Functional and perioperative outcomes in elderly men after robotic-assisted radical prostatectomy for prostate cancer.

PURPOSE: We aimed to compare postoperative functional outcomes following robotic-assisted radical prostatectomy (RARP) in elderly men with localized prostate cancer. METHODS: A retrospective review of a prospectively maintained database of men who underwent RARP between January 2007 and November 2018 was performed. Patients over 65 years of age were selected (N = 302) and then stratified by age group: 66-69 years old (N = 214) and ≥ 70 years old (N = 88). Full continence was defined as strict 0-pad per day usage. Preoperative potency included those with a Sexual Health Inventory for Men score ≥ 17. Preoperative and postoperative functional outcomes were assessed. Kaplan-Meier analysis was used to estimate time to recovery of continence in both groups. RESULTS: Both groups had comparable preoperative parameters. Continence rates at 1, 3, 6, 9, 12, 18 and 24 months in the 66-69-year-old group were 6%, 34%, 61%, 70%, 74%, 80% and 87%, respectively. Comparatively in the ≥ 70-year-old group, continence rates were significantly lower at all time points (3%, 22%, 50%, 56%, 66%, 69% and 75%, respectively). Men in the 66-69-year-old group were significantly more likely to be continent after RARP when compared to patients 70 years of age and above [(Hazards ratio (HR) 0.73; 95%confidence interval 0.54-0.97, (p = 0.035)]. CONCLUSION: Our results suggest that RARP is feasible in elderly patients. Nevertheless, elderly patients in the ≥ 70-year-old group had significantly inferior postoperative continence rates compared to patients aged 66-69 years. Such information is valuable when counselling men during preoperative RARP planning to ensure that they have realistic postoperative expectations.

Management of nonmetastatic castration-resistant prostate cancer.

PURPOSE OF REVIEW: The widespread use of prostate-specific antigen (PSA) resulted in stage migration of prostate cancer where androgen deprivation therapy (ADT) is administered for biochemical recurrence in patients following primary treatment. A proportion of these patients progress to a disease state termed nonmetastatic castration-resistant prostate cancer (nmCRPC), with a rising PSA despite ADT and without evidence of metastases on conventional imaging. We will review the treatment options in nmCRPC, especially in light of recent trials showing significant improvement in metastasis-free survival with newer agents. RECENT FINDINGS: Historically, nmCRPC patients were followed-up if PSA doubling-time (PSADT) exceeded 10 months. Treatment options for patients with shorter PSADT included hormonal manipulations that often resulted in transient PSA decline. Denosumab was found to delay the onset of bone metastasis but did not impact survival. Recently, phase 3 trials showed that second-generation antiandrogens resulted in a significant delay in metastasis and a trend toward survival improvement in a select group of nmCRPC patients. SUMMARY: The importance of reducing mortality and morbidity associated with metastasis has led to the acceptance of new primary endpoints in the design of trials for nmCRPC and might result in widespread approval of new agents for this disease state.

Pathology review impacts clinical management of patients with T1-T2 bladder cancer.

INTRODUCTION: We sought to evaluate the contemporary role of a pathology review on management implications of patients with bladder cancer. METHODS: A total of 98 consecutive specimens from transurethral resections in patients with suspected bladder tumours were reviewed at our institution by genitourinary pathologist. Patients were classified into risk groups according to pathology reports obtained before and after review. A management course was proposed according to local institutional practice patterns and main urological guidelines. RESULTS: Overall, 34.7% of pathological reviews had significant changes associated with management implications, the majority of which were due to changes in risk category (and/or stage). On review pathology, 12 patients were recommended radical cystectomy instead of conservative management and two patients avoided radical cystectomy. Six patients initially staged as T1 and whose staging did not change after review had a proposed change in management in the form of early cystectomy as a treatment option, as they were deemed very high-risk secondary to high-risk features (such as carcinoma in situ or lymphovascular invasion found on review). Ten patients initially staged as T2 demonstrated high-risk features on review. CONCLUSIONS: Review by genitourinary pathologist remains important, as it defines more clearly the tumour risk category and influences the management of T1-T2 bladder cancer patients. A complete initial pathological report has the potential to further decrease the discrepancy between initial and review reports.

The role of bone-targeted therapies for prostate cancer in 2017.

PURPOSE OF REVIEW: Bone-targeted agents (BTAs), such as zoledronic acid and denosumab, delay the occurrence of skeletal-related events (SREs) in metastatic prostate cancer (PCa) patients. Recently, several agents, such as abiraterone acetate, enzalutamide and radium-223, were approved for the treatment of metastatic castration-resistant PCa (mCRPC). These agents resulted in improved overall survival (OS), pain control and had positive effects on bone health. Combining BTAs to the newly approved agents demonstrates additional benefits that warrant a review of available evidence looking at appropriate combination therapies and timing of BTAs for optimizing the management of advanced and metastatic PCa. RECENT FINDINGS: Post-hoc analyses of randomized trials demonstrated some benefits from combination therapy, such as increased OS when denosumab was used concurrently with radium-223 and when BTAs were used with abiraterone acetate. BTAs were not beneficial for the prevention of bone metastases. SUMMARY: There is a suggestion of synergy or additive effects between BTAs and new agents approved for the treatment of metastatic PCa, resulting in potential clinical benefits. Therefore, prospective randomized studies evaluating the safety and benefits of combination therapies to address gaps in the literature are needed to optimize treatment of mCRPC.

