demonstrations and peer feedback. MATERIALS AND METHODS: The study population consisted of two balanced groups of ten senior medical students with minimal experience in laparoscopy. The control group trained with continuous expert feedback while for the experimental group only video demonstrations and external feedback from peers were available. Training was completed when a previously determined expert level was achieved on two consecutive attempts (proficiency criterion). Students were tested on their suturing skills 1 week after the training as well as after 4 months. A composite score assessing quality and quantity of suturing performance was used. Data are shown as median (interquartile range, IQR). RESULTS: Students' performance improved more than 200% after training. Learning curves did not differ between groups (p = 0.28). One week after training, scores were 192 s (IQR 65 s) for the control and 190 s (IQR 27 s) for the experimental group (p = 0.63). After 4 months this was 223 s (IQR 88 s) and 220 s (IQR 37 s), respectively (p = 0.60). CONCLUSIONS: Both training methods are very efficient at improving laparoscopic suturing skills and provide excellent skill retention. We therefore conclude that structured training with video demonstrations and peer feedback can replace expert supervision to teach laparoscopic suturing skills to novices. This will facilitate practical organization of skills training.
Subject(s)
Clinical Competence/standards , Internship and Residency , Laparoscopy/education , Suture Techniques/education , Adult , Case-Control Studies , Feedback , Female , Humans , Learning Curve , Male , Psychomotor Performance , Teaching/methods , Teaching Materials , Young AdultABSTRACT
Purpose: To develop a prospective non-muscle-invasive bladder cancer (NMIBC) data registry by generating NMIBC-specific electronic case report forms (eCRFs) in our institution's electronic patient file system, and to report on the development and implementation of a prospective multicentric registry. Methods: Templates for data collection, including clinical outcome parameters and quality indicators, were developed in InfoPath™ as an eCRF and were incorporated in our hospital's electronic patient file system. Quality parameters for managing NMIBC patients that were identified by comprehensive literature review were included in the eCRFs. Three separate eCRFs were developed for the management of NMIBC patients: surgery report, bladder instillation form, and multidisciplinary team form. Results: In August 2013, we started a Flemish prospective clinical and pathological data registry for all patients undergoing transurethral resection of bladder tumor (TURBT) for NMIBC in four participating hospitals, three of which continued using this to date. Three more hospitals started enrolling in 2017, 2018, and 2019, respectively. Written reports of the registered clinical actions are automatically generated within the electronic medical file. When urologists complete these eCRFs, an automated ready-to-send letter to the general practitioner is generated. Up till May 2019, 2,756 TURBTs in 2,419 patients are included in the dataset. Currently, we are recruiting over 600 TURBTs every year. Conclusions: Easy-to-use eCRFs were developed and included in the electronic patient file system. This registration tool was implemented in 7 hospitals, 6 of which are still using it today. The register harvests important clinical data, while performing routine clinical practice. The data will be used to analyze real-life data of NMIBC patients, to challenge the existing guidelines, to create novel risk stratification tools, and to develop, monitor and validate quality parameters for NMIBC management.