Quality indicators in the management of bladder cancer: A modified Delphi study.

BACKGROUND: Survival in patients with bladder cancer has only moderately improved over the past 2 decades. A potential reason for this is nonadherence to clinical guidelines and best practice, leading to wide variations in care. Common quality indicators (QIs) are needed to quantify adherence to best practice and provide data for benchmarking and quality improvement. OBJECTIVE: To produce an evidence- and consensus-based list of QIs for the management of bladder cancer. METHODS: A modified Delphi method was used to develop the indicator list. Candidate indicators were extracted from the literature and rated by a 27-member Canadian expert panel in several rounds until consensus was reached on the final list of indicators. In rounds with numeric ratings, a frequency analysis was performed. RESULTS: A total of 86 indicators were rated, 52 extracted from the literature and 34 suggested by the panel. After iterative rounds of ratings and discussion, a final list of 60 QIs spanning several disciplines and phases of the cancer care continuum was developed. CONCLUSIONS: This is the first study to comprehensively produce common QIs representing structure, process, and outcome measures in bladder cancer management. Though developed in Canada, these indicators can be used in other countries with slight modifications to track performance and improve care.

Contemporary Management of Primary Distal Urethral Cancer.

Primary urethral cancer is one of the rare urologic tumors. Distal urethral tumors are usually less advanced at diagnosis compared with proximal tumors and have a good prognosis if treated appropriately. Low-stage distal tumors can be managed successfully with a surgical approach in men or radiation therapy in women. There are no clear-cut indications for the choice of the most appropriate treatment modality. Organ-preserving modalities have shown effective and should be used whenever they do not compromise the oncological safety to decrease the physical and psychological trauma of dismemberment or loss of sexual/urinary function.

Follow-up in non-muscle-invasive bladder cancer-International Bladder Cancer Network recommendations.

OBJECTIVE: Non-muscle-invasive bladder cancer (NMIBC) comprises a wide spectrum of tumors with different behaviors and prognoses. It follows that the surveillance for these tumors should be adapted according to the risks of recurrence and progression and should be dynamic in design. METHODS AND MATERIALS: Medline search was conducted from 1980 to 2016 using a combination of MeSH and keyword terms. The highest available evidence was reviewed to define different risk groups in NMIBC. The performance of different follow-up tools such as urine cytology, cystoscopy, and upper tract imaging in detecting bladder carcinoma was assessed. Different commercially available urinary markers were investigated to determine whether such markers would contribute to the surveillance of patients with NMIBC. A follow-up scheme based on the early evidence is proposed. RESULTS: A risk-based approach is paramount. Cystoscopy and cytology are recommended to be done at 3 months following transurethral resection of bladder tumor. For low-risk tumors, annual cystoscopy alone is sufficient; no upper tract evaluations or cytology is needed except at diagnosis. High-risk tumors should be followed up with a more intense schedule: cystoscopy every 3 months for 2 years, 6 months for 2 years, and then annually, with cytology at frequent intervals, and imaging for upper tract evaluation at 1 year and then every 2 years. Intermediate-risk tumors should be subclassified as per the International Bladder Cancer Group recommendations and when associated with 3 or more of the following findings (multiple tumors, size≥3cm, early recurrence<1 year, frequent recurrences>1 per year) then a surveillance strategy similar to that of high risk should be followed. Several urine markers were more sensitive than cytology in the detection of NMIBC; however, these tests are still costly, require specialized laboratories, and do not replace cystoscopy. Until better and cheaper markers are available, their routine use has not been integrated in the follow-up recommendation of current guidelines. CONCLUSIONS: Surveillance of NMIBC should follow a risk-adapted approach, with a combination of cystoscopy, cytology, and upper tract imaging. The aim of this approach is to minimize the therapeutic burden of a disease with high recurrence rates without missing progressing tumors. When designing a diagnostic pathway, first-line diagnostic imaging tests should have high sensitivity to ensure disease positives are included in the test population for further investigation. Second-line investigations should be highly specific, to ensure false-positives are minimized.

Incidence, Characteristics and Implications of Thromboembolic Events in Patients with Muscle Invasive Urothelial Carcinoma of the Bladder Undergoing Neoadjuvant Chemotherapy.

PURPOSE: Neoadjuvant chemotherapy and pelvic surgery are significant risk factors for thromboembolic events. Our study objectives were to investigate the timing, incidence and characteristics of thromboembolic events during and after neoadjuvant chemotherapy and subsequent radical cystectomy in patients with muscle invasive bladder cancer. MATERIALS AND METHODS: We performed a multi-institutional retrospective analysis of 761 patients who underwent neoadjuvant chemotherapy and radical cystectomy for muscle invasive bladder cancer from 2002 to 2014. Median followup from diagnosis was 21.4 months (range 3 to 272). Patient characteristics included the Khorana score, and the incidence and timing of thromboembolic events (before vs after radical cystectomy). Survival was calculated using the Kaplan-Meier method. The log rank test and multivariable Cox proportional hazards regression were used to compare survival between patients with vs without thromboembolic events. RESULTS: The Khorana score indicated an intermediate thromboembolic event risk in 88% of patients. The overall incidence of thromboembolic events in patients undergoing neoadjuvant chemotherapy was 14% with a wide variation of 5% to 32% among institutions. Patients with thromboembolic events were older (67.6 vs 64.6 years, p = 0.02) and received a longer neoadjuvant chemotherapy course (10.9 vs 9.7 weeks, p = 0.01) compared to patients without a thromboembolic event. Of the thromboembolic events 58% developed preoperatively and 72% were symptomatic. On multivariable regression analysis the development of a thromboembolic event was not significantly associated with decreased overall survival. However, pathological stage and a high Khorana score were adverse risk factors for overall survival. CONCLUSIONS: Thromboembolic events are common in patients with muscle invasive bladder cancer who undergo neoadjuvant chemotherapy before and after radical cystectomy. Our results suggest that a prospective trial of thromboembolic event prophylaxis during neoadjuvant chemotherapy is warranted.

A Review of Neoadjuvant and Adjuvant Chemotherapy for Nonmetastatic Muscle Invasive Bladder Cancer.

INTRODUCTION: Radical cystectomy is the standard treatment for muscle invasive bladder cancer but survival remains poor with radical cystectomy alone. We reviewed the relevant available data on adjuvant and neoadjuvant chemotherapy for bladder cancer. METHODS: We performed a MEDLINE® database literature search to identify original articles and meta-analyses. A key word search was done using the terms urinary bladder neoplasms, cystectomy, chemotherapy, and adjuvant and neoadjuvant therapy. The search was restricted to adults. RESULTS: We studied adjuvant chemotherapy in several prospective, randomized trials that demonstrated improvement in disease-free survival. Many of the trials failed to achieve the target number of accruals, closed early or had major flaws in design. Evidence of the use of neoadjuvant chemotherapy was based on more robust studies that showed a small but significant 5% improvement in overall survival. However this benefit concerned a small set of patients who responded to chemotherapy while another set seemed to fare well with or without neoadjuvant chemotherapy. CONCLUSIONS: Perioperative chemotherapy improves survival in patients with muscle invasive bladder cancer. Molecular predictors of the response to chemotherapy are still in the investigational phase and not yet incorporated into clinical practice. Thus, a risk adapted approach by reserving neoadjuvant chemotherapy for cisplatin eligible patients with high risk disease features may balance the benefits of neoadjuvant chemotherapy while minimizing overtreatment.

Renal Angiomyxolipoma: Its First Appearance!

Angiomyxolipoma is considered a very rare subtype of lipoma, with the latter being the most common type of mesenchymal neoplasm. Only 17 cases have been described in English medical literature. Angiomyxolipomas have been described in many locations, mostly in the subcutaneous tissue. In this report, we present the first case of renal angiomyxolipoma ever encountered. Diagnosis was made after many differential diagnoses had been ruled out. Subsequent management and follow-up are illustrated along with a discussion and review of literature.

Iatrogenic penile glans amputation: major novel reconstructive procedure.

Circumcision is a very common urological practice. Even though it is relatively safe, it is not a complication-free procedure. We describe a patient that underwent a neonatal circumcision complicated by iatrogenic complete glans amputation. Reconstructive repair of a neoglans using a modified traditional method was used. Postoperative followup to 90 days is illustrated. Despite being a simple procedure, circumcision in unprofessional hands can have major complication impacting the emotional and sexual life of patients. Surgical reconstruction is possible with varying satisfactory results.

Laparoscopic donor nephrectomy: The Middle East experience.

OBJECTIVES: To summarize the experience of the Middle East in laparoscopic donor nephrectomy (LDN), to discuss the associated advantages and salient problems, to examine the learning curve encountered compared with that of the pioneering centres in the West, and the contribution of the regional centres to the worldwide experience. METHODS: We searched Medline and PubMed for all centres performing LDN in the Middle East. Questionnaires were e-mailed to the regional transplantation centres, and programme directors, and leading urological and transplant surgeons were contacted by telephone. RESULTS: LDN in the Middle East was first introduced in 2000; this approach has been pioneered and practised at seven transplant centres within five countries in the region, and was restricted to only three Arab countries, i.e. Lebanon, Egypt and Kuwait. Data collection yielded a total of 888 procedures over one decade, representing only 2% of the total of ≈50,000 transplants during the same period. Despite variability of accurate reporting the overall outcomes were similar to those of open DN. The spectrum of complications was comparable to that from major centres in the USA during their learning curve. CONCLUSIONS: The introduction of LDN in the Middle East has been gratifying. The relative hesitancy in introducing LDN in the rest of the Arab Middle East is multifaceted. The advantages conferred to the donor underscore the need for further expansion of this approach for kidney retrieval